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A realist review to assess for whom, under what conditions and how pay for performance programmes work in low- and middle-income countries

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  • Singh, Neha S.
  • Kovacs, Roxanne J.
  • Cassidy, Rachel
  • Kristensen, Søren R.
  • Borghi, Josephine
  • Brown, Garrett W.

Abstract

Pay for performance (P4P) programmes are popular health system-focused interventions aiming to improve health outcomes in low-and middle-income countries (LMICs). This realist review aims to understand how, why and under what circumstance P4P works in LMICs.We systematically searched peer-reviewed and grey literature databases, and examined the mechanisms underpinning P4P effects on: utilisation of services, patient satisfaction, provider productivity and broader health system, and contextual factors moderating these. This evidence was then used to construct a causal loop diagram.We included 112 records (19 grey literature; 93 peer-reviewed articles) assessing P4P schemes in 36 countries. Although we found mixed evidence of P4P's effects on identified outcomes, common pathways to improved outcomes include: community outreach; adherence to clinical guidelines, patient-provider interactions, patient trust, facility improvements, access to drugs and equipment, facility autonomy, and lower user fees. Contextual factors shaping the system response to P4P include: degree of facility autonomy, efficiency of banking, role of user charges in financing public services; staffing levels; staff training and motivation, quality of facility infrastructure and community social norms. Programme design features supporting or impeding health system effects of P4P included: scope of incentivised indicators, fairness and reach of incentives, timely payments and a supportive, robust verification system that does not overburden staff. Facility bonuses are a key element of P4P, but rely on provider autonomy for maximum effect. If health system inputs are vastly underperforming pre-P4P, they are unlikely to improve only due to P4P. This is the first realist review describing how and why P4P initiatives work (or fail) in different LMIC contexts by exploring the underlying mechanisms and contextual and programme design moderators. Future studies should systematically examine health system pathways to outcomes for P4P and other health system strengthening initiatives, and offer more understanding of how programme design shapes mechanisms and effects.

Suggested Citation

  • Singh, Neha S. & Kovacs, Roxanne J. & Cassidy, Rachel & Kristensen, Søren R. & Borghi, Josephine & Brown, Garrett W., 2021. "A realist review to assess for whom, under what conditions and how pay for performance programmes work in low- and middle-income countries," Social Science & Medicine, Elsevier, vol. 270(C).
    • Handle: RePEc:eee:socmed:v:270:y:2021:i:c:s0277953620308431
    DOI: 10.1016/j.socscimed.2020.113624
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    Cited by:

    1. Cassidy, Rachel & Tomoaia-Cotisel, Andrada & Semwanga, Agnes Rwashana & Binyaruka, Peter & Chalabi, Zaid & Blanchet, Karl & Singh, Neha S. & Maiba, John & Borghi, Josephine, 2021. "Understanding the maternal and child health system response to payment for performance in Tanzania using a causal loop diagram approach," Social Science & Medicine, Elsevier, vol. 285(C).
    2. Lohmann, Julia & Koulidiati, Jean-Louis & Robyn, Paul Jacob & Somé, Paul-André & De Allegri, Manuela, 2022. "Why did performance-based financing in Burkina Faso fail to achieve the intended equity effects? A process tracing study," Social Science & Medicine, Elsevier, vol. 305(C).
    3. Fichera, Eleonora & Anselmi, Laura & Gwati, Gwati & Brown, Garrett & Kovacs, Roxanne & Borghi, Josephine, 2021. "Can Results-Based Financing improve health outcomes in resource poor settings? Evidence from Zimbabwe," Social Science & Medicine, Elsevier, vol. 279(C).
    4. Laura Anselmi & Julius Ohrnberger & Eleonora Fichera & Pedroso Nhassengo & Quinhas F. Fernandes & Sergio Chicumbe, 2023. "The impact of performance‐based financing within local health systems: Evidence from Mozambique," Health Economics, John Wiley & Sons, Ltd., vol. 32(7), pages 1525-1549, July.
    5. Tsai, Wen-Chen & Huang, Kuang-Hua & Chen, Pei-Chun & Chang, Yu-Chia & Chen, Michael S. & Lee, Chiachi Bonnie, 2023. "Effects of individual and neighborhood social risks on diabetes pay-for-performance program under a single-payer health system," Social Science & Medicine, Elsevier, vol. 326(C).

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