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

New 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.

The 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.

The 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.

This 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.

The 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.