Featured Review: Paying for performance to improve the delivery of healthcare services in low- and middle-income countries

recently published review from Cochrane Effective Practice and Organisation of Care (EPOC) Group looks at the effects of ‘pay for performance’ strategies on the delivery of healthcare services in low- and middle-income countries.

Karin Diaconu, first author of this review, notes, "There is growing interest in paying for performance as a strategy for aligning the work of health providers and healthcare organizations with public health goals. The volume of schemes implementing paying for performance has increased over the last decade and so has the number of studies on the effectiveness of these strategies in low- and middle-income countries.

This review brings this evidence together and asks how successful schemes are in improving health care and health. The review notes that paying for performance may have some positive effects: it may lead to increased uptake of some health services, better quality of care, and improve the availability of resources as well as improving autonomy of involved healthcare organisations."

Key messages

Pay for performance strategies may have both positive and negative effects on the health services they target. These strategies 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. This strategy is usually directed at health workers or healthcare organizations. The health workers or healthcare organizations 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.

Planners use these strategies to target specific health problems and services that need improvement. But it is also possible that pay for performance strategies have positive or negative effects, including on other services that are not specifically targeted. For instance, these strategies could lead health workers to improve the quality of the other services they deliver. But it could also lead them to avoid services that do not give 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 of the strategies. 

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 strategies to health facilities who were doing business as usual. Seventeen studies compared health facilities that used pay for performance strategies to facilities that used other strategies. In most of these studies, health facilities using pay for performance strategies were compared to facilities who were given the same amount of funds but without 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 strategies: 

  • may improve 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 strategies: 

  • probably improve some health outcomes 
  • may improve the delivery, use and quality of some health services but may make little or no difference to others
  • 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 strategies 

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

  • may improve service quality 
  • may make little or no difference to health outcomes
  • may have mixed effects on the delivery and use of health services and on the availability of equipment and medicines, including both positive and negative effects

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

  • 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.