Explore the vast range of titles available.

Background Despite limited evidence of its effectiveness, performance-based payments (P4P) are seen by leading policymakers as a potential solution to the slow progress in reaching Millennium Development Goal 5: improved maternal health. This paper offers insights into two of the aspects that are lacking in the current literature on P4P, namely what strategies health workers employ to reach set targets, and how the intervention plays out when implemented by local government as part of a national programme that does not receive donor funding. Methods A total of 28 in-depth interviews (IDIs) with 25 individuals were conducted in Mvomero district over a period of 15 months in 2010 and 2011, both before and after P4P payments. Seven facilities, including six dispensaries and one health centre, were covered. Informants included 17 nurses, three clinical officers, two medical attendants, one lab technician and two district health administrators. Results Health workers reported a number of strategies to increase the number of deliveries at their facility, including health education and cooperation with traditional health providers. The staff at all facilities also reported that they had told the women that they would be sanctioned if they gave birth at home, such as being fined or denied clinical cards and/or vaccinations for their babies. There is a great uncertainty in relation to the potential health impacts of the behavioural changes that have come with P4P, as the reported strategies may increase the numbers, but not necessarily the quality. Contrary to the design of the P4P programme, payments were not based on performance. We argue that this was due in part to a lack of resources within the District Administration, and in part as a result of egalitarian fairness principles. Conclusions Our results suggest that particular attention should be paid to adverse effects when using external rewards for improved health outcomes, and secondly, that P4P may take on a different form when implemented by local implementers without the assistance of professional P4P specialists.

