Paying for performance and the social relations of health care provision: an anthropological perspective

Over the past decade, the use of financial incentive schemes has become a popular form of intervention to boost performance in the health sector. Often termed "paying for performance" or P4P, they involve "…the transfer of money or material goods conditional upon taking a measurable action or achieving a predetermined performance target" (Eldridge & Palmer, 2009, p.160). P4P appear to bring about rapid improvements in some measured indicators of provider performance, at least over the short term. However, evidence for the impact of these schemes on the wider health system remains limited, and even where evaluations have been positive, unintended effects have been identified. These have included: "gaming" the system; crowding out of "intrinsic motivation"; a drop in morale where schemes are viewed as unfair; and the undermining of social relations and teamwork through competition, envy or ill feeling. Less information is available concerning how these processes occur, and how they vary across social and cultural contexts. While recognizing the potential of P4P, the authors argue for greater care in adapting schemes to particular local contexts. We suggest that insights from social science theory coupled with the focused ethnographic methods of anthropology can contribute to the critical assessment of P4P schemes and to their adaptation to particular social environments and reward systems. We highlight the need for monitoring P4P schemes in relation to worker motivation and the quality of social relations, since these have implications both for health sector performance over the long term and for the success and sustainability of a P4P scheme. Suggestions are made for ethnographies, undertaken in collaboration with local stakeholders, to assess readiness for P4P; package rewards in ways that minimize perverse responses; identify process variables for monitoring and evaluation; and build sustainability into program design through linkage with complementary reforms.