Performance-based financing as a quality governance reform in primary health care: workforce perspectives

Abstract

This study aims to examine how primary health care (PHC) professionals experience the early implementation of age-differentiated capitation and performance-based payment mechanisms in Georgia. It aims to explore how financing reform influences workload, accountability, perceptions of fairness, and professional identity, and to assess its implications for quality governance. A qualitative study was conducted using semi-structured interviews with PHC professionals across urban and rural settings in Georgia. Data were collected during the first year of reform implementation and analyzed using reflexive thematic analysis. The study was guided by an integrative conceptual framework combining quality governance, organizational justice, and frontline implementation theory. The reform functioned as a multi-level governance intervention that reshaped clinical practice and organizational dynamics. Five key themes emerged: work intensification driven by performance indicators; increased accountability without corresponding participation in decision-making; perceived misalignment between standardized indicators and local realities; transformation of professional identity toward preventive and population-based care; and emotional strain associated with uncertainty and evaluation pressure. Perceived fairness and transparency emerged as critical mediators of workforce engagement. This study contributes to the literature by conceptualizing performance-based financing as a quality governance mechanism rather than a purely economic incentive. It highlights the central role of workforce perceptions, particularly fairness and participation, in shaping reform outcomes. By providing empirical evidence from a middle-income country, the study extends existing research beyond high-income settings and offers policy-relevant insights into the conditions required for sustainable quality improvement in PHC.