Design/methodology/approach: We used a comparative mixed methods case study design involving a theory of change workshop, document review and key informant interviews. Multiple rounds of Demographic Health Surveys (DHS) evaluated the effect of P4P on service use and, in Zimbabwe, health outcomes, using difference in difference regressions. Three frameworks guided cross country comparisons.
Findings: P4P indicators were aligned to national strategies and the scheme benefited from government co-financing in Zimbabwe; whereas there was limited national buy-in to the donor funded scheme in Mozambique. Scheme designs were similar in both countries, with differences including the: verification system, share of funds allocated to staff, and pricing of indicators. There were limited P4P effects on service delivery outcomes, while in-country evaluations reported more widespread effects. Improvements in supervision, health information systems, drug availability, facility infrastructure, and staff morale were reported in both countries. Staff shortages and small catchment populations limited provider capacity to achieve targets, especially in smaller health facilities, while removal of demand side barriers and greater facility spending autonomy facilitated P4P effects.
Originality: This study adds to the literature on P4P by assessing how context shapes the design and effects of P4P schemes across countries. The findings show P4P in weaker health systems requires sufficient facility funding and spending autonomy to support responsiveness to local context. Efficient verification and quality assessment systems can mitigate P4P effects on workload.
|Journal||International Journal of Public Sector Management|
|Publication status||Accepted/In press - 20 Sept 2023|
- Payment for Performance
- health systems