Implementing a successful and sustainable pay-for-performance system at a large family planning NGO in Jordan

The interest in and use of pay-for-performance (P4P) systems is increasing in healthcare delivery in developing countries. While there are some successful cases of implementation of P4P, questions of financial and programmatic sustainability remain. After the end of financial and programmatic assistance, few organizations in developing countries possess the monitoring expertise or the funding to continue P4P programs. Employee suspicion of program manipulation and favoritism also decrease effectiveness. In this study, program personnel helped a large family planning (FP) NGO in Jordan to implement a self-sustaining performance bonus system that was transparent and accepted by all employees. The program supplied cash bonuses for employees at FP clinics which met pre-set targets for: 1) number of visits, 2) clinical guideline compliance, and 3) client satisfaction. System design and targets were set through a stakeholder process involving all employees of the NGO. Bonus amounts were set by the NGO board of directors and CFO. At baseline, one clinic met the targets. By the fourth quarter of implementation, 12 clinics reached the targets. If current success rates continue, bonus amounts will be offset by increased revenue in year two of implementation, making the system financially self-sustaining. Key performance indicators were selected from those already a part of the automated health management information system: no extra data collection is necessary for clinics and management to know whether clinics have met the targets. Several lessons learned concerning success factors will be of use to others wanting to implement P4P systems in developing country healthcare settings.