[Pay for performance in public directly managed healthcare centers. Part 1: General framework. SESPAS Report 2024]

Assessing and compensating performance in professional organizations is extremely difficult in direct public management settings of health services. Performance assessment is technically complex and, more so, with multiplicity of principals influencing goal setting. Incentives are a lever to generate directionality and motivation, both structural (for attracting and retaining workers) and specific ones (rewarding performance and directing behavior towards institutional goals). Incentives influence the behavior of workers in various ways, and their effectiveness seams weak and controversial in publicly run health services. To overcome the problems of deciding and evaluating performance, both good governance models and the revitalization of contractual management are required. To improve the effectiveness of incentive models, it is convenient to: 1) widen the conceptual framework of incentives, to incorporate the structural aspects of employment contract and payment; 2) improve the designs from a greater understanding of the determinants of motivation; and 3) broaden the lens to survey the extra-mural factors that alter the behavior of workers, trying to counter them.