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Should performance-based incentives be used to motivate health care providers? Views of health sector managers in Cambodia, China and Pakistan

Published online by Cambridge University Press:  31 January 2019

Mishal Khan*
Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
Imara Roychowdhury
Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
Ankita Meghani
Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
Farah Hashmani
People’s Primary Healthcare Initiative (PPHI) Sindh, Karachi, Pakistan
Josephine Borghi
Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
Marco Liverani
Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK Faculty of Public Health, Mahidol University, Bangkok, Thailand
*Correspondence to: Mishal Khan, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, LondonWC1H 9SH, UK. Email:


This study qualitatively investigates what factors apart from or in addition to financial incentives can encourage better performance of frontline health care providers. We interviewed health sector managers in Pakistan, Cambodia and China, and they highlighted many potential limitations in the applicability of financial incentives in their contexts. There was a consistent view that providers are not always primarily driven by monetary rewards and that non-monetary rewards – such as recognition from direct supervisors and career development – could have a greater influence on performance. Managers also highlighted several challenges related to the design and implementation of performance management schemes: supervisors may not have performance information necessary to determine which agents to reward; when performance information is available, organisational culture may value other attributes such as social ties or years of experience; finally, concentration of power at higher levels of the health system can reduce supervisors’ ability to manage performance, rewards and accountability. Although health sector managers were enthusiastic about measures to improve performance of providers, our study indicated that specific social, cultural and health system factors may mean that non-monetary rewards and structural changes to support a more transparent and meritocratic working environment should also be considered.

© Cambridge University Press 2019

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These two authors contributed equally to the work.


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