abstract: 'Although pay-for-performance (P4P) schemes have been implemented across

  low- and middle-income countries (LMICs), little is known about their

  distributional consequences. A key concern is that financial bonuses are

  primarily captured by providers who are already better able to perform

  (for example, those in wealthier areas), P4P could exacerbate existing

  inequalities within the health system. We examine inequalities in the

  distribution of pay-outs in Zimbabwe''s national P4P scheme (2014-2016)

  using quantitative data on bonus payments and facility characteristics

  and findings from a thematic policy review and 28 semi-structured

  interviews with stakeholders at all system levels. We found that in

  Zimbabwe, facilities with better baseline access to guidelines, more

  staff, higher consultation volumes and wealthier and less remote target

  populations earned significantly higher P4P bonuses throughout the

  programme. For instance, facilities that were 1 SD above the mean in

  terms of access to guidelines, earned 90 USD more per quarter than those

  that were 1 SD below the mean. Differences in bonus pay-outs for

  facilities that were 1 SD above and below the mean in terms of the

  number of staff and consultation volumes are even more pronounced at 348

  USD and 445 USD per quarter. Similarly, facilities with villages in the

  poorest wealth quintile in their vicinity earned less than all

  others-and 752 USD less per quarter than those serving villages in the

  richest quintile. Qualitative data confirm these findings. Respondents

  identified facility baseline structural quality, leadership, catchment

  population size and remoteness as affecting performance in the scheme.

  Unequal distribution of P4P pay-outs was identified as having negative

  consequences on staff retention, absenteeism and motivation. Based on

  our findings and previous work, we provide some guidance to policymakers

  on how to design more equitable P4P schemes.'
affiliation: 'Borghi, J (Corresponding Author), London Sch Hyg \& Trop Med, Dept Global
  Hlth \& Dev, 15-17 Tavistock Pl, London WC1H 9SH, England.

  Kovacs, Roxanne; Borghi, Josephine, London Sch Hyg \& Trop Med, Fac Publ Hlth \&
  Policy, Dept Global Hlth \& Dev, 15-17 Tavistock Pl, London WC1H 9SH, England.

  Brown, Garrett W., Univ Leeds, Sch Polit \& Int Studies POLIS, Woodhouse Leeds LS2
  9JT, England.

  Kadungure, Artwell, Training \& Res Support Ctr TARSC, Harare, Zimbabwe.

  Kristensen, Soren R., Univ Southern Denmark, Danish Ctr Hlth Econ, DK-5000 Odense
  C, Denmark.

  Kristensen, Soren R., Imperial Coll London, Fac Med, Inst Global Hlth Innovat, London
  SW7 2AZ, England.

  Gwati, Gwati, Minist Hlth \& Child Care, Harare, Zimbabwe.

  Anselmi, Laura, Univ Manchester, Hlth Serv Res \& Primary Care, Div Populat Hlth,
  Manchester M13 9NT, Lancs, England.

  Midzi, Nicholas, Minist Hlth \& Child Care, Natl Inst Hlth Res, Harare, Zimbabwe.'
author: Kovacs, Roxanne and Brown, Garrett W. and Kadungure, Artwell and Kristensen,
  Soren R. and Gwati, Gwati and Anselmi, Laura and Midzi, Nicholas and Borghi, Josephine
author-email: Josephine.Borghi@lshtm.ac.uk
author_list:
- family: Kovacs
  given: Roxanne
- family: Brown
  given: Garrett W.
- family: Kadungure
  given: Artwell
- family: Kristensen
  given: Soren R.
- family: Gwati
  given: Gwati
- family: Anselmi
  given: Laura
- family: Midzi
  given: Nicholas
- family: Borghi
  given: Josephine
da: '2023-09-28'
doi: 10.1093/heapol/czab154
earlyaccessdate: JAN 2022
eissn: 1460-2237
files: []
issn: 0268-1080
journal: HEALTH POLICY AND PLANNING
keywords: Health financing; pay-for-performance; inequality; Zimbabwe
keywords-plus: CARE; QUALITY; PENALTIES; SERVICES; PAYMENT
language: English
month: APR 13
number: '4'
number-of-cited-references: '26'
orcid-numbers: Borghi, Josephine/0000-0002-0482-5451
pages: 429-439
papis_id: 73b64692c3d9da9b29f33192e6fa8082
ref: Kovacs2022whois
times-cited: '0'
title: Who is paid in pay-for-performance? Inequalities in the distribution of financial
  bonuses amongst health centres in Zimbabwe
type: Article
unique-id: WOS:000757460500001
usage-count-last-180-days: '1'
usage-count-since-2013: '3'
volume: '37'
web-of-science-categories: Health Care Sciences \& Services; Health Policy \& Services
year: '2022'