Understanding P4P process and pathways. A Tanzanian case study

Payment for performance (P4P) is a purchasing mechanism which provides funds to health providers based on the achievement of pre-specified performance targets with a view to improving the quality of health services and enhance service coverage.  Despite the roll out of such schemes across a range of low and middle income countries, the evidence base remains limited and importantly we lack understanding of the pathways through which P4P results (or not) into outcome changes.  Specific areas where information is lacking include P4P effects on facility resourcing and internal and external accountability mechanisms, as well as how P4P affects health facilities of differing characteristics (e.g. levels of care, population socio-economic status, baseline performance).  Further we have little understanding of the pathways through which P4P achieves outcomes and the extent to which financing, governance, and human resources mediate P4P effects. 

The overall aim of the study is to contribute to filling these knowledge gaps.  The study draws primarily on data collated as part of an evaluation of P4P in Pwani region of Tanzania and involves further analysis of these data.  Available data include surveys with households, patients, health workers and facilities conducted at two points in time in all intervention districts and selected comparison areas with no P4P.  These data can be uniquely linked at the facility level enabling new analyses to be undertaken.  We also draw on in-depth interviews and focus groups carried out with a range of implementers during three rounds of data collection.  Additional qualitative data collection to gain insights into variations in the evolution of the accountability structures over time and community perspectives is also planned.