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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.
Tanzania is a low income country with gross domestic product (GDP) per capita (PPP) of $1,775 USD, where total health expenditure accounts for 7% of GDP [13]. Officially, P4P was launched in January 2011 in Pwani region of Tanzania (Figure 1). However, the training, that informed health workers about the content of the scheme, was not done until the second half of 2011 and the first payments were made in the first quarter of 2012. A couple of years prior to the start of the scheme, the government launched a national P4P programme, but this was never fully implemented, meaning health workers are less likely to have changed their behavior in response to the scheme until the first payment was made. Therefore, although health workers were aware of the scheme, they only started to respond to the scheme in the second quarter of 2012. The scheme is implemented by the Tanzanian Ministry of Health and Social Welfare, with technical assistance from the Clinton Health Access Initiative and financial support from the Government of Norway. All facilities (public, private and faith-based) providing reproductive and child health (RCH) services in Pwani were eligible to participate in the pilot. A series of maternal and child health services including, for example, institutional deliveries, and provision of two doses of Intermittent Preventive Treatment (IPT) for malaria during antenatal care are incentivised by the scheme [14]. 75%-90% of facility bonuses are paid to health workers with the remainder going to facility strengthening (drug, supply purchase or minor renovation). Bonus payments account for approximately 10% of the average monthly salaries for RCH workers. In addition, district and regional staff are eligible for bonus payments subject to the performance of the facilities in their district and region and timely and complete compilation of reports. Fund pay-outs are administered by the National Health Insurance Fund, and made every six months based on performance in the previous cycle. Regions in Tanzania. Pwani is in the eastern part of the country. Source: Gregor Aisch on Wikimedia Commons with full permission of usage. Process and impact evaluations of the P4P programme were carried out. As part of the process evaluation, data was collected from a sample of districts over three time points during the life time of the pilot [14]. Here we present the findings from the first round of qualitative data collected from December 2011 to March 2012. We report findings from in-depth interviews and focus group discussions with health workers, and regional, district and facility managers on their perceptions of the environment in which P4P was introduced and its influence on implementation. Qualitative findings presented are supplemented by results from facility and health worker surveys carried out in January 2012, as part of the evaluation of the impact of P4P on service use and quality. Five out of the seven intervention districts were sampled for qualitative data collection, including peri-urban and rural districts and a remote island. Three health facilities participating in the pilot were purposively selected from each of the five districts to ensure representation of each level of care and ownership type (public, faith-based and private), with a total sample of 15 facilities (6 dispensaries, 4 health centers and 5 hospitals; 13 government owned facilities, one faith-based and one private). Interviews were conducted with health workers (n = 27), and with district managers (n = 13). Focus group discussions were held with Health Facility Governing Committee members responsible for facility resource management, from three government facilities and with regional managers. Qualitative data was collected by four Tanzanian social scientists working in pairs at the time of the first cycle of payment. Interviews were conducted in Kiswahili and tape recorded. Audio tapes were transcribed and translated into English by the researchers who conducted the interviews. Data was entered and analysed in Nvivo 9 using thematic content analysis. A survey of 75 facilities and 101 health workers were carried out in Pwani region. Of the 75 sampled facilities, the majority were dispensaries (71%), followed by health centres (21%) and hospitals (8%). The majority of facilities (83%) were owned by the government, 12% by faith based institutions and 5% were parastatal/military facilities. Most of the health workers interviewed (71%) were female and just above half (53%) had college level education or above. The sample of health workers was roughly equally distributed between clinical cadres (44%) and nursing cadres (45%) with the remainder being paramedical cadres. The survey measured basic service provision within the facility (staffing levels, opening hours, facility management, as well as facility infrastructure, drug and equipment availability) in the 12-month period before P4P was implemented. Availability of equipment was based on provider recall. Availability of drugs and supplies was based on review of the drug register/stock cards at facilities. Facilities were sampled from those that were eligible to participate in the scheme and included all eligible hospitals, health centres and non-public dispensaries. Public dispensaries were sampled at random with probability proportional to the number of public dispensaries in a given district. The health worker survey measured the P4P effects on providers’ working conditions and attitudes towards work at the selected facilities. Health workers were sampled at random from each facility from those who were on duty at the facility on the day the interviewers were present. Data was collected from facility staff members by 8 teams of 7 interviewers and 1 supervisor. Data was collected using Samsung Galaxy devices (health worker survey) and on paper (facility survey). Data was analysed using Stata 12. Ethical approval was received from the Ifakara Health Institute institutional review board approval number: 1BI1IRB/38 and the ethics committee of the London School of Hygiene & Tropical Medicine. Written informed consent was obtained from all respondents.
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