The impact of payment-for-performance (P4P) schemes in the health sector has been documented, but there has been little attention to the distributional effects of P4P across health facilities. We examined the distribution of P4P payouts over time and assessed whether increased service coverage due to P4P differed across facilities in Tanzania. We used two service outcomes that improved due to P4P [facility-based deliveries and provision of antimalarials during antenatal care (ANC)], to also assess whether incentive design matters for performance inequalities. We used data from 150 facilities from intervention and comparison areas in January 2012 and 13 months later. Our primary data were gathered through facility survey and household survey, while data on performance payouts were obtained from the programme administrator. Descriptive inequality measures were used to examine the distribution of payouts across facility subgroups. Difference-in-differences regression analyses were used to identify P4P differential effects on the two service coverage outcomes across facility subgroups. We found that performance payouts were initially higher among higher-level facilities (hospitals and health centres) compared with dispensaries, among facilities with more medical commodities and among facilities serving wealthier populations, but these inequalities declined over time. P4P had greater effects on coverage of institutional deliveries among facilities with low baseline performance, serving middle wealth populations and located in rural areas. P4P effects on antimalarials provision during ANC was similar across facilities. Performance inequalities were influenced by the design of incentives and a range of facility characteristics; however, the nature of the service being targeted is also likely to have affected provider response. Further research is needed to examine in more detail the effects of incentive design on outcomes and researchers should be encouraged to report on design aspects in their evaluations of P4P and systematically monitor and report subgroup effects across providers. On dispose de beaucoup d’informations sur l’impact des systèmes de rémunération au rendement (P4P) dans le secteur de la santé, mais on s’est peu intéressé aux effets distributifs du P4P dans l’ensemble des établissements de santé. Nous avons examiné la répartition des paiements P4P au fil du temps et évalué si en Tanzanie, l’augmentation de la couverture des services consécutive au P4P variait d’une formation sanitaire à l’autre. Nous avons utilisé deux résultats de services qui se sont améliorés grâce au P4P [accouchements en milieu hospitalier et fourniture d’antipaludéens pendant les soins prénatals (SPN)], pour évaluer également dans quelle mesure le développement des mesures incitatives influe sur les inégalités de performance. Nous avons utilisé les données collectées dans 150 formations sanitaires des zones d’intervention et des zones témoins en janvier 2012, et puis 13 mois plus tard. Nos principales données ont été recueillies dans le cadre d’une enquête sur les formations sanitaires et d’une enquête auprès des ménages, tandis que les données sur les rémunérations au rendement ont été obtenues auprès du gestionnaire du programme. Des mesures descriptives des inégalités ont été utilisées pour examiner la répartition des paiements entre les sous-groupes des formations sanitaires. On a eu recours aux analyses de régression des écarts dans les différences pour identifier les effets différentiels du P4P sur les deux résultats de la couverture des services dans les sous-groupes des formations sanitaires. Nous avons constaté qu’initialement, les paiements au rendement étaient plus élevés dans les établissements de niveau supérieur (hôpitaux et centres de santé) que dans les dispensaires, mais également dans les établissements disposant de produits médicaux en quantité ainsi que les formations sanitaires desservant des populations nanties; mais ces inégalités ont diminué au fil du temps. L’incidence du P4P a été bien plus importante sur la couverture des accouchements médicalisés dans les établissements ayant un faible rendement de base, desservant les populations moyennement riches et situés dans les zones rurales. L’incidence du P4P sur la fourniture d’antipaludiques pendant les SPN a été la même d’une formation sanitaire à l’autre. Les inégalités de rendement ont été influencées par la mise en place de mesures incitatives et une gamme de caractéristiques des formations sanitaires; toutefois, la nature du service ciblé est également susceptible d’avoir influé sur la réaction des prestataires. Des recherches approfondies sont nécessaires pour examiner plus en détail l’incidence de mesures incitatives sur les résultats, et il faudrait encourager les chercheurs à rendre compte des aspects de la conception dans leurs évaluations du P4P, et de manière systématique, à contrôler et à rendre compte de l’incidence des sousgroupes sur les prestataires. 按绩效付费 （P4P） 对卫生部门的影响曾有文献报告, 但很少 关注P4P在卫生机构间的分配效应。我们分析了P4P分红在坦 桑尼亚不同机构间的分配, 评估P4P带来的服务覆盖率提高在 不同医疗机构之间是否有差异。我们还采用P4P改善的两项服 务结局（机构内分娩和产前提供抗疟药物）来评估激励机制 是否影响绩效差异。我们使用2012年1月和13个月后干预地区 和对照地区150家机构的数据。通过机构调查和家庭调查收集 一手数据, 通过项目行政人员获得P4P分红的数据。采用描述 性不平等测量值来评估不同机构亚组间分红分配的情况。采 用双重差分回归分析来估计P4P对不同机构亚组两种服务结局 的效果差异。我们发现, 绩效分红起初在高级别机构（医院和 卫生中心）中高于药房, 同时倾向于医疗品较多的机构和服务 较富裕人口的机构, 但这种不平等随时间逐渐降低。在基线水 平低、服务中等收入人口和位于农村地区的机构中, P4P对机 构内分娩覆盖率的效果最强。P4P对产前提供抗疟药物的效果 在不同机构间无明显差异。绩效不平等受到激励机制和一系 列机构特征的影响；但是, 服务本身的性质也可能影响卫生服 务提供者的绩效。需进一步详细研究激励措施对结局的效果, 应鼓励研究者报告P4P评估中的设计细节, 系统监督和报告不 同卫生机构亚组的效果。 ¿El pago por desempeño aumenta la inequidad en el desempeño entre proveedores de la salud? Un estudio de caso de Tanzania El impacto de los esquemas de pago-por-desempeño (PPD) en el sector de salud ha sido documentado, pero se les ha prestado poca atención a los efectos distributivos del PPD a través de los servicios de salud. Examinamos la distribución de los pagos de PPD durante el tiempo y evaluamos si el incremento en la cobertura de servicio a causa del PPD fue diferente entre los servicios de salud en Tanzania. Utilizamos dos resultados de servicio que mejoraron a causa del PPD [partos basados en las instalaciones de salud y la provisión de medicamentos contra la malaria durante las visitas de cuidado prenatal (CPN)], para también evaluar si el diseño de los incentivos tiene efecto en las inequidades en el desempeño. Usamos datos de 150 instalaciones de áreas de intervención y comparación en enero de 2012 y 13 meses después. Nuestros datos primarios se recogieron a través de una encuesta en las instalaciones y una encuesta de hogar, mientras que los datos sobre el pago por desempeño se obtuvieron del administrador del programa. Medidas escriptivas de inequidades se utilizaron para examinar la distribución de pagos a través de sub-grupos de instalaciones. Se utilizó un análisis de regresión de diferencias-endiferencias para identificar efectos diferenciales del PPD en las dos medidas de resultados de cobertura de servicio a través de los sub-grupos de instalaciones. Encontramos que los pagos por desempeño fueron inicialmente más altos en los servicios de nivel más alto (hospitales y centros de salud) comparado con instalaciones dispensadoras, en las instalaciones con más productos médicas y en las instalaciones que cubren poblaciones más pudientes, pero estas inequidades disminuyeron con el tiempo. El PPD tuvo mayor efecto en la cobertura de partos en las instalaciones en instalaciones con más bajo desempeño en el punto de partida, en aquellas que cubrían poblaciones de ingresos medios, y que estaban localizadas en áreas rurales. Los efectos de PPD en la provisión de medicamentos contra la malaria durante las visitas de CPN fueron similares entre las instalaciones. Las inequidades en el desempeño fueron influenciadas por el diseño de incentivos y un rango de características de las instalaciones; sin embargo, es probable que la aturaleza misma de los servicios en los que nos enfocamos también haya afectado la respuesta del proveedor. Se necesita más investigación para examinar en mayor detalle los efectos del diseño de incentivos en los resultados y los investigadores deben ser incentivados a reportar sobre aspectos de diseño de sus evaluaciones de PPD y monitorear y reportar de manera sistemática los efectos de sub-grupos en los diferentes proveedores.

