University of Arizona, P.O. Box 210030, Tucson, AZ 85721-00030, USA.
Soc Sci Med. 2012 Nov;75(10):1778-85. doi: 10.1016/j.socscimed.2012.07.025. Epub 2012 Aug 5.
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. While recognizing the potential of P4P, the authors argue for greater care in adapting schemes to particular local contexts. We suggest that insights from social science theory coupled with the focused ethnographic methods of anthropology can contribute to the critical assessment of P4P schemes and to their adaptation to particular social environments and reward systems. We highlight the need for monitoring P4P schemes in relation to worker motivation and the quality of social relations, since these have implications both for health sector performance over the long term and for the success and sustainability of a P4P scheme. Suggestions are made for ethnographies, undertaken in collaboration with local stakeholders, to assess readiness for P4P; package rewards in ways that minimize perverse responses; identify process variables for monitoring and evaluation; and build sustainability into program design through linkage with complementary reforms.
在过去的十年中，使用财务激励计划已成为提高卫生部门绩效的一种流行干预方式。这种方式通常被称为“按绩效付费”或 P4P，它涉及“……以可衡量的行动或实现预定的绩效目标为条件，转移资金或物质商品”（Eldridge & Palmer，2009 年，第 160 页）。P4P 似乎至少在短期内会迅速提高提供者绩效的某些可衡量指标。然而，这些计划对更广泛的卫生系统的影响的证据仍然有限，即使评估结果是积极的，也已经确定了一些意外的影响。这些影响包括：“操纵”系统；“内在动机”被挤出；由于计划被视为不公平而导致士气下降；以及通过竞争、嫉妒或不良情绪破坏社会关系和团队合作。关于这些过程如何发生以及它们在不同的社会和文化背景下如何变化的信息较少。尽管认识到 P4P 的潜力，但作者主张在适应计划时更加谨慎，要考虑到特定的当地情况。我们认为，社会科学理论的见解加上人类学的集中民族志方法可以为 P4P 计划的批判性评估及其在特定社会环境和奖励系统中的适应提供帮助。我们强调需要监测 P4P 计划与工人动机和社会关系质量的关系，因为这既对长期的卫生部门绩效有影响，也对 P4P 计划的成功和可持续性有影响。我们建议进行民族志研究，与当地利益相关者合作，评估 P4P 的准备情况；以最小化不良反应的方式包装奖励；确定监测和评估的过程变量；并通过与互补改革联系起来，将可持续性纳入方案设计中。
