P4P pilots in Tanzania showed signs of enhancing accountability in the health system. Internal accountability improved as P4P led to timelier and more constructive supervision that focused on problem-solving. It also reduced stockouts and interruptions in service delivery. External accountability increased as health workers were found to be more respectful and responsive to patients. Community involvement in facility governance was also strengthened under P4P. While resource limitations hindered some outreach activities, P4P increased the number of outreach visits when measured at the district level. In conclusion, P4P demonstrated potential to improve various accountability mechanisms in the health system.

1. Signs of P4P enhanced functioning
of accountability mechanisms in
the health system: experience
from Pwani Pay for Performance
(P4P) pilot
Iddy Mayumana

2. Introduction
RBF seen as a policy option to improve
providers’ motivation, accountability
and performance
Little is known about its effects on
accountability
This study examines the effects of the P4P
pilot on accountability mechanisms

3. Methods
Process monitoring (2011-2015)
• In-depth interviews (86)
• Group interviews (12)
• Focus group discussions (18)
• Review of relevant documents
• Observations during performance
feedback meetings conducted

4. Methods
Impact evaluation (2012 and after 2013)
• 150 health facilities
• Household survey of 3000 women
delivered in last 12 months prior to the
interview was conducted

5. Conceptual framework: Cleary et al
(2013)
Internal accountability:
aims at regulating answerability on the
supply side
by focusing on accountability within and/or
between different levels of the health
system, such as management and supervision,
as well as budgeting and prioritisation
External accountability :
aims at regulating answerability between
providers and service users

6. Internal accountability:
Management and Supervision
P4P had a positive and significant effect on:
• Timeliness of supervision
• The provision of positive and negative feedback during
supervision.
Close supervision improved health data reporting for
P4P targeted services
Supervision visits aimed at problem solving (drugs, HR
issues) – improved relations
No significant effect on the number of administrative
or managerial meetings held during the last 90 days
Improved relations between district and national level
stakeholders (less bureucratic) – some staff at
district level did not cooperate

7. Internal accountability: budgeting
and prioritisation
Score cards and payment to facility accounts
enhanced trust
P4P entailed a significant reduction of the
interruption of service delivery due to broken
equipment and in the stock out rate of
drugs and medical supplies
Funds allocation at the facility level was mainly
influenced by a goal to achieve P4P targets

8. External accountability: to users
Health workers more responsive and respectful to
their clients
Increase in provider kindness reported by patients
during delivery, a positive 0.38 point increase in
the mean kindness score (95% CI: -0.06 to 0.80).
No significant effect of P4P on the proportion of
health facilities with a governing committee
A positive and significant increase on the probability
of having hold a meeting in the last 90 days
HFGC involvement was enhanced during P4P fund
management (approve the budget)
Bonus spent on allowances for committee members

9. External accountability: to users
Health workers reported wanting to increase
outreach activities but were hindered by lack
of resources
No effect on number of outreach activities in
the communities in the last 90 days
(transport?)
When clustering at district level we find a
significant increase of 0.52 (SE: 0.0274) in the
number of outreach visits

10. Conclusions
P4P has shown to have the potential to
contribute to:
• Improving supportive supervision;
• Data reporting and verification;
• Financial management at the facility level;
• Build trust, relationship and teamwork for
addressing systemic challenges
• Strengthening community oversight
mechanisms in public facilities and
improve providers’ respect and kindness to
their clients

11. Acknowledgement
Co-researchers and contributers
Peter Binyaruka
Laura Hanselim
Irene Mashasi
Ikunda Njau
Josephine Borghi
Masuma Mamdani
Siri Lange
Funders
Norwegian Research Council (GLOBVAC)
RESYST