Background: Pay for Performance (P4P) programs are strategic health policy interventions intended to improve health worker performance and service delivery. Introduced in Tanzania in January 2011, the P4P program aimed to enhance reproductive and child health services. This study evaluates the effectiveness of the P4P program in improving maternal and child health services in Mkuranga District, assessing its impact on the quality and accessibility of these services.

Methodology: A cross-sectional explorative evaluation combining qualitative and quantitative approaches was conducted. The study involved 31 health facilities and 123 healthcare workers providing maternal and child health services. Data on performance and motivation across four indicators were collected retrospectively before and after the Pay for Performance (P4P) program. Changes in motivation levels and client service proportions were analyzed for significance. To measure attitudes, a Likert scale was employed. Qualitative data were gathered through in-depth interviews with health workers.

Results: The number of Antenatal Care (ANC) clients receiving IPT2 increased significantly in health centers and dispensaries (p<0.001). Measles vaccination rates showed no significant increase in hospitals (p=0.36), but significant improvements were observed in health centers (p<0.001) and dispensaries. Facility deliveries increased significantly in health centers and dispensaries (p<0.001), with hospitals exceeding target populations. A slight, non-significant drop in PENTA 3 vaccinations was observed (p<0.001).

Conclusions: The P4P program positively impacts health worker motivation and performance. It is recommended to expand the P4P policy to other regions in Tanzania. Further case-control studies should be conducted to validate these findings.

• Pay for performance

• Maternal health

• Child health

• Health worker motivation

• Tanzania

Kalugira P, Sijaona J (2024) Evaluating the Impact of Pay for Performance Programs on Maternal and Child Health Outcomes: A Study from Mkuranga District, Tanzania. JSM Trop Med Res 5(1): 1021.

Human resources for health constitute a critical component of the health system, as emphasized by the World Health Organization (WHO). In low-income countries, including Tanzania, this sector faces severe challenges, notably a significant shortage of health workers in rural areas, where the demand for healthcare is high. The scarcity of healthcare professionals is compounded by low job satisfaction and high levels of demotivation among the existing workforce. This situation undermines efforts to achieve the Millennium Development Goals (MDGs), particularly in regions where the health workforce is inadequate to meet basic healthcare needs. In Africa, there is an urgent need to increase the number of trained health workers by at least one million to provide essential health services and improve health outcomes [1,2].

Motivation plays a pivotal role in enhancing the performance and productivity of health workers. It involves stimulating and sustaining behavior to achieve desired outcomes, such as improved quality of healthcare delivery. Effective motivation requires a combination of both monetary and non-monetary factors, including a supportive working environment, opportunities for continuing education, career advancement, and recognition [3,4]. Research indicates that intrinsic factors, such as personal fulfillment and professional growth, often have a more substantial impact on performance than extrinsic factors, like financial incentives [5]. Understanding these motivational drivers is crucial for developing strategies that improve health worker performance and, consequently, healthcare quality.

In recent years, Pay for Performance (P4P) programs have emerged as a prominent approach to address health system inefficiencies. These programs aim to incentivize health workers by linking compensation to performance metrics, thereby encouraging improvements in service delivery and patient outcomes. Despite the growing adoption of P4P schemes, there remains a lack of rigorous evidence on their effectiveness and optimal design. P4P programs are designed to reward quality of care through financial incentives based on predefined performance indicators. This approach has gained traction for its potential to enhance healthcare quality, although challenges remain in designing and implementing effective P4P schemes [6,7].

The P4P program in Tanzania was introduced in January 2011 with the goal of improving reproductive and child health services. In the Pwani region, including Mkuranga District, the program focuses on four main objectives: improving health service efficiency, increasing health information use for decision- making, motivating healthcare workers, and managing program implementation effectively. The incentive structure includes bonuses for health workers, with a portion allocated to facility improvements and the rest distributed among staff based on performance. Indicators for the program are derived from routine health information system data and include measures such as Antenatal Care (ANC) coverage and vaccination rates [8].

Evaluating the impact of the P4P program in Mkuranga District is essential to understand its effectiveness in achieving its objectives and to identify areas for improvement. This study aims to assess the program’s role in improving maternal and child health services by evaluating performance indicators related to ANC services, vaccination coverage, and facility-based deliveries.

