INTRODUCTION:
Pay-for-performance (P4P) has evolved as a prominent health financing mechanism in Sub-Saharan Africa (SSA), rooted in the rationale of improving service provision by motivating health professionals through financial incentives.1 It specifically seeks to address inequities in access to quality health services.2 Despite the proliferation of these programs, there has been no comprehensive systematic review of qualitative research focusing on the perceptions and lived experiences of the health professionals tasked with implementing them.3,4 This paper addresses that gap through a thematic synthesis of studies reporting on provider experiences with P4P across SSA.

METHODS:
We systematically searched four electronic databases; Medline, Embase, PubMed, and the African Index Medicus for qualitative studies reporting health providers' perceptions of P4P in SSA.5 A detailed search strategy was developed using the key term "pay for performance." Study quality was assessed using the Joanna Briggs Institute’s Critical Appraisal Checklist for Qualitative Research, and the extracted data were analyzed through a multi-stage thematic synthesis approach to identify overarching descriptive and analytical themes.6-8

RESULTS:
Eighteen studies were included in the final analysis. Six descriptive themes emerged: autonomy, financing, perceived motivation, teamwork, governance, and staffing. The analysis revealed that P4P-related autonomy empowered health professionals to prioritize local bottlenecks and achieve performance targets effectively.9-11 Furthermore, a strong level of teamwork was observed, as the collective desire to reach targets encouraged mutual support.12,13 However, systemic barriers such as delayed bonus payments, uneven distribution of incentives, rigid facility eligibility criteria, and the "cherry-picking" of medical procedures were perceived to have negatively impacted program morale and overall effectiveness.14-18

CONCLUSIONS:
Findings suggest that while P4P offers benefits like increased autonomy and collaboration, inherent structural attributes can deter efficient service provision. Understanding the health worker perspective is vital. Incorporating the lived experiences of implementers will better inform policymakers on refined approaches for future implementation.