Pay for performance: a health systems perspective

Understanding Pay for Performance process and pathways in Tanzania


Pay for performance (P4P) is a purchasing mechanism that provides funds to health care providers based on the achievement of pre-specified performance targets, with a view to improving the quality of health services and enhancing service coverage. Despite the roll out of such schemes across a range of low and middle-income countries, the evidence base remains limited. In particular, we lack an understanding of the pathways through which P4P results (or not) in outcome changes, for instance through improved resourcing, more functional accountability mechanisms, and/or improved motivation of health workers.

This cross-theme research study aims to better understand how P4P affects health facilities with different characteristics and achieves outcomes in Pwani region of Tanzania, where a pilot P4P scheme has been implemented since 2011. It examined the effect of P4P on the functioning of accountability mechanisms within the health system, and on facility resourcing (drugs, supplies and equipment availability) and resource allocation. This enabled researchers to test possible mediation pathways through which P4P results in changes in outcomes.

The research was conducted prior to a phased national roll out of P4P in Tanzania. It is hoped that the key findings of the study will shape the roll out process to maximise positive impacts of P4P on population health.

Key findings

P4P has been piloted in Tanzania to increase rates of delivery in health facilities and improve maternal and child health, with largely positive effects on the wider health system: P4P bonus was used by health facilities to purchase drugs for delivery, leading to a significant reduction in stock-outs. This also meant that patients didn’t need to pay for some drugs themselves.

P4P provided an incentive for health workers to be more respectful towards their clients, and improvements in provider kindness and quality of care led to increased use of health services. P4P also strengthened relationships between health workers and managers involved in the intervention; however, it created tensions between other health workers who didn’t benefit from P4P.


Video: The health system effects of pay for performance in Pwani region, Tanzania

Research summary: Understanding Pay for Performance process and pathways

Blog: 10 things I learned (or learned more) about pay-for-performance

Journal publication: Protocol for the evaluation of a pay for performance programme in Pwani region in Tanzania: a controlled before and after study (RESYST related)

Poster: Evaluation of a pay for performance scheme in Tanzania (RESYST related)