A realist review to assess for whom, under what conditions and how pay for performance programmes work in low- and middle-income countries

Pay for performance (P4P) programmes are popular health system-focused interventions aiming to improve outcomes in low-and middle-income countries (LMICs). This realist review aims understand how, why and under what circumstance P4P works LMICs.We systematically searched peer-reviewed grey literature databases, examined the mechanisms underpinning effects on: utilisation of services, patient satisfaction, provider productivity broader system, contextual factors moderating these. evidence was then used construct a causal loop diagram.We included 112 records (19 literature; 93 articles) assessing schemes 36 countries. Although we found mixed P4P's on identified outcomes, common pathways improved include: community outreach; adherence clinical guidelines, patient-provider interactions, trust, facility improvements, access drugs equipment, autonomy, lower user fees. Contextual shaping system response degree efficiency banking, role charges financing public services; staffing levels; staff training motivation, quality infrastructure social norms. Programme design features supporting or impeding included: scope incentivised indicators, fairness reach incentives, timely payments supportive, robust verification that does not overburden staff. Facility bonuses key element P4P, but rely autonomy maximum effect. If inputs vastly underperforming pre-P4P, they unlikely only due P4P. is first describing how initiatives work (or fail) different LMIC contexts by exploring underlying programme moderators. Future studies should examine other strengthening initiatives, offer more understanding shapes effects.