Singh, NS, Kovacs, RJ, Cassidy, R et al. (3 more authors) (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 and Medicine, 270. 113624. ISSN 0277-9536
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.
Metadata
Item Type: | Article |
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Authors/Creators: |
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Copyright, Publisher and Additional Information: | © 2020 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/). |
Keywords: | Realist synthesis; Realist review; Pay for performance; Performance-based financing; Maternal health; Child health; Low- and middle-income countries |
Dates: |
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Institution: | The University of Leeds |
Academic Units: | The University of Leeds > Faculty of Education, Social Sciences and Law (Leeds) > School of Politics & International Studies (POLIS) (Leeds) |
Funding Information: | Funder Grant number MRC (Medical Research Council) MR/P014429/1 |
Depositing User: | Symplectic Publications |
Date Deposited: | 09 Jun 2021 14:36 |
Last Modified: | 25 Jun 2023 22:41 |
Status: | Published |
Publisher: | Elsevier |
Identification Number: | 10.1016/j.socscimed.2020.113624 |
Open Archives Initiative ID (OAI ID): | oai:eprints.whiterose.ac.uk:175038 |