Performance-based incentives

Performance-based incentive (PBI) schemes are used increasingly in developing country health systems to induce health-related actions or performance targets. Supply-side PBIs—used to improve the quality and availability of services—are given either to health care providers or managers at the facility, district, or national level, conditional on achieving certain service delivery or public health goals. Supply-side PBIs often are being incorporated into national public health delivery systems, social insurance schemes, contracts with service delivery organizations, and safe motherhood schemes in low- and middle-income settings (Witter et al. 2012).

Demand-side PBIs that encourage the demand for essential health services and access to them are provided directly to households or patients to change certain health-related behaviors. Conditional cash transfer programs are a commonly used demand-side PBI scheme.

Historically, PBIs in low-resource settings have provided incentives to units of care, such as an attended birth, rather than performance measures linked to quality of care (that is, what was done in the care process). Recognition is increasing of the potential negative, unintended consequences of productivity-driven performance incentives on quality of care, as well as recognition of the potential benefits of quality performance measures in low-resource settings to improve delivery of best practices (Ergo et al. 2012).

Providing incentives to motivate providers and organizations to participate in quality performance and maintain it is as important as sanctions, particularly in voluntary programs like accreditation. Financial incentives, such as linkages to payment systems and quality bonuses, can be powerful motivators to maintain high compliance with quality standards and reward organizations’ superior performance. Symbolic rewards, including professional and public recognition through publicity or special awards, also can be highly motivating, particularly if these are perceived to endow the provider or organization with a competitive advantage.