Cochrane Review investigates pros and cons of paying for performance in healthcare

By Press Office

A review of the effects of paying for performance (P4P) in the provision of health care in low and middle income countries suggests that although there may be positive effects on some health outcomes and services, it is a complex picture.

In a P4P approach, usually directed at health workers or healthcare facilities, people are given money or other rewards if they carry out a particular task or meet a particular target. It can be used to target specific health problems and services that need improvement but could also affect other services that are not targeted. For instance, it could lead health workers to improve the quality of the other services they deliver or to avoid services that don’t lead to extra payment.

The studies included in the review from Cochrane Effective Practice and Organisation of Care (EPOC) Group looked at P4P approaches that varied in their design, setting and implementation. Researchers assessed the effects of paying for performance on both targeted and untargeted services. This included looking for any unintended effects.

The review included 59 relevant studies, mostly from sub-Saharan Africa and Asia and most of the schemes were funded by National Ministries of Health, also with the support of the World Bank. Compared to other approaches, P4P for health services specifically targeted may improve service quality but may make little or no difference to health outcomes.

Karin Diaconu, Research Fellow in the Institute of Global Health and Development at Queen Margaret University and lead author of the report, said:

“There is growing interest in performance-based approaches, but rigorous evidence across both high and low- and middle-income countries is lacking. P4P not a uniform intervention, but rather a range of approaches. The effects of any approach taken depend on several issues, including: the design of the intervention, for example who receives payments and the amount of additional funding that health workers or facilities receive; ancillary components such as technical support; and also broader country and health system contexts.

“We found that overall paying for performance may lead to increased uptake of some health services, better quality of care, and improve the availability of resources and the autonomy of involved healthcare organisations.”

Read the full review at: The Cochrane Report

Notes to Editor

For further information contact Maggie Wright on 07801 710360 or email 

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