After two decades of pay-for-performance in LMICs, what have we learned? Reflections from Rwanda and Haiti

Money tree

In this blog, Maria-Gorreti Ndunwere (MSc, BPharm; GHPU student MSc Global Health Policy 2021/22) reflects on the implementation of pay-for-performance incentives in Rwanda and Haiti.

Pay-for-Performance (P4P) is a widely-contested policy idea in which payment-based incentives are used to reshape healthcare provider and/or population behaviour, with the overall aim of improving the quality, efficiency, and value of healthcare (Soucat, et al., 2017; Honda, 2012). Although P4P policies have been implemented in diverse settings globally, they continue to be controversial and many note the unintended consequences of these policies, such as health workers focusing on incentivised, at the expense of non-incentivised, services (Ireland, et al., 2011). However, in many low-and-middle-income countries (LMICs), P4P has increasingly been used as a strategy to improve the quality of healthcare services and health outcomes (Zeng, et al., 2018).

Nearly two decades after P4P began to gain prominence, it is important to critically reflect on the value of these policies. Although P4P can be a great stimulant to improve the utilisation of health services and patient satisfaction in LMICs, it has become increasingly apparent that other factors in the health system must be addressed to meet health system goals. In this blog, I look specifically at two LMICs, Rwanda and Haiti, where P4P serves an important role in each country’s health system (Ministry of Health, 2021; Ministere de la Sante Population, 2018). In both cases, P4P was introduced to help achieve health system goals, namely, to improve the use and quality of basic health services and patient satisfaction in these countries.

One of the ways P4P programmes have improved healthcare outcomes in LMICs is by increasing the utilisation of health services. For example, in Rwanda and Haiti, performance incentives were introduced to provide and promote the use of basic services such as maternal and child health (MCH) services (Rusa, et al., 2009). In Rwanda, P4P in public health facilities led to a 132% rise in preventive care visits for children aged 1-5 years (Basinga, et al., 2011) with consequent significant effects on their height-for-age, an important health outcome (Gertler & Vermeersch, 2012). More recently, Rwanda has been able to continue to surpass MCH outcome goals. For example, skilled birth attendance has increased to 94% in recent years; 4% higher than the targeted level. While this has been attributed to P4P being implemented at the community level (Ministry of Health, 2021), other factors – chiefly the expansion of health insurance which has helped remove the financial barrier to seeking care – likely played an important role as well (Skiles et al., 2015).

In Haiti, similar successes have been documented. Eichler et al. (2009) reported an 85% and 70% increase in immunisation rates and institutional delivery rates respectively upon implementing P4P in facilities. Moreover, when comparing the utilisation of incentivised and non-incentivised MCH services, the utilisation of the former was higher than the latter by three points (Zeng et al. 2013). This further suggests that P4P potentially impacts health outcomes by influencing healthcare providers’ behaviour. Healthcare providers in Haiti possibly favoured the delivery of incentivised services over non-incentivised ones because incentives were used to upgrade health facilities and infrastructure (Zeng et al. 2013).

Despite these early successes, more recently, the utilisation of incentivised services has remained constant or even reduced when compared to previous years. For instance, utilisation of maternal health services such as postnatal home visits remained constant, while the number of pregnant women who finished vaccination increased by 20% to about 6000 women in 2017 then dropped to approximately 5000 women by the end of 2017 (Ministere de la Sante Population, 2018). This suggests that other factors, such as financial barriers to seeking care and medication stock-outs, may be impacting the use of these services, underlining the need for wider health system reforms in addition to P4P to maintain improvements (Gage et al., 2018; Fletcher, 2018).

Additionally, P4P programmes have the potential to improve patient satisfaction through decreased waiting times and improvements in quality. In Rwanda, although reductions in waiting times were not incentivised, there were improvements in waiting times for pregnant women (Lannes, 2015). There is a possibility that healthcare providers devised techniques to reduce waiting times for this group, which represent the source of the highest potential financial reward in the P4P scheme (ibid). Since the scheme rewarded institutional delivery the highest, it seemed useful to improve satisfaction for these women and influence their decisions to have deliveries at the facilities. However, other health system interventions outside of P4P, including the improvement in productivity, availability and competence of the health workforce, ensured the availability of skilled staff to provide services, reducing delays and dissatisfaction (Ngo et al. 2017).