Study site

The study was conducted in health facilities across Mkuranga District, including public, faith based, and private sectors. The district comprises one government hospital, two government health centres, twenty-two government dispensaries, four private dispensaries, and six faith-based dispensaries.

Study population

The study targeted Healthcare Workers (HCWs) from thirty- five health facilities in Mkuranga District that had participated in at least one cycle of the Pay-for-Performance (P4P) program. These facilities included dispensaries, health canters, and the district hospital, totalling 288 HCWs: 235 from public facilities, 31 from Faith-Based Organizations (FBOs), and 22 from private facilities.

Study design

A cross-sectional explorative evaluation design was utilized. Key performance indicators were assessed using data from the District Health Information System (DHIS) for the years 2010 and 2012, collected before and after the P4P program. HCWs’ motivation levels before and after the program were measured through structured questionnaires administered during interviews.

Sampling procedures

All health facilities involved in the P4P program were purposively selected, including one hospital, two health centres, and twenty-five dispensaries. All HCWs present during the study period at these facilities were included, except for those in hospitals and health canters who were specifically involved in reproductive and child health services. Facility in-charges identified relevant HCWs.

For in-depth interviews, key informants were purposively selected from one hospital, two government health centres, two private dispensaries, and all six FBO dispensaries. Simple random sampling was used to select five out of twenty-two government dispensaries. A sampling frame of government dispensaries involved in all four P4P cycles was created, and a rotary method was used for selection. Additionally, purposive sampling was employed to select two CHMT key informants (Reproductive and Child Health Coordinators and District P4P/DHIS focal persons) and health facility in-charges, resulting in a total of 18 key informants.

The inclusion criteria were public, private, and faith-based health facilities in Mkuranga District that participated in the Pay- for-Performance (P4P) program for four cycles, from January 2011 to December 2012. Healthcare Workers (HCWs) from these facilities who participated in at least one cycle of the P4P program were also included. Health facilities that participated in the P4P program but did not measure any of the indicators evaluated in this study were excluded.

Research assistants with prior data collection experience were recruited and trained for two days. The training covered study objectives, questionnaire administration, and interviewing techniques to ensure accurate data collection.

Pre-testing

The pre-testing of the questionnaire was conducted by the principal investigator and research assistants. The pre-test involved fifteen respondents (three from the hospital, four from health canters, and eight from dispensaries in Kibaha District, Pwani Region) to assess the tool’s coherence, consistency, accuracy, and validity.

Data collection instruments

Quantitative data were collected using structured closed- ended questionnaires, initially developed in English and then back-translated into Kiswahili. The Kiswahili version was used for data collection. The questionnaire assessed HCWs’ motivation in four areas: (1) ANC clients receiving IPT2, (2) facility-based deliveries, (3) children under one year receiving measles vaccine, and (4) children under one year receiving PENTA 3 vaccine.

For in-depth interviews, a tape recorder was used to capture responses. An interview guide was employed for interviews with key informants from the CHMT and health facilities.

Data collection procedure

Following permission from the District Medical Officer (DMO), health facilities were visited, and researchers introduced themselves to the facility in-charge. The study procedures were explained, and the facility in-charge identified HCWs involved in maternal and child health services with at least one cycle of P4P experience. Verbal consent was obtained from participants, and face-to-face interviews were conducted in private settings using the structured questionnaires. To ensure comprehensive data collection, health facilities were visited multiple times. Only two HCWs were not interviewed due to being on leave or in school.

In-depth interviews with health facility in-charges and selected CHMT members focused on factors affecting P4P performance and measures taken to address issues. These interviews were recorded using a tape recorder.

Documentary review

Performance indicator data for each P4P cycle were obtained from DHIS/P4P District focal persons using the DHIS 2 tool at the DMO’s office. Indicators included the number of ANC clients receiving IPT2, facility-based deliveries, and children under one year receiving measles and PENTA 3 vaccines. This data was used to calculate the proportion of clients receiving services and assess indicator performance.

HCWs providing reproductive and child health services in hospitals and health centres were interviewed. The questionnaire included closed-ended questions on HCWs’ motivation before and after the P4P program, using a 5-point Likert scale. Topics included IPT2 coverage, measles vaccination, PENTA 3 vaccination, and health facility deliveries.

In-depth interview

In-depth interviews were conducted with reproductive and child health in-charges of selected facilities and CHMT key informants. These interviews were recorded and focused on factors affecting HCW performance at both facility and district levels and the steps taken to address these issues.

