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Holding health institutions accountable for achieving explicitly defined results by linking payment to results can be a powerful strategy to improve health system performance. The Director of a USAID supported project that funds nongovernmental organizations in Haiti to provide basic health services used strategic purchasing to improve the effectiveness of primary health care by paying providers for results. These providers had been operating under a payment system that reimbursed their expenses up to a ceiling. The new system set performance targets and withheld a portion of their historical budget, allowing them to earn back the withheld amount plus a bonus if they met the targets. As a result, immunization coverage increased from an average of only 46% to over 70% in just one year. This case presents the process of design and implementation of performance based payment from the point of view of the strategic purchaser. The ability to link payments to performance is one of the schemes that can be used by Ministries to guide the health system. The case presents a simple but successful approach in this line.