Structural, institutional and organizational factors associated with successful pay for performance programmes in improving quality of maternal and child health care in low and middle income countries: a systematic literature review.

backgroundPay for Performance (P4P) mechanisms to health facilities and providers have been implemented in several low- and middle-income countries (LMIC) to improve maternal and child health (MCH). These are tied to predetermined quality and quantity indicators. There is limited synthesized information on the structural, institutional and organizational factors that influence the success of P4P programmes with respect to quality of care. This review, which builds on a previously published review sets out to synthesize existing literature on the factors that influence the outcome of P4P programmes and quality of care.

methodsA literature review was conducted of published studies documenting implementation of P4P interventions and quality of care in low and middle income countries. Records published between June 2014 and September 2017 were selected and combined with articles from January 1990 to June 2014 previously identified by colleagues.

results13 studies were included in the final analysis. The majority of studies found a positive impact on quality of care scores and at least one study showed significant reductions in mortality outcomes in newborns. One study from Afghanistan did not show any positive effects. Structural factors associated with likely success of P4P programmes included: explicit acceptance and understanding by health workers; limiting the number of indicators measured with inputs from health workers. Organisational factors included sufficient incentive payments. Notably the main positive outcome identified was facility financial autonomy from additional payments. Verification by external assessors revealed no major manipulation to achieve payment trigger levels. The primary institutional factors identified that P4P programmes fared better when introduced alongside other health reforms and increased funding.

conclusionsThis review has found that P4P is not a uniform intervention, but rather a range of approaches with a substantial variation and complexity in how programmes incorporate quality of care considerations. P4P has shown to have an impact on the quality of a number of limited aspects of maternal and child health care. Further research is needed to understand whether additional aspects of the quality of MCH care could be positively influenced by P4P programmes and how health worker motivation and acceptance are linked to this.