Performance-based Incentives to Improve Health Status of Mothers and Newborns: What Does the Evidence Show?

Publication Details

Eichler, R., Agarwal, K., Askew, I., Iriarte, E., Morgan, L. and Watson, J. (2013) Performance-based incentives to improve health status of mothers and newborns: what does the evidence show? Journal of Health, Population and Nutrition, 31 (4 suppl 2), s36-47. 

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Rena Eichler, Koki Agarwal, Ian Askew, Emma Iriarte, Lindsay Morgan, Julia Watson
East Asia and Pacific (includes South East Asia), South Asia, Middle East and North Africa, Sub-Saharan Africa, Latin America and the Caribbean
Health Nutrition and Population
Health Sector Reform, Health Financing, Insurance and User Fees, Health Services, Hospitals- Secondary & Tertiary, Mortality, Preventive Health and Health Behavior, Primary Health- including reproductive health
Equity Focus
None specified
Review Type
Effectiveness review

Main findings

Headline Findings: a summary statement

The authors found that PBI schemes that reward healthcare providers increase the number of women giving birth in health care facilities, but impact on outcomes for mothers and newborns, or on quality of health services, is inconclusive. 

Evidence Base

The authors included nine studies: three employed pre-post study designs (comparing baseline and endline data), four included comparison or control groups, one applied econometric methods and one reported results from a randomised controlled trial. Looking at the context of the studies, two examined performance-based incentive schemes implemented in public-sector facilities; one in the Democratic Republic of Congo and one in Rwanda. One study examined performance-based incentives implemented as part of a social insurance reform project in Egypt. Three studies (conducted in in Afghanistan, Cambodia and Haiti) examined schemes that incorporated performance-based incentives into payments for non-government organisations and a further three studies included incentives for both health care organisations and patients (implemented in Bangladesh, Nepal and the Philippines). 

Implications for policy and practice

  • Performance-based incentives that reward providers for the number of women giving birth in healthcare facilities result in more women giving birth in health care facilities. 
  •  The impact on quality of health services is mixed; for example, some studies showed that performance-based incentives can improve the quality of antenatal care but a high-quality study showed there was no difference between intervention and control facilities in the number of women receiving at least four antenatal care visits. 
  • The impact of performance-based incentives on health outcomes for mothers and newborns, such as maternal and infant morbidity and mortality, is inconclusive. 

Implications for further research

The authors state that high-quality studies are lacking, making it difficult to assess the impact of performance-based incentive schemes. They call for future research to assess the costs and benefits of performance-based incentive schemes compared with other approaches that aim to improve maternal and child health. They call for more robust and rigorous quantitative studies are needed on effectiveness as well as more qualitative studies to provide data to improve programme implementation. The authors also note that future research should consider the impact of performance-based incentives on the functioning of health systems, including whether incentives improve health information systems, the productivity and effectiveness of health workers, the accountability of health systems to citizens, shortages of essential medicines, and supervision and governance in health systems. 


In sub-Saharan Africa, women have a 1 in 39 lifetime risk of maternal death, whereas for women in developed countries this risk is just 1 in 3,800. There are proven and cost-effective interventions to improve the health of women and newborns, but health systems in developing countries often fail to provide such interventions, particularly for the poorest in societies. This failure is partly due to a lack of necessary equipment, facilities, staff and effective referral systems. However, the incentives that govern the actions of providers can also be key. For example, low salaries that do not vary with performance can result in low productivity, absenteeism, poor quality and lack of innovation. 

Performance-based incentive schemes reward people and organisations for actions that contribute to better health outcomes or for achieving particular performance measures. This review focuses on performance-based incentive (PBI) initiatives that pay providers (whether individuals or organisations) and their supervisors (including government agencies) if they achieve performance measures relating to the health of mothers and newborns. 

Research objectives

The review aims to assess whether performance-based incentive schemes that reward health care providers and their supervisors for meeting targets contribute to the use and quality of maternal and neonatal health services. 


The authors searched ABI inform, the Cochrane library, PubMed, SCOPUS, EconLit, Embase, SocioAbstracts and CABI for peer reviewed studies. The authors included studies of interventions in lower- and middle-income countries published in English from 1990 onwards. Experts were also contacted to provide includable studies. To be included, studies had to be of performance-based incentive schemes in public-sector facilities, social insurance reforms, contracts for non-government organisations and targeted safe delivery schemes. Studies also needed to include a control group or collect pre- and post-implementation data and to measure an outcome related to demand for health services, staff providing maternal/neonatal care, or maternal/neonatal health. Included studies were synthesised narratively.

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