{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,2]],"date-time":"2026-10-02T14:39:45Z","timestamp":1790951985956,"version":"4.1.0"},"reference-count":26,"publisher":"Oxford University Press (OUP)","issue":"4","license":[{"start":{"date-parts":[[2022,1,28]],"date-time":"2022-01-28T00:00:00Z","timestamp":1643328000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100000265","name":"Medical Research Council","doi-asserted-by":"publisher","award":["MRCZ\/A\/2225"],"award-info":[{"award-number":["MRCZ\/A\/2225"]}],"id":[{"id":"10.13039\/501100000265","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2022,4,13]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:p>Although pay-for-performance (P4P) schemes have been implemented across low- and middle-income countries (LMICs), little is known about their distributional consequences. A key concern is that financial bonuses are primarily captured by providers who are already better able to perform (for example, those in wealthier areas), P4P could exacerbate existing inequalities within the health system. We examine inequalities in the distribution of pay-outs in Zimbabwe\u2019s national P4P scheme (2014\u20132016) using quantitative data on bonus payments and facility characteristics and findings from a thematic policy review and 28 semi-structured interviews with stakeholders at all system levels. We found that in Zimbabwe, facilities with better baseline access to guidelines, more staff, higher consultation volumes and wealthier and less remote target populations earned significantly higher P4P bonuses throughout the programme. For instance, facilities that were 1 SD above the mean in terms of access to guidelines, earned 90\u2009USD more per quarter than those that were 1 SD below the mean. Differences in bonus pay-outs for facilities that were 1 SD above and below the mean in terms of the number of staff and consultation volumes are even more pronounced at 348\u2009USD and 445\u2009USD per quarter. Similarly, facilities with villages in the poorest wealth quintile in their vicinity earned less than all others\u2014and 752\u2009USD less per quarter than those serving villages in the richest quintile. Qualitative data confirm these findings. Respondents identified facility baseline structural quality, leadership, catchment population size and remoteness as affecting performance in the scheme. Unequal distribution of P4P pay-outs was identified as having negative consequences on staff retention, absenteeism and motivation. Based on our findings and previous work, we provide some guidance to policymakers on how to design more equitable P4P schemes.<\/jats:p>","DOI":"10.1093\/heapol\/czab154","type":"journal-article","created":{"date-parts":[[2022,1,28]],"date-time":"2022-01-28T15:15:07Z","timestamp":1643382907000},"page":"429-439","source":"Crossref","is-referenced-by-count":5,"title":["Who is paid in pay-for-performance? Inequalities in the distribution of financial bonuses amongst health centres in Zimbabwe"],"prefix":"10.1093","volume":"37","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4631-3227","authenticated-orcid":false,"given":"Roxanne","family":"Kovacs","sequence":"first","affiliation":[{"name":"Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Garrett W","family":"Brown","sequence":"additional","affiliation":[{"name":"School of Politics and International Studies (POLIS), University of Leeds, Woodhouse Leeds LS2 9JT, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Artwell","family":"Kadungure","sequence":"additional","affiliation":[{"name":"Training and Research Support Centre (TARSC), Harare, Zimbabwe"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"S\u00f8ren R","family":"Kristensen","sequence":"additional","affiliation":[{"name":"Danish Centre for Health Economics University of Southern Denmark, 5000 Odense C Denmark & Imperial College London, Faculty of Medicine, Institute of Global Health Innovation, London SW7 2AZ, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gwati","family":"Gwati","sequence":"additional","affiliation":[{"name":"Ministry of Health and Child Care, Harare, Zimbabwe"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Laura","family":"Anselmi","sequence":"additional","affiliation":[{"name":"Division of Population Health, Health Services Research & Primary Care, The University of Manchester, Manchester, M13 9NT, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nicholas","family":"Midzi","sequence":"additional","affiliation":[{"name":"National Institute of Health Research, Ministry of Health and Child Care, Harare, Zimbabwe"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Josephine","family":"Borghi","sequence":"additional","affiliation":[{"name":"Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2022,1,29]]},"reference":[{"key":"2022041308281918200_R1","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1186\/s12913-017-2148-9","article-title":"Exploring implementation practices in results-based financing: the case of the verification in Benin","volume":"17","author":"Antony","year":"2017","journal-title":"BMC Health Services Research"},{"key":"2022041308281918200_R2","doi-asserted-by":"crossref","first-page":"1421","DOI":"10.1016\/S0140-6736(11)60177-3","article-title":"Effect on maternal and child health services in Rwanda of payment to primary health-care providers for performance: an impact evaluation","volume":"377","author":"Basinga","year":"2011","journal-title":"The Lancet"},{"key":"2022041308281918200_R3","doi-asserted-by":"crossref","DOI":"10.1136\/bmjgh-2020-002326","article-title":"Understanding efficiency and the effect of pay-for-performance across health facilities in Tanzania","volume":"5","author":"Binyaruka","year":"2020","journal-title":"BMJ Global Health"},{"key":"2022041308281918200_R4","doi-asserted-by":"crossref","first-page":"92","DOI":"10.1111\/tmi.12809","article-title":"Improving quality of care through payment for performance: examining effects on the availability and stock-out of essential medical commodities in Tanzania","volume":"22","author":"Binyaruka","year":"2017","journal-title":"Tropical Medicine and International Health"},{"key":"2022041308281918200_R5","doi-asserted-by":"crossref","first-page":"1026","DOI":"10.1093\/heapol\/czy084","article-title":"Does payment for performance increase performance inequalities across health providers? 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