BACKGROUND:
The analysis of "professional motivations", mainly through the possible crowding-out effects between extrinsic and intrinsic motivations, has become an issue of great concern in the economic literature. This paper aims at applying this topic to the healthcare professions where the proper scaling up of pay-for-performance (P4P) policies by public authorities is at stake.

METHODS:
We used a panel of 528 self-employed general practitioners in the "Provence-Alpes-Cote d'Azur" region in France to provide an interpersonal statistical decomposition between extrinsic and intrinsic motivations with regard to preventive actions. Then, we applied a Tobit model in order to specify the main explicative variables of the share of intrinsic motivations entering into physicians' total motivations.

RESULTS:
The relative share of intrinsic motivations was quite high among physicians paid with fixed fees. We found a significant effect of age on intrinsic motivations describing a U-shaped curve which can be interpreted as being the result of a "life cycle of medical motivations" or a generational effect.

CONCLUSION:
The cross-sectional nature of the data does not allow us to draw any conclusions concerning the predominance of the generational effect or the "life cycle effect" on the evolution of the relative share of physician's intrinsic motivations. Nevertheless, the U-shaped relation between intrinsic motivations and age questions the suitability of using uniformly P4P mechanisms. The generations or age groups of self-employed physicians who seem to be less responsive to extrinsic motivations are more likely to favour the introduction of other types of payment schemes (capitation or salary systems) or regulation tools such as clinical practice guidelines.

Since 2000, the fight against aids, tuberculosis and malaria has contributed to significant shifts in the main paradigms of the health economics literature applied to developing countries: improvements in public health of the population are now considered a prerequisite, rather than a consequence, of economic growth; for health care financing, priority is given to promoting prepayment and health insurance mechanisms rather than "cost recovery" policies and user fees at the point of consumption; differential pricing for access to essential medicines and flexibility in international norms for intellectual property rights are increasingly recommended; disease-targeted "vertical" programs are viewed as a way to improve efficiency and strengthen health care systems as a whole. The article discusses the theoretical and empirical limitations of these new paradigms. Classification JEL : G22, I1, I18, O11, O34

The book is based on original data and field studies from Brazil, Thailand, India and Sub-Saharan Africa. Focusing on the issue of universal and free access to treatment (a goal now taken to heart by the international community), it assesses the progress made and presents a rigorous diagnosis of the obstacles that remain, especially the constraints imposed by TRIPS and the poor state of most public health systems in Southern countries. In so doing, the book renews our understanding of the political economy of HIV/AIDS in these vast regions, where it continues to spread with devastating social and economic consequences.