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Paying for performance and the social relations of health care provision: An anthropological perspective


  • Magrath, Priscilla
  • Nichter, Mark


Over the past decade, the use of financial incentive schemes has become a popular form of intervention to boost performance in the health sector. Often termed “paying for performance” or P4P, they involve “…the transfer of money or material goods conditional upon taking a measurable action or achieving a predetermined performance target” (Eldridge & Palmer, 2009, p.160). P4P appear to bring about rapid improvements in some measured indicators of provider performance, at least over the short term. However, evidence for the impact of these schemes on the wider health system remains limited, and even where evaluations have been positive, unintended effects have been identified. These have included: “gaming” the system; crowding out of “intrinsic motivation”; a drop in morale where schemes are viewed as unfair; and the undermining of social relations and teamwork through competition, envy or ill feeling. Less information is available concerning how these processes occur, and how they vary across social and cultural contexts.

Suggested Citation

  • Magrath, Priscilla & Nichter, Mark, 2012. "Paying for performance and the social relations of health care provision: An anthropological perspective," Social Science & Medicine, Elsevier, vol. 75(10), pages 1778-1785.
  • Handle: RePEc:eee:socmed:v:75:y:2012:i:10:p:1778-1785
    DOI: 10.1016/j.socscimed.2012.07.025

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    References listed on IDEAS

    1. Gilson, Lucy & Palmer, Natasha & Schneider, Helen, 2005. "Trust and health worker performance: exploring a conceptual framework using South African evidence," Social Science & Medicine, Elsevier, vol. 61(7), pages 1418-1429, October.
    2. Harvey, David, 2007. "A Brief History of Neoliberalism," OUP Catalogue, Oxford University Press, number 9780199283279.
    3. Mark Shenkin & Andrea B. Coulson, 2007. "Accountability through activism: learning from Bourdieu," Accounting, Auditing & Accountability Journal, Emerald Group Publishing, vol. 20(2), pages 297-317, April.
    4. Ssengooba, Freddie & McPake, Barbara & Palmer, Natasha, 2012. "Why performance-based contracting failed in Uganda – An “open-box” evaluation of a complex health system intervention," Social Science & Medicine, Elsevier, vol. 75(2), pages 377-383.
    5. Franco, Lynne Miller & Bennett, Sara & Kanfer, Ruth, 2002. "Health sector reform and public sector health worker motivation: a conceptual framework," Social Science & Medicine, Elsevier, vol. 54(8), pages 1255-1266, April.
    6. Nichter, Mark A., 1986. "The primary health center as a social system: PHC, social status, and the issue of team-work in South Asia," Social Science & Medicine, Elsevier, vol. 23(4), pages 347-355, January.
    7. Faguet, Jean-Paul & Ali, Zulfiqar, 2009. "Making Reform Work: Institutions, Dispositions, and the Improving Health of Bangladesh," World Development, Elsevier, vol. 37(1), pages 208-218, January.
    8. Rena Eichler & Paul Auxila & Uder Antoine & Bernateau Desmangles, 2007. "Performance-Based Incentives for Health: Six Years of Results from Supply-Side Programs in Haiti," Working Papers 121, Center for Global Development.
    9. Gilson, Lucy, 2003. "Trust and the development of health care as a social institution," Social Science & Medicine, Elsevier, vol. 56(7), pages 1453-1468, April.
    10. Nichter, Mark, 1983. "Paying for what ails you: Sociocultural issues influencing the ways and means of therapy payment in South India," Social Science & Medicine, Elsevier, vol. 17(14), pages 957-965, January.
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    Cited by:

    1. Tschakert, Petra & Ricciardi, Vincent & Smithwick, Erica & Machado, Mario & Ferring, David & Hausermann, Heidi & Bug, Leah, 2016. "Situated knowledge of pathogenic landscapes in Ghana: Understanding the emergence of Buruli ulcer through qualitative analysis," Social Science & Medicine, Elsevier, vol. 150(C), pages 160-171.
    2. Bonfrer, Igna & Van de Poel, Ellen & Van Doorslaer, Eddy, 2014. "The effects of performance incentives on the utilization and quality of maternal and child care in Burundi," Social Science & Medicine, Elsevier, vol. 123(C), pages 96-104.
    3. Lange, Isabelle L. & Kanhonou, Lydie & Goufodji, Sourou & Ronsmans, Carine & Filippi, Véronique, 2016. "The costs of ‘free’: Experiences of facility-based childbirth after Benin's caesarean section exemption policy," Social Science & Medicine, Elsevier, vol. 168(C), pages 53-62.


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