Iranian primary care staff see promise and pitfalls in pay for performance

A qualitative study of primary health care personnel in Iran found that performance-based payment was perceived as both promising and problematic, with its effectiveness depending on system design, local conditions and organizational capacity. Researchers examined how managers, rural insurance physicians, midwifery experts and community health workers understood a pay-for-performance, or P4P, system within the Pakdasht healthcare network. The study included 25 participants recruited through purposive sampling, with recruitment continuing until data saturation was reached.

Interviews lasted approximately one hour and were guided by a common interview protocol. All were audio-recorded, transcribed verbatim and analyzed iteratively to identify codes, subthemes and broader themes. Researchers applied Braun and Clarke’s thematic-analysis framework and used ATLAS.ti version 7 to manage relationships among themes and codes.

This qualitative design was designed to illuminate the perceived justice and legitimacy of performance payment, the validity of performance measurement and data integrity, and the dynamics of oversight and monitoring; it did not quantify changes in motivation, job performance, service quality or patient outcomes. Analysis identified three overarching dimensions of performance-for-payment systems. The first addressed perceived justice and legitimacy through four main themes: the status quo as a catalyst for reform, conditional legitimacy and the promise of objectivity, advocacy for a hybrid model, and economic adequacy with the risk of systemic burnout.

Participants did not reject the idea of performance-related payment outright. Their accounts suggest that willingness to accept it depended on whether the system appeared objective, economically adequate and responsive to existing working conditions. Some favored combining fixed salaries with performance incentives, while concerns remained that a target-linked model could intensify pressure and contribute to burnout.

In this respect, dissatisfaction with existing arrangements could create support for reform, but it did not guarantee that a new incentive model would be regarded as fair. The second dimension concerned the validity of financial incentives as representations of actual work and the integrity of the data used to calculate payments. It included themes of conditional motivation, limited validity in representing work accuracy, gaming and unintended consequences of target-driven payment, and quality-sensitive verification as a prerequisite for credibility.

Participants questioned whether monetary incentives and performance indicators could adequately capture the complexity and accuracy of the work performed. They also raised the possibility that meeting targets might produce gaming or other unintended consequences. The findings therefore distinguish the act of attaching money to performance from the validity of the measures used for that purpose.

A narrow indicator may not represent the full range or quality of services delivered, while evaluation systems that recognize quality and context can affect whether incentives are trusted. Because these themes arose from interviews, the study did not establish the frequency or magnitude of gaming, nor demonstrate that either conditional motivation or weakened motivation changed behavior in measurable ways. The third dimension examined oversight and monitoring through themes of visibility and accountability, relational opacity, structural constraints, financial salience, and quality assurance and the defense of fairness.

Participants regarded oversight as a possible conduit for making work visible and holding staff accountable, but this function depended on the transparency and perceived fairness of the process. The analysis indicated that monitoring has a dual role in a P4P system: it is needed to verify performance and protect fairness, yet the way decisions are made, communicated and reviewed also affects whether employees accept the payment arrangement as legitimate. Structural limitations and the salience of money added further complexity, making governance inseparable from the design of incentives.

In the interviews, oversight was not merely a technical mechanism for checking results; it was part of the institutional relationship through which performance payment could be accepted or resisted. Overall, participants viewed performance-based payment as a conditional strategy rather than a universally effective or inherently flawed model. The reported promise of P4P was therefore closely tied to whether payment was adequate, whether measures reflected the realities of primary health care work, and whether oversight was capable of defending fairness and quality.

At the same time, the study offers no causal evidence that these features improve productivity, clinical behavior or health outcomes. Its evidence comes from 25 purposively selected participants in one healthcare network, so the findings cannot automatically be generalized to other Iranian regions, health professions or payment systems.

Subject of Research: How Iranian primary health care personnel perceive performance-based payment

Article Title: Perspectives on a pay-for-performance model and its implications for motivation and job performance: insights from primary health care staff in Iran

Article References: Shakerian, S., & Ghasemi, M. (2026). Perspectives on a pay-for-performance model and its implications for motivation and job performance: insights from primary health care staff in Iran. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15548-1

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15548-1

Keywords: pay for performance, primary health care, community health workers, health workforce motivation, performance measurement, payment reform, organizational fairness, qualitative study, Iran, health services research, Perspectives, pay-for-performance