Data management

The principal researcher supervised research assistants and reviewed collected data daily to identify and correct inconsistencies. Questionnaires were assigned serial numbers before data entry. Data transportation was conducted using public transport, with photocopies securely stored in a locked cabinet and electronic files on a CD and hard drive with restricted access. Data cleaning was performed before analysis.

Data analysis

HCWs’ performance on indicators (ANC clients receiving IPT2, children receiving measles and PENTA 3 vaccines, and health facility deliveries) was assessed using six questions on motivation with a 5-point Likert scale. Mean scores before and after the P4P program were compared using a t-test for statistical significance. Indicator performance was calculated by finding the proportion of clients receiving services and compared to set targets. Coverage above 85% was considered high for PENTA 3, measles vaccines, and health facility deliveries, while above 80% was high for IPT2. Performance below 50% was deemed low. Statistical significance was tested using percentages at a 95% confidence interval, with data analyzed using SPSS version 15.0.

Challenges affecting HCWs’ performance were   analyzed by transcribing recorded interviews, categorizing responses into main and sub-themes, and analyzing these themes before discussion.

The study proposal was reviewed and approved by the School of Public Health and Social Sciences (SPHSS) and the MUHAS Research and Publication Committee. Permissions to conduct the research were obtained from the Regional Administrative Secretary (RAS) of Pwani Region, the District Executive Director (DED) of Mkuranga, and the DMO of Mkuranga DC. Researchers reported to ward and village government officers before introducing themselves to HCWs for interviews. Informed consent was obtained from participants after explaining the study’s aims, methodology, and potential benefits. Participation was voluntary, and refusal did not incur any penalty.

Socio-demographic characteristics

The majority of the respondents were female (82.9%), with the highest proportion belonging to the age group of 30 to 39 years (43.9%). Most respondents (64%) were from government health facilities, while a smaller fraction (24.4%) was from private facilities. Dispensaries had the highest number of respondents (75.6%), whereas hospitals had the fewest (14.6%). Additionally, the study included a small number of doctors (2.4%), with medical attendants constituting the largest group of respondents (42.3%) (Table1).

Table 1: Socio-demographic characteristics of the study sample by sex.

Notes

• Doctor’s category: Medical Doctor and Assistant Medical Officer.
• Clinician’s category: Clinical Officer and Assistant Clinical Officer.
• Nurses’ category: Nursing Officers, Assistant Nursing Officers, and Enrolled Nurses.
• Medical Attendant: Medical Attendant.

Duration of program implementation

Table 2 highlights that the majority of health workers (79.7%) had been in the program for 24 months, while very few (3.3%) had implemented the program for only 6 months.

Table 2: Duration of implementing P4P in a facility.

Impact on ANC clients receiving IPT2

Table 3 demonstrates a significant increase in the number of ANC clients who received the IPT2 dose across all facility levels after the implementation of the P4P program. The increase was statistically significant (p<0.001) for both health centres and dispensaries.

Table 3: Number of ANC clients receiving IPT2 before and after the P4P program.

*Number of clients attended was greater than the expected target population.

Impact on measles vaccination coverage

Table 4 shows an increase in the number of children receiving the measles vaccine at all facility levels after the P4P program. The increase was statistically significant for health centres and dispensaries (p<0.001), while the increase in hospitals was not significant (p=0.36).

Table 4: Number of children receiving measles vaccine before and after the P4P program.

*Number of clients attended was greater than the expected target population.

Impact on PENTA 3 vaccination coverage

Table 5 indicates a significant increase in the number of children receiving the PENTA 3 vaccine at health centres and dispensaries after the P4P program. The increase was statistically significant for health centres (p<0.001), while the decrease observed in hospitals was not significant (p=0.303).

Table 5: Number of children receiving PENTA 3 vaccine before and after the P4P program.

*Number of clients attended was greater than the expected target population.

Impact on facility deliveries

Table 6 illustrates a significant increase in the number of facility deliveries across all facility levels after the P4P program. The increase was statistically significant for health centers and dispensaries (p<0.001).

Table 6: Number of health facility deliveries before and after the P4P program.

*Number of clients attended was greater than the expected target population.

