Paying for performance to improve the delivery of health interventions in low‐ and middle‐income countries

Paying for performance to improve the delivery of healthcare services in low‐ and middle‐income countries

The aim of this Cochrane Review was to assess the effects of ‘pay for performance’ on the delivery of healthcare services in low‐ and middle‐income countries. The review authors collected and analysed all relevant studies to answer this question and found 59 studies.

Key messages

The studies included in this review looked at pay for performance approaches that varied in their design, setting and implementation. The review shows that pay for performance may have both positive and negative effects on the health services it targets. It may also have positive effects on other health services that are not directly targeted and may have no unintended negative effects on these services. However, most of this evidence is of low certainty and we need more, well‐conducted studies on this topic.

What is ‘pay for performance’?

In a 'pay for performance' approach, people are given money or other rewards if they carry out a particular task or meet a particular target. Pay for performance is usually directed at health workers or healthcare facilities. The health workers or healthcare facilities are rewarded if they offer particular services or deliver care that is of a certain quality, or if their patients use particular services and achieve better health as a result.

Pay for performance can be used  to target specific health problems and services that need improvement. But pay for performance could also affect other services that are not specifically targeted. For instance, it could lead health workers to improve the quality of the other services they deliver. But it could also lead them to avoid services that don’t lead to extra payment. To find out more, the review authors assessed the effects of paying for performance on both targeted and untargeted services. This included looking for any unintended effects.

What are the main results of the review?

The review included 59 relevant studies. Most were from sub‐Saharan Africa and Asia. Most of the pay for performance schemes in the studies were funded by national Ministries of Health, also with support of the World Bank.

Forty‐nine studies compared health facilities that used pay for performance with health facilities that were doing business as usual. Seventeen studies compared health facilities that used pay for performance with facilities that used other approaches. In most of these studies,  these approaches involved giving similar amount of funds but without insisting on a pay for performance element.

The effects of paying for performance compared to business as usual  

For health services that are specifically targeted, pay for performance:

‐ may improve some health outcomes, may improve service quality and probably increase the availability of health workers, medicines and well‐functioning infrastructure and equipment; but

‐ may have both positive and negative effects on the delivery and use of health services.

For health services that are untargeted, pay for performance:

‐ probably improves some health outcomes;

‐ may improve the delivery, use and quality of some health services but may make little or no difference to others; and

‐ may have few or no unintended effects.

We don’t know what the effects of pay for performance are on the availability of medicines and other resources because the evidence was of very low certainty

The effects of paying for performance compared to other approaches

For health outcomes and services that are specifically targeted, pay for performance:

‐ may improve service quality;

‐ may make little or no difference to health outcomes; and

‐ may have both positive and negative on the delivery and use of health services and on the availability of equipment and medicines.

For health outcomes and services that are untargeted, pay for performance:

‐ may make little or no difference to health outcomes and to the delivery and use of health services.

We don’t know what the effects of pay for performance are on service quality, on the availability of resources, and on unintended effects because the evidence was missing or of very low certainty

How up to date is this review?

The review authors included studies that had been published up to April 2018.