Background Prompted by the need to achieve progress in health outcomes, payment for performance (P4P) schemes are becoming popular policy options in the health systems in many low income countries. This paper describes the policy process behind the introduction of a payment for performance scheme in the health sector of Tanzania illuminating in particular the interests of and roles played by the Government of Norway, the Government of Tanzania and the other development partners. Methods The study employed a qualitative research design using in-depth interviews (IDIs), observations and document reviews. Thirteen IDIs with key-informants representing the views of ten donor agencies and government departments influential in the process of introducing the P4P scheme in Tanzania were conducted in Dar es Salaam, Tanzania and Oslo, Norway. Data was collected on the main trends and thematic priorities in development aid policy, countries and actors perceived to be proponents and opponents to the P4P scheme, and P4P agenda setting in Tanzania. Results The initial introduction of P4P in the health sector of Tanzania was controversial. The actors involved including the bilateral donors in the Health Basket Fund, the World Bank, the Tanzanian Government and high level politicians outside the Health Basket Fund fought for their values and interests and formed alliances that shifted in the course of the process. The process was characterized by high political pressure, conflicts, changing alliances, and, as it evolved, consensus building. Conclusion The P4P policy process was highly political with external actors playing a significant role in influencing the agenda in Tanzania, leaving less space for the Government of Tanzania to provide leadership in the process. Norway in particular, took a leading role in setting the agenda. The process of introducing P4P became long and frustrating causing mistrust among partners in the Health Basket Fund.

Introduction: The central premise underlying international payments for Reducing Emissions from Deforestation and forest Degradation (REDD+) is that offering governments ex post payments for verified success in reducing emissions will motivate them to protect and restore forests. However, the extent to which performance-based payments motivate governments to protect and restore forests has yet to be evaluated quantitatively. Researchers have only quantitatively evaluated performance-based payments to non-governments for forest outcomes (e.g. payments for ecosystem services) and to governments for non-forest outcomes (e.g. results-based aid). Methods: We describe how researchers now have an opportunity to more easily evaluate performance-based payments to governments for forest outcomes thanks to India's new ecological fiscal transfers (EFTs), which provide $6-12 billion per year to Indian states in proportion to their forest cover. Discussion: India's EFTs differ from REDD+ programs in that they pay for states' stock of forest area in the recent past rather than reductions in the rate of forest carbon loss in the near-future. Nevertheless, India's EFTs focus on a single outcome and have many recipient governments, significant financial scale, lack of contemporaneous confounding policy changes, universal participation, and long-term data collection. Conclusion: These features make India's EFTs especially useful for testing the payment-for-performance premise of REDD+.

Many countries are turning their attention to the use of explicit financial incentives to drive desired improvements in healthcare performance. However, we have only a weak evidence-base to inform policy in this area. The research challenge is to generate robust evidence on what financial incentives work, under what circumstances, for whom and with what intended and unintended consequences.

本文主要採用文獻分析法，彙整與教師獎金有關的國會審議紀錄及諸法規範，從行政法學的觀點，探討教育部「公立學校教師獎金支給辦法草案」之適法性。教師獎金名目不一，部分攸關績效；部分則與績效無直接關係。《教師法》、《教師待遇條例》所稱的獎金允屬於前者，至於資深優良教師獎金、年終工作獎金等，則歸類於後者。各類獎金立意不同，或慰勉；或績效，效益自是不同，不可混淆。此外，個人或團隊獎金設計，目的不同，不可一概而論。專任校長與專任教師，身分有別，獎金支給規範允應明確。再者，《教師法》、《教師待遇條例》既立意於績效，奈又僅用「獎金」二字，教育部所擬訂法規命令之草案，連帶祇能照用獎金二字，此舉讓該法令於「明確性原則」之檢驗，徒惹爭議。最後，在衡平行政管理與法治要求、尋求教師獎金規範整體和協的前提下，本文建議適度修正教育部「公立學校教師獎金支給辦法草案」之部分規定。