Impact on family planning services

Table 7 highlights a significant increase in the number of clients receiving family planning services at all facility levels  after the P4P program. The increase was statistically significant for health centers and dispensaries (p<0.001).

Table 7: Number of clients receiving family planning services before and after the P4P program.

*Number of clients attended was greater than the expected target population

Table 8 demonstrates that the majority of health workers had a positive attitude towards the P4P program. A significant portion agreed that the program improved their motivation, with a higher proportion observed among those from dispensaries.

Table 8: Attitude of health workers on the P4P program.

Qualitative findings on factors affecting the performance of health care workers

Lack of skills and sufficient health staff: The study found that the majority of Reproductive and Child Health (RCH) in charges reported a shortage of health staff as a significant factor compromising the delivery of health services. Many government dispensaries had an average of only three health care workers, responsible for providing reproductive and child health services both at the facility and within the community. One RCH in charge stated:

“We are only two health workers and have to do all the work in the facility at the same time. We have to conduct mobile and outreach clinics to the villages; you can imagine how tiresome it is, and sometimes you miss documenting and organizing the records.”

Another health worker shared

“Our facility is attending many clients, even those who are not in our catchment area. Due to these intensive clinics, we are not even sure if what we are doing is what we are supposed to do. You can imagine we are very few and have to vaccinate more than 150 children, and at the same time, patients have to be attended to, and we don’t have a clinician” (R3).

A CHMT member reported

“The quality of data is a problem, and the reason is that many health care workers in the facilities are unskilled. Despite big efforts to equip these health workers with data management skills, their understanding is limited, although they are trying their best” (R17).

Shortage of medicines and medical supplies

Shortages of medicines and medical equipment were reported in some facilities as factors compromising service delivery. Items like Sulfadoxine-Pyrimethamine (SP), delivery supplies (e.g., cotton wool, gloves, forceps), and vaccines were mentioned.

One RCH in charge stated

“For the case of IPT2, sometimes we run short of SP, and when we advise clients to go and buy them, they cannot afford it. Even when they respond positively, it is difficult for me to document in the records since I’m not sure if they administered it, so it becomes difficult to achieve our set target” (R4).

Another RCH in charge mentioned

“Sometimes we run short of vaccines, and they are not available in private medical stores. The only thing we can do is wait for the DMO’s office to deliver so we can continue to provide service” (R6).

“Currently, the number of facility deliveries is improving, but before P4P, we had shortages of equipment for deliveries, and clients had to buy from private medical stores. This discouraged them, and the number of facility deliveries dropped. After P4P, we have been using facility payout to buy equipment and supplies for deliveries, and the situation is much better” (R10).

Lack of reliable transportation was reported as a significant problem for facilities providing mobile clinics to distant villages. Health workers often had to rely on transportation provided by villagers, which led to inefficiencies and safety concerns.

One RCH in charge stated

“We have one village which is very far from here. We rely on bicycles from the village for transportation; it is not safe, and when we get there, we are already tired. Sometimes we use our own money to facilitate transport. At least the DMO’s office should make transportation arrangements for mobile routes” (R7).

A CHMT member also highlighted the issue

“Transportation is still a challenge, and we fail to conduct supportive supervision to health facilities on data management, making the quality of data recorded substandard” (R17).

Unreliable health information

Health workers reported challenges with health information recording and reporting. The standard of these activities varied across facilities, and many relied on untrained staff with limited understanding of the processes involved. Increased workload further exacerbated documentation issues.

One RCH in charge reported

“Sometimes when we have a lot of clients, recording of information is a challenge. We concentrate on providing services until the end of the day and then realize that there are many gaps in the registers that do not correspond with the number of clients attended” (R6).

A CHMT member emphasized

“We need more health staff to enter data in the DHIS tool because there are so many facilities with lots of forms to validate and enter into the system. In the current situation, it’s very tiresome. As a result, sometimes we make mistakes entering data or fail to enter data on time” (R17).

The findings of this study highlight the significant impact of the Pay for Performance (P4P) program on maternal and child health services in Mkuranga District, with noticeable improvements in key health indicators. The data indicate substantial increases in the number of Antenatal Care (ANC) clients receiving IPT2, measles vaccination coverage, PENTA 3 vaccination coverage, facility deliveries, and family planning services across various facility levels. These results align with similar studies in other low- and middle-income countries, such as Rwanda and Kenya, where P4P programs have demonstrated effectiveness in improving health service delivery and health outcomes [9,10]. The positive reception of the P4P program by health workers, as indicated by their attitudes, suggests that financial incentives can enhance motivation and performance, which is consistent with broader literature on the subject [11-13].