In Haiti, decreased waiting times were directly incentivised with a 10% bonus, causing an expected increase in the number of patients who attended clinics to receive healthcare services (Eichler, et al., 2009). Healthcare providers received a 10% bonus for achieving a 50% reduction in patient waiting times (ibid). One concern with this type of incentive structure is that healthcare providers likely focused on reducing waiting times at the expense of providing complete and compassionate care. However, in Haiti, there was no evidence of adverse quality impacts (e.g., providers shifting away from non- or less- incentivised services for more incentivised services as was seen in Rwanda (Zeng et al. 2013). Some authors have attributed this to the design of the policy itself, where performance bonuses were not only given to staff but also used to upgrade health facilities (Zeng et al. 2013; Pollock, 2003). Furthermore, individual healthcare providers were rewarded for the provision of the total package of MCH services rather than specific MCH services, as in Rwanda (Zeng et al, 2013; Basinga et al. 2011). Consequently, this bonus policy arguably contributed to rebuilding the health system following its collapse in 2014 (Population, 2017).

So, what might we conclude about the role of P4P in improving the quality of healthcare in LMICs? The two case studies examined here suggest that P4P can serve as a catalyst towards achieving health system goals, as the literature shows notable improvements in key metrics over time. However, P4P policies can vary widely, and these two cases also highlight that careful design of each incentive is critical to ensure that adverse effects are minimised.



Basinga, P. et al., 2011. Effect on maternal and child services in rwanda of payment to primary health-care providers for performance: an impact evaluation. Lancet, Volume 377, pp. 1421-28.

Eichler, R., Auxila, P., Antoine, U. & Desmangles, B., 2009. Haiti: going to scale with a performance incentive model. In: R. Eichler & R. Levine , eds. Performance incentives for global health: potential and pitfalls. Washington D.C.: Centre for global development, pp. 165-188.

Fletcher, K. 2018. Maternal and child health in Borgne, Haiti.

Gage, A.D., Leslie, H.H., Bitton, A., Jerome, J.G., Joseph, J.P., Thermidor R. & Kruk, M.E. 2018. Does quality influence utilisation of primary healthcare? Evidence from Haiti. Globalization and Health, 14, 59.

Gertler, P. & Vermeersch, C., 2012. Using performance incentives to improve health outcomes. Policy research working paper, Volume 6100.

Ireland, M., Paul, E. & Dujardin, B., 2011. Can performance-based financing be used to reform health systems in developing countries?. Bull World Health Organ, Volume 89, pp. 698-699.

Lannes, L., 2015. Improving health worker performnace: the patient-perspective from a PBF program in Rwanda. Social science and medicine, Volume 138, pp. 1-11.

Management Sciences for Health. (2017). Performance-based financing improves quantity and quality of health services in Haiti. Republique d’Haiti: Management Sciences for Health.

Ministry of Health, Rwanda, 2021. Health Sector Annual Performance Report 2020-2021. In: ministry of health. (ed.). Republic of Rwanda.

Ministere de la Sante Publique et de la Population. 2017. Bulletin FBR. Republique d’Haiti: Ministere de la Sante Publique et de la Population.

Ministere de la Sante Publique et de la Population. 2018. Bulletin FBR. Republique d’Haiti: Ministere de la Sante Publique et de la Population.

Pollock, J. 2003. Performance-based contracting with NGOs in Haiti. Performance improvement, 42, 20-24.

Rusa, L., Schneidman, M., Fritsche, G. & Musango, L., 2009. Rwanda: Performance-based financing in the public sector. In: R. Eichler & R. Levine, eds. Performance incentives for global health. Washington D.C.: Center for global development, pp. 189-214.

Skiles, M.P., Curtis, S.L., Basinga, P., Angeles, G. & Thirunurthy, H. 2015. The effects of performance-based financing on illness, care-seeking and treatment among children: an impact evaluation in Rwanda. BMC Health Services Research, 15, 375.

Soucat, A., Dale, E., Mathauer, I. & Kutzin, J., 2017. Pay-for-performance debate: not seeing the forest for the trees. Health systems & reforms, 3(2), pp. 74-79.

Zeng, W., Cros, M., Wright, K.D. and Shepard, D.S., 2013. Impact of performance-based financing on primary health care services in Haiti. Health policy and planning28(6), pp.596-605.

Zeng, W. et al., 2018. Strengthening performance-based financing as a health system approach for quality improvement. Jornal Global health, 8(2).