Pay-for-performance in healthcare provision: the role of discretion in policy implementation in Turkey

Abstract

PurposeNew Public Management-informed pay-for-performance policies are common in public sectors internationally but can be controversial with delivery agents. More attention is needed on contingent forms of bottom-up implementation of challenging policies, in emerging market economies, for professionals who face tensions between policies and their codes of practice. Street-level bureaucrats (SLBs) mediate policy implementation through discretionary practices; health professionals have enhanced space for discretion based on autonomy derived from professional status. The authors explore policy implementation, adaptation and resistance by physicians, focusing on payments for health workers in Turkey.Design/methodology/approachThe researchers conducted semi-structured qualitative interviews with 12 physicians in Turkish hospitals and thematic analysis of interview transcripts, using a blended (deductive and inductive) approach.FindingsThe policy fostered discretionary behaviours such as cherry-picking (high volume, low risk procedures) and pro-social rule-breaking (e.g. “upcoding”), highlighting clinical autonomy to navigate within policy restrictions. Respondents described damage to relationships with patients and colleagues, and dissonance between professional practice and perverse policy incentives, sometimes leading to disengagement from clinical work. Policymakers were perceived to be detached from the realities experienced by SLBs. Tensions between the policy and professional values risked alienating physicians.Research limitations/implicationsThis study utilises participant self-reported perceptions of discretionary behaviours. Further work may adopt alternative methods to explore the relationship between self-reporting and observed practice.Originality/valueThe authors contribute to research on differentiated, contingent roles of groups with high scope for discretion in bottom-up implementation, pointing to the potential for policy-professional role conflicts between top-down P4P policies, and the values and codes of practice of professional SLBs.

Shared professional logics amongst managers and bureaucrats in Brazilian social security: a street-level mixed-methods study

“…However, Hosmer and Lemeshow goodness-of-fit tests show reasonable results (p > 0.05) Table 8. Logistic regressions for aiming to expand coverage (EPC), odds ratios Shared professional logics of deepening pay-for-performance-related issues (Aktas et al, 2023), automaticity could, in many ways, render local overseeing obsolete. Although our qualitative findings hint this could be the case (see Group 1 quotes in Table 10), more in-depth research is needed.…”

“…However, these decisions are also affected by managerial values, penetrating street-level welfare work through shifts in organisations’ structures, procedures and performance criteria introduced by new public management (NPM) reforms (Aoki, 2019; Evetts, 2009; Møller and Hill, 2021). At the core, NPM-backed implementations strive to circumvent professional discretion on behalf of standardisation and efficiency (Hupe and van der Krogt, 2013; Aktas et al ., 2023). However, these implementations are often carried out by professionals too, the “managing professionals” (Pekkola et al ., 2018), who, on service frontlines, are known as street-level managers (SLMs; Gassner and Gofen, 2018).…”

Guest editorial: Payment for performance: comparing policy making, design and implementation in health, social care and education

“…This special issue gathers three types of comparative studies: cross-country comparisons (Zitti et al , 2023; Andersen, 2023), intra country comparisons (Aktas et al , 2023; Srinivasan and Sarin, 2023; Coelho et al , 2023; Dos Anjos et al , 2023) and world-wide meta-analysis from existing literature (Kristensen et al , 2023; Briganti et al, 2023 ). Authors carry out policy process analyses, employing qualitative, mixed methods and review techniques, combined with comparative analytical descriptive accounts.…”

“…Another block of four papers develops in depth single country studies, breaking the analysis into smaller analytical units in different locations, examining sub-national or sub-regional aspects or administrative variations within a country. They develop cases analysis of original or new data focusing on Turkey (Aktas et al , 2023), India (Srinivasan and Sarin, 2023) and Brazil (Coelho et al , 2023; Dos Anjos et al , 2023).…”

“…The paper by Aktas et al (2023) explores how physicians use adaptation and forms of resistance during the implementation of P4P in hospitals in Turkey. The findings highlight that doctors had considerable autonomy to deal with policy restrictions, thus the implementation displayed challenging characteristics such as cherry-picking (high volume, low risk procedures) and pro-social rule breaking.…”