However, the study also underscores persistent challenges that could undermine the sustainability of these improvements. The reported shortages of health staff, medicines, and medical supplies, as well as issues with transportation and health information management, are critical barriers to optimal service delivery. These challenges are not unique to Mkuranga District; they are prevalent across many health systems in sub-Saharan Africa, as documented in various studies. For instance, a study in Uganda highlighted those shortages in medical supplies and staff significantly affected the delivery of essential health services, similar to the findings in Mkuranga [14].

The qualitative findings provide a deeper understanding of the operational difficulties faced by health workers, such as the need for better transportation for outreach services and the necessity for improved health information systems. These insights resonate with global health literature that emphasizes the importance of a well-functioning health system infrastructure to support frontline health workers [15]. Moreover, the reliance on undertrained staff for data management and the consequent data quality issues reflect a broader systemic problem that requires urgent attention to ensure accurate monitoring and evaluation of health programs.

While the P4P program has evidently contributed to enhancing maternal and child health outcomes in Mkuranga District, addressing the underlying systemic issues is crucial for maintaining and furthering these gains. Strengthening health workforce capacity, ensuring consistent supply of essential medicines and equipment, and improving transportation and health information systems are necessary steps. This holistic approach will not only sustain the improvements achieved through the P4P program but also ensure long-term resilience and efficiency in health service delivery. Integrating these findings with broader health system strengthening strategies, as recommended by the World Health Organization, could lead to more sustainable health improvements.

Furthermore, comparing these results with other P4P studies highlights the potential scalability and adaptability of such programs. For instance, the success observed in Rwanda’s P4P initiatives, which significantly improved maternal and child health indicators, suggests that with proper customization to local contexts, P4P could be a valuable model for other regions facing similar health challenges [16]. However, it is essential to consider that the success of P4P programs can be highly context- dependent, influenced by factors such as governance, health infrastructure, and community engagement.

The positive attitudes of health workers   towards   the P4P program are particularly noteworthy, as they indicate a willingness to embrace performance-based incentives despite existing challenges. This finding aligns with global evidence suggesting that financial incentives can significantly boost health worker motivation and job satisfaction, ultimately leading to better health outcomes [17,18]. However, for these incentives to be most effective, they must be complemented by supportive measures such as ongoing training, adequate resources, and a conducive working environment.

The P4P program in Mkuranga District has shown promising results in improving maternal and child health services. Nevertheless, to build on these gains, there is a need for comprehensive strategies that address systemic challenges, ensure the sustainability of improvements, and leverage the positive attitudes of health workers towards performance-based initiatives. Future research should focus on exploring the long- term impacts of P4P programs and identifying best practices for integrating these initiatives into broader health system strengthening efforts.

Ethical approval and Consent to participate

Ethical approval was granted by the Muhimbili University of Health and Allied Sciences (MUHAS) Ethical Committee. Additionally, permission to collect data was obtained from the relevant institutions involved in the study.

Consent to participate

Informed consent was secured from all participants prior to their involvement in the study. Each respondent received 

a detailed explanation of the study’s purpose, procedures, potential risks, and benefits. Participants were assured that their participation was entirely voluntary and that they could withdraw from the study at any time without facing any negative consequences.

Participants provided written consent by signing a consent form, which confirmed their understanding and agreement to participate. The consent form guaranteed confidentiality, the right to withdraw, and provided information on how their data would be used and protected. Participants were given the opportunity to ask questions and seek clarification before consenting to the study.

Consent for Publication

Not applicable.

All data generated for this study, figures and tables areincluded in this manuscript.

Conflicts of Interest

The authors declare that they have no conflict of interest

This work was financially supported by USAID through the Directorate of Postgraduate Studies at MUHAS. The funder had no involvement in the study’s design, data collection, analysis, interpretation of data, or manuscript writing.

PK designed the study, developed methodology and participated in data collection. JS participated in data analysis and interpretation. JS and PK drafted the manuscript, critically reviewed the manuscript and approved the final version.

We extend our sincere gratitude to the participants who took part in this study. Their willingness to share their experiences was essential to the success of this research.

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