SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
August, 2016 - SUPPORT Summary of a systematic review | print this article | download PDF
Pay for performance refers to the transfer of money or material goods on the condition that measurable actions are taken or predetermined performance targets are achieved in the delivery of healthcare services. Linking payments to performance is a strategy to align incentives for health workers and health providers with public health goals. This approach is currently used by a number of organisations in different countries, including low and middle income countries.
-Adverse selection (for example, excluding high risk people from care in order to obtain better performance)
-Gaming (i.e. inaccurate or false reporting)
-Distortion (i.e. ignoring important tasks that are not rewarded with incentives)
Witter S, Fretheim A, Kessy FL, Lindahl AK. Paying for performance to improve the delivery of health interventions in low and middle income countries. Cochrane Database of Systematic Reviews 2012, Issue 2. Art. No.: CD007899.
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
Pay for performance schemes vary in different ways. For example, payments can be targeted at different levels of the health system, including individual providers of healthcare, healthcare facilities, private sector organisations, public sector organisations and national or sub national levels of government. Pay for performance interventions can also reward a wide range of measurable actions, including achievement of health outcomes, the delivery of effective interventions (such as immunisation), the utilisation of services (such as prenatal visits or births at an accredited facility), and quality of care. Such schemes can also include ancillary components which focus, for example, on increasing the availability of resources to healthcare, on education, supplies, technical support or training, monitoring and feedback, increasing salaries, construction of new facilities, and improvements in planning and management systems or in information systems.
| Review objectives: To assess the current evidence for the effects of pay for performance schemes on the provision of healthcare and health outcomes in low and middle income countries | ||
| Type of | What the review authors searched for | What the review authors found |
|---|---|---|
| Study designs & interventions | Randomised trials, non randomised trials, controlled before after studies, and interrupted time series studies evaluating paying for performance in the form of conditional cash payments, the conditional provision of material goods, or target payments. |
9 studies were found: 1 randomised trial, 6 controlled before after studies, and 2 interrupted time series studies. The interventions were target payments linked to quality of care or coverage indicators; conditional cash transfers, with and without quality measurements; and a mix of targeted payments and conditional cash transfers. |
| Participants | Providers of healthcare services, subnational organisations, national governments, and combinations of these, in the public or private sector |
4 studies were conducted at public facilities and facilities run by faith-based organisations; 2 focused on primary care facilities alone; 2 focused on hospitals; and 1 on individual private practitioners. |
| Settings | Any setting in which explicit financial incentives have been used to improve the provision of healthcare in low and middle income countries |
Included studies were conducted in Rwanda (2 studies), Vietnam, China, Zambia, Tanzania, the Democratic Republic of the Congo, the Philippines, and Burundi. 8 studies were conducted in rural or rural and urban areas. |
| Outcomes | Measures of provider performance (e.g. the delivery or utilisation of healthcare services, or patient outcomes), unintended effects, and changes in resource use |
Patient health indicators, utilisation or coverage changes, and changes in resource use |
| Date of most recent search: June 2011 | ||
| Limitations: This is a well conducted systematic review with only minor limitations. | ||
Witter S, Fretheim A, Kessy FL, Lindahl AK. Paying for performance to improve the delivery of health interventions in low and middle income countries. Cochrane Database of Systematic Reviews 2012, Issue 2. Art. No.: CD007899.
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
The review included 9 studies that were conducted in Rwanda (2 studies), Vietnam, China, Zambia, Tanzania, the Democratic Republic of Congo, the Philippines and Burundi. Rural areas were included in eight of the studies. The payment of incentives to facilities was the most common arrangement, but in three studies the incentives were given directly to health workers.
All nine included studies compared a pay for performance scheme to non conditional payments.
Pay for performance compared with no conditional incentives |
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| People: Providers of healthcare services in low and middle income countries Settings: Vietnam, China, Uganda, Rwanda, Tanzania, the Democratic Republic of Congo, Burundi, the Philippines Intervention: Pay for performance (P4P) Comparison: No pay for performance |
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| Outcomes | Impact | Certainty of the evidence (GRADE) |
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Provider performance (quality of care) |
The impact of P4P on service delivery is uncertain. Four studies measured the coverage of tetanus vaccinations among pregnant women, and reported mixed findings. Results from one study showed little or no impact on tuberculosis case detection. |
Very low |
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Utilisation of services: antenatal care |
The impact of P4P on attendance rates for antenatal care is uncertain. The study reported both negative and positive impacts on attendance. |
Very low |
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|
Utilisation of services: institutional deliveries |
Whether P4P schemes lead to an increase in institutional deliveries is uncertain. The range of the reported effect estimates was wide, including substantially larger increases in areas without P4P schemes, to an almost two fold increase in areas with P4P schemes. | Very low | |
|
Utilisation of services: preventive care for children , including vaccination |
It is uncertain whether the use of P4P leads to an increase in the utilisation of preventive care services for children. One study reported that attendance rates for children’s preventive services doubled. However, the impact on immunisation rates varied across the four studies and negative and positive impacts were reported. | Very low | |
|
Utilisation of services: number of outpatients |
The use of P4P schemes might increase the utilisation of services. However, this association has not been rigorously evaluated, and the studies did not yield consistent results. | Very low | |
| Patient outcomes | The study results were inconsistent across different measures that included general self reported health, Creactive protein in blood (a possible measure of acute infection) and anaemia rates. | Very low | |
| Unintended effects | It is uncertain whether P4P results in unintended effects. | Very low | |
| Resource use | P4P schemes tend to increase facility revenues and to increase staff pay. However, their impact on wider resource use indicators, such as other funding sources, patient payments, and efficiency of service provision are uncertain. | Very low | |
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GRADE: GRADE Working Group grades of evidence (see above and last page) P4P: Pay for performance |
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| Findings | Interpretation* |
|---|---|
| APPLICABILITY | |
| Due to the very low certainty of the evidence, we are uncertain about the effects of pay for performance schemes in low and middle income countries. |
Evidence from high income countries is also limited (see related literature), and we are uncertain about the relative effectiveness of different types of pay for performance schemes in different settings.
-The availability and reliability of routine data on quality of care -The availability of resources to finance the incentives beyond restructuring existing payment systems -Existing remuneration systems for individual healthcare providers and groups of providers (e.g capitation or fee for service) -The feasibility of measures, such as monitoring, to prevent gaming and distortion
|
| EQUITY | |
| No reliable evidence regarding equity was reported. |
The choice of quality indicators and financial incentives might result in differential effects on disadvantaged populations.
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| ECONOMIC CONSIDERATIONS | |
| The use of pay for performance schemes may lead to increases in facility revenues and payments for workers, but the other economic consequences of such schemes and their cost effectiveness are uncertain. |
There is uncertainty about the magnitude, frequency and duration of the financial incentives needed to ensure quality improvements. Similarly, the resource requirements for scaling up pay for performance schemes at different levels are unclear and estimates are needed for specific schemes in specific settings.
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| MONITORING & EVALUATION | |
| The evidence summarised is inconclusive. |
There is substantial uncertainty about the beneficial and adverse effects of paying for performance. These schemes should therefore be carefully designed and rigorously evaluated before they are implemented in low and middle income countries.
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*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the re view and consultation with researchers and policymakers in low income countries. For additional details about how these judgements were made see:www.supportsummaries.org/methods |
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Cristian Herrera, Unit for Health Policy and Systems Research, School of Medicine, Pontificia Universidad Católica de Chile, Chile
None declared. For details, see: www.supportsummaries.org/coi
This summary has been peer reviewed by: David Yondo, Sