Skip to main content

Table 5 An example of important uncertainties about potentially important harms

From: SUPPORT Tools for evidence-informed health Policymaking (STP) 17: Dealing with insufficient research evidence

Although there is little doubt that financial incentives, if they are large enough, can change behaviours, they can also cause unintended behaviours. The costs of both the incentives and their administration can also be substantial [25]. Unintended effects of paying for performance (the provision of payment for the attainment of well-defined results) that have been observed include:

• Unintended behaviours: Conditional cash transfers (CCT) have caused some mothers to keep their children malnourished in order to retain eligibility. An increase in fertility of between 2% and 4%, noted in another study, may have been due to the fact that only pregnant women were eligible for a CCT subsidy

• Distortions: Financial incentives may cause recipients to ignore other important tasks

• Gaming: Financial incentives can result in gaming (changes in reporting rather than desired changes in practice)

• Corruption: Financial incentives may be stolen or misused, if not adequately managed

• Cherry-picking: Performance incentives for providers can influence whether healthcare is accessible to patients by altering how willing healthcare workers or organisations are to care for sicker patients, more disadvantaged populations, or more difficult patients

• Widening the resource gap between rich and poor: Performance incentives for providers may widen the resource gap that exists between organisations that serve disadvantaged patients and those that do not

• Dependency on financial incentives: Relying on incentives may foster dependency on them. If provider behaviours are not ingrained, they may decline or disappear when the incentives end or new incentives are introduced

• Demoralisation: Financial incentives may cause feelings of injustice and demoralisation in instances where, for example, professionals on short-term contracts receive more financial incentives than those who have established long-term practices, or where favouritism is perceived

• Bureaucratisation: Results-based financing schemes may have substantial administrative costs associated with monitoring performance and managing disbursement of the financial incentives