Payment for Performance (P4P) aims to improve provider motivation to perform better, but little is known about the effects of P4P on accountabiliy mechanisms.

This study conducted a series of in depth interviews, focus group discussions and surveys to examine the effects of P4P in Tanzania on internal and external accountability mechanisms.

The results show that:

• P4P had some positive affect on internal accountability.
• Management practices became less hierarchical and less bureaucratic.
• Increased financial autonomy led to improved services.
• Health workers experienced improved responsiveness from managers.
• The involvement of health facility governing comittees was not enhanced.

"The improved relations between managers and providers, and greater teamwork, coupled with enhanced provider autonomy over funds, entailed an improved handling of systemic challenges like staff availability and lack of medicines and supplies."