Pay for performance at a crossroads: lessons from taking a global perspective

Purpose: The use of pay for performance (P4P) as an instrument to incentivise quality improvements in health care is at a crossroads in high-income countries but has remained a commonly used tool in low- and middle-income countries. The authors aimed to take stock of the evidence on effectiveness and design from across income settings to reveal insights for the future design of performance payment across income contexts. Design/methodology/approach: The authors identified Cochrane literature reviews of the use of P4P in health care in any income setting, tracked the development in the quantity and quality of evidence over time, and compared the incentive design features used across high-income countries compared to low- and middle-income countries. Findings: The quantity and quality of the evidence base have grown over time but can still be improved. Scheme design varies across income settings, and although some design choices may reflect differences in context, the authors find that incentive designers in both income settings can learn from practices used in the other setting. Originality/value: The research and literature on P4P in high-, low- and middle-income countries largely operate in silos. By taking stock of the evidence on P4P from across income settings, the authors are able to draw out key insights between these settings, which remain underexplored in the literature.