Pay for performance: an analysis of the context of implementation in a pilot project in Tanzania.

BACKGROUND: Pay for performance schemes are increasingly being implemented in low income countries to improve health service coverage and quality. This paper describes the context within which a pay for performance programme was introduced in Tanzania and discusses the potential for pay for performance to address health system constraints to meeting targets. METHOD: 40 in-depth interviews and four focus group discussions were undertaken with health workers, and regional, district and facility managers. Data was collected on work environment characteristics and staff attitudes towards work in the first phase of the implementation of the pilot. A survey of 75 facilities and 101 health workers were carried out to examine facility resourcing, and health worker employment conditions and job satisfaction. RESULTS: Five contextual factors which affect the implementation of P4P were identified by health workers: salary and employment benefits; resource availability, including staff, medicines and functioning equipment; supervision; facility access to utilities; and community preferences. The results suggest that it is important to consider contextual issues when implementing pay for performance schemes in low income settings. It highlights the importance of basic infrastructures being in place, a minimum number of staff with appropriate education and skills as well as sufficient resources before implementing pay for performance. CONCLUSION: Health professionals working within a pay for performance scheme in Tanzania were concerned about challenges related to shortages of resources, limited supplies and unfavourable community preferences. The P4P scheme may provide the incentive and means to address certain constraints, in so far as they are within the control of providers and managers, however, other constraints will be harder to address.

A health system in economic crises: a case study from Iceland.

BACKGROUND: There has been a lack of systematic inquiry into how governments respond during times of crises, how well these responses comply with good governance, and how they affect health systems. The aim of this study was to analyse the reactions of the Icelandic health system during the first 7 months of the economic crisis in 2008. METHODS: The grounded theory approach was used in data sampling, collection, and data analysis. Secondary data were collected from parliamentary documents, news, and health discussions in two of the largest newspapers in Iceland. Primary data were collected through interviews with key stakeholders in the health sector. Atlas.ti. 5.2 was used to analyse the data. RESULTS: The health sector's first response to the crisis was to close and merge wards on hospitals as well as making structural changes to reduce the overhead costs in healthcare institutions. The Minister of Health attempted to introduce radical changes but because of failures in good governance practices, such as a lack of transparency and fair participation together with a lack of supporting documents, the proposed changes were not executed. CONCLUSIONS: Economic crises are a critical test of health systems' resilience. The manner in which governance practices, together with strong stewardship, influence the ability of the health system to adapt to changes and reorganise without causing stress, confusion, or anger and without changing its basic structure and function are important, and open to robust evaluation.

The fallacy of the equity-efficiency trade off: rethinking the efficient health system.

In the health systems literature one can see discussions about the trade off between the equity achievable by the system and its efficiency. Essentially it is argued that as greater health equity is achieved, so the level of efficiency will diminish. This argument is borrowed from economics literature on market efficiency. In the application of the economic argument to health, however, serious errors have been made, because it is quite reasonable to talk of both health equity being a desirable output of a health system, and the efficient production of that output. In this article we discuss notions of efficiency, and the equity-efficiency trade off, before considering the implications of this for health systems.