Performance of health providers:
a common objective, diverse strategies
Jean Perrot
WHO
1|

Performance:
• In developing countries it's mainly about increasing
provider activity (quantitatively and qualitatively)
• In developed countries it's mainly about insuring a correct
(efficient) use of resources
• We are not talking here about health system performance
but health provider performance (micro level point of view)
2|

Result and Performance
Objective
Strategy Tool
Contracting
Performance
Incentives
Regulation
Sanctions
Values
3|

The general model is indeed this:
• Increasing the performance of health service providers is
always the objective
• The usual strategies that rely on sanctions or the respect
of certain values (professional consciousness and values,
etc.) yield only modest results
• Resorting to incentives is a new strategy
• Implementation of this strategy will make use of
contractual or regulatory tools
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Result and Performance
Rwanda model
Use of incentives
Ste
p2
Contracting
Regulation
Predefined result
Inputs or
Maximize result
Ste
p 1
Contracting
Regulation
Attribution of incentives
5|

In the \"Rwanda model\":
• Step 1: Criteria for attributing incentives rely on results,
maximizing results. Bonus. Contract for a commitment to
purchase
• Step 2: Use of the bonus focuses on inputs - top ups for staff
who are thus motivated to increase the institution's results. This
step is not included in the provider performance contract
6|

Result and Performance
Mali Hospital Model
Attribution and use of
incentives
Ste
ps1
et 2
Contracting
Regulation
Result
Inputs
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In the \"Mali – hospital model\":
• The results are not linked to the incentives
• Step 1: The criteria for attributing incentives focus on inputs,
changes in behavior and practices of actors in institutions
• Step 2: Use of the bonus focuses on inputs (collective use);
underlying hypothesis is that these changes in behavior will
influence the results. This step is taken into account in the
performance contract with providers
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• There is a profound change of rationale
• Political acceptation, labour unions, … in the society
9|

• Some important points:
• Need to have financial resources for the activity: project
approach is easier than general budget support
• Never forget that the actors have different interests:
opportunistic behaviour: gaming, dumping
• Institutional performance – hypothesis of the need to incite
the individuals; complex systems such as hospitals
• Artificial change of behaviour: not acting on the causes
• Effect of taking things for granted
• W hat is the part of the performance linked payments in the provider's
budget ? Inclusion of all the activities or just a few ( prioritizing)
10 |

Messages:
. Avoid thinking that there is only one way of doing things
For example, better to reward progress than results
. The role of development partners is important:
- They often initiate the activities
- One can push but not impose; one should not give up too soon
11 |

Key messages:
Performance based payment should not be regarded as a
simple reward system that mechanically produces
changes for the health workers, but as platform for a
process of modifying practices
12 |