When incentives work too well: locally implemented pay for performance (P4P) and adverse sanctions towards home birth in Tanzania - a qualitative study.

Background: Despite limited evidence of its effectiveness, performance-based payments (P4P) are seen by leading policymakers as a potential solution to the slow progress in reaching Millennium Development Goal 5: improved maternal health. This paper offers insights into two of the aspects that are lacking in the current literature on P4P, namely what strategies health workers employ to reach set targets, and how the intervention plays out when implemented by local government as part of a national programme that does not receive donor funding.

Methods: A total of 28 in-depth interviews (IDIs) with 25 individuals were conducted in Mvomero district over a period of 15 months in 2010 and 2011, both before and after P4P payments.

Informal payments and health worker effort: a quantitative study from Tanzania.

Informal payments-payments made from patients to health personnel in excess of official fees--are widespread in low-income countries. It is not obvious how such payments affect health worker effort. On the one hand, one could argue that because informal payments resemble formal pay for performance schemes, they will incite higher effort in the health sector.

Assessing performance enhancing tools: experiences with the open performance review and appraisal system (OPRAS) and expectations towards payment for performance (P4P) in the public health sector in Tanzania.

Background: Health workers' motivation is a key determinant of the quality of health services, and poor motivation has been found to be an obstacle to service delivery in many low-income countries. In order to increase the quality of service delivery in the public sector in Tanzania, the Open Performance Review and Appraisal System (OPRAS) has been implemented, and a new results-based payment system, Payment for performance (P4P) is introduced in the health sector. This article addresses health workers' experiences with OPRAS, expectations towards P4P and how lessons learned from OPRAS can assist in the implementation of P4P.

Pro-social preferences and self-selection into the public health sector: evidence from an economic experiment.

Motivational crowding-out theory establishes that the effectiveness of financial incentive schemes, like pay-for-performance, crucially depends on the underlying social preferences of health workers. In this paper we study the extent to which heterogeneity in the strength and structure of social preferences is related to career choices by testing whether preferences vary systematically between Tanzanian health worker students who prefer to work in the private for-profit health sector and those who prefer to work in the public health sector. Despite its important policy implications, this issue has received little attention to date.