Research for stronger health systems during and after crisis

Building programme theory for Pay for Performance in Low and Middle-Income Countries


This panel focuses on the application and use of a realist approach to understanding how pay for performance (P4P) affects health systems to bring about outcome improvements, and whether this is context specific.  The aim is to develop the field around this methodology and its use to understand mechanisms for complex interventions.

Date: October 11th 2018


About the session

The successful design of health system interventions requires an understanding of how health systems respond to change, and the mechanisms through which such interventions work, together with an understanding of how the context in which they are implemented shapes these transformations.  

A realist approach assumes that complex interventions do not operate in a silo, instead they operate within social systems, and it is ‘the mechanism’ - the response and behaviour of agents interacting within the social system - that determines outcomes within a given context. The realist approach seeks to build theories of how interventions work in different contexts.

This session applies the realist approach to pay for performance (P4P), a popular strategy aimed at strengthening health systems, through financial incentives to health care providers and/or their managers based on service delivery performance.  

The session follows the realist tradition, starting with a proposed programme theory developed and tested through a realist synthesis of international literature.  The theory will then be reviewed against empirical realist studies in three country settings - Zimbabwe, Mozambique and Georgia - through which country-level programme theories have been developed.  The session will conclude with a cross-study comparison and collective debate about definitive programme theory and what contextual factors are key in shaping this. 



Chair: Gwati Gwati, Ministry of Health & Child Care, Zimbabwe


  • Artwell Kadungure - TARSC (Training and Research Support Centre), Zimbabwe

  • Amilcar Magaco - National Institute of Health, Mozambique

  • Sophie Witter - Institute for Global Health and Development, Queen Margaret University, UK

  • Neha Singh - London School of Hygiene and Tropical Medicine, UK


Discussant: Garrett W Brown, University of Leeds, UK




Chair will introduce the session and its objectives.

Presentations and panel

Presentation 1 - Neha Singh

Understanding for whom, why and in what circumstances payment for performance works in low and middle-income countries - this presentation provides an overview of the findings from a realist synthesis based on international literature, reporting on the programme theory of mechanisms emerging from the review, together with evidence of how context shapes this.  

Presentation 2 - Artwell Kadungure

This presentation will share current findings from a case study in Zimbabwe outlining the initial programme theory for P4P established through a document review and how the programme actually unfolded based on interviews, together with how various contextual factors moderated programme effects.

Presentation 3 - Amilcar Magaco

This presentation will outline the original expectations associated with a P4P programme in Mozambique based on document reviews and will examine the key mechanisms through which the programme worked and how context affected this. 

Presentation 4 - Sophie Witter

This session will present a case study from Georgia, where the research team was involved in developing a diagnosis of systemic problems relating to TB services, developing a P4P intervention to address them, and together with policy-makers, outlining a theory of change for how the intervention might work. The team will be using realist methods for evaluating the intervention, combined with a pragmatic trial and cost-effectiveness analysis. The presentation will provide reflections on engagement in the development process and also the importance of context, which in Georgia includes a largely privatised service provision system.


Garrett W Brown will lead a facilitated discussion to compare and contrast the three case studies and the findings emerging from the global literature review with the aim of finding common elements of how, when and in what circumstances P4P works or doesn’t work as a health system reform mechanism. In order to broaden our understanding of how P4P can be shaped by contextual factors, audience members will be asked to contribute to the findings of these cases by adding findings from their own research on P4P, and/or by providing additional insights from realist evaluations pertaining to other health system research. Finally, general insights on the usefulness of a realist approach for P4P programme analysis will be discussed with a particular focus on how to improve the approach both in theory and methodology.


Who is the session aimed at?

This session is aimed at those who are using realist approaches to study health system strengthening programmes and those researching or implementing pay for performance schemes.