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

Community health workers (CHWs) play a well-documented role in advancing health indicators across Iran. Evidence indicates that financial incentives significantly influence their performance and motivation. Pay-for-performance (P4P) has emerged as a powerful strategy to enhance staff motivation and performance. However, little is known about how CHWs themselves perceive this model. This study therefore explored frontline health workers’ perspectives on the P4P system. This qualitative study employed thematic analysis based on Braun and Clarke’s framework. Twenty-five participants, including managers, rural insurance physicians, midwifery experts, and community health workers (CHWs) from the Pakdasht healthcare network, were selected through purposive sampling and recruitment continued until data saturation. Data were collected via semi-structured interviews lasting approximately one hour, guided by an interview protocol. All interviews were audio-recorded, transcribed verbatim, and analyzed iteratively to identify codes, subthemes, and themes. Relationships between themes and codes were managed using ATLAS.ti version 7. The analysis identified three overarching dimensions of performance-for- payment systems, each comprising main interpretive themes, sub-themes, and descriptive codes derived from participant accounts. The first dimension, perceived justice and legitimacy of performance-for- payment, encompassed four main themes and eight sub-themes: the status quo as a catalyst for reform; conditional legitimacy and the promise of objectivity; advocating for a hybrid model; and economic adequacy and the risk of systemic burnout. The second dimension, performance measurement validity and data integrity, comprised four main themes and 12 sub-themes: conditional motivation; the limited validity of financial incentives in representing actual work accuracy; gaming, and the unintended consequences of target-driven payment; and quality-sensitive verification and contextual fairness as prerequisites for the system’s credibility. Finally, the third dimension, dynamics of oversight and monitoring, included four main themes and eight sub-themes: oversight as a conduit for visibility and accountability; relational opacity and the contingency of legitimacy; structural constraints and financial salience; and quality assurance and the defense of fairness. Collectively, these findings illuminate the multifaceted determinants of payment-system effectiveness, integrating stakeholder experiences and perspectives on legitimacy, measurement, and governance. Participants perceived performance-based payment systems as simultaneously promising and problematic. Its effectiveness is conditional upon design, context, and capacity. For policymakers and managers, this implies that payment reforms should integrate fixed salaries with performance incentives, ensure timely and multi-criteria compensation, establish transparent evaluation processes, and strengthen monitoring systems.