Performance-Based Incentives

Performance Incentives for Global HealthA June 2009 CGD book, Performance Incentives for Global Health: Potential and Pitfalls, is the result of the analysis and deliberations of the Working Group on Performance-based Incentives, which was established to take stock of a growing set of international experiences with the use of “pay for performance” approaches.

The book and accompanying video have been widely shared with staff at leading institutions working in global health, including the GAVI Alliance, the Global Fund to Fight AIDS, TB and Malaria, the World Bank and several bilateral donors. In addition, the book has formed the basis for discussions within the International Health Partnership+’s InterAgency Working Group on Results-Based Financing.

Over the past decade or so, many countries -- often with the financial and technical support of donors -- have introduced performance-based incentives in the health sector. These are transfers of money or other material rewards that are provided contingent on improved performance or a particular type of behavior change. Some incentives have been designed to directly affect provider behavior, promoting delivery of more and better quality services; others have focused on stimulating changes in household or patient behavior, aiming to increase the use of health services and/or continuation of long-duration treatments for TB or other ailments. While only a few of the performance-based incentive programs have been subject to rigorous evaluation, significant experience has been accrued about how these approaches are working and how their introduction can reinforce (or compete with) other ways to strengthen health systems.

Working Group Objective

The central objective of the Working Group on Performance-Based Incentives was to learn from the application of performance incentives so that future global health programs can be more effective.


In February 2006, the Center for Global Development convened the Working Group on Performance-Based Incentives to review experiences with “paying for performance” in the health sector. The group used available evidence to take a look at how the innovations are working, how they are affecting (or could affect) the broader health system, and if and how they can be used to change key health-related behaviors. The resulting book, Performance Incentives for Global Health: Potential and Pitfalls, draws lessons for donor agencies and policymakers in developing countries seeking to broaden the menu of ways to improve health systems. The book synthesizes available evidence about how performance incentives affect utilization, quality and efficiency; provides guidance for the design, implementation and evaluation of performance incentive arrangements; and sets out recommendations for the donor community and for policymakers and program managers in developing countries. Case studies included in the book are:

  • Latin America: Cash Transfers to Support Better Household Decisions
  • United States : Orienting Pay-for-Performance to Patients
  • Afghanistan: Paying NGOs for Performance in a Postconflict Setting
  • Haiti: Going to Scale with a Performance Incentive Model
  • Rwanda: Performance-Based Financing in the Public Sector
  • Nicaragua: Combining Demand- and Supply-Side Incentives
  • Worldwide: Incentives for Tuberculosis Diagnosis and Treatment

Working Group Composition

Led by CGD vice president for programs and operations and senior fellow Ruth Levine, the Working Group consisted of individuals with expertise in institutional and household economics, health finance and management, quality of care and program implementation.

Related Content

  • Carola Alvarez, Inter-American Development Bank
  • Paul Auxila, Management Sciences for Health
  • Leslie Castro, Ministry of the Family, Nicaragua
  • Karen Cavanaugh, US Agency for International Development
  • David Cutler, Harvard University
  • Rena Eichler, Broad Branch Associates [technical advisor to the Working Group]
  • Maha Adel El-Adawy, United Nations Development Program
  • Luis Fernando Sampaio, Ministry of Health, Brazil
  • Tom Foels, Independent Health
  • Mark Gersovitz, Johns Hopkins University
  • Paul Gertler, University of California, Berkeley
  • Amanda Glassman, Inter-American Development Bank
  • Markus Goldstein, World Bank
  • Davidson Gwatkin, Results for Development
  • Akramul Islam, BRAC Health Program
  • Dan Kress, Bill & Melinda Gates Foundation
  • Ken Leonard, University of Maryland, College Park
  • Ruth Levine, Center for Global Development [chair of the Working Group]
  • Phil Musgrove, Health Affairs
  • Natasha Palmer, London School of Hygiene and Tropical Medicine
  • John Peabody, University of California-San Francisco Institute for Global Health
  • Miriam Schneidman, World Bank
  • Robert Soeters, SINA Health Consult
  • Sally Theobald, International Health Research Group, Liverpool School of Tropical Medicine
  • Kevin Volpp, Philadelphia Veterans Affairs Medical Center and University of Pennsylvania
  • Axel Weber, Asian Development Bank
  • Diana Weil, World Health Organization

Members of the Working Group were invited to join in a personal capacity and on a voluntary basis. Institutional affiliations for identification purposes only.

Working Papers on Case Studies

Four working papers were prepared as inputs to the Working Group's deliberations:

Background Paper

Access the background paper prepared by Rena Eichler, Can "Pay for Performance" Increase Utilization by the Poor and Improve the Quality of Health Services? (pdf), which defines and describes performance-based incentive schemes, identifies problems they might help to solve, discusses the conceptual framework behind them, places them within a broader health systems context and briefly summarizes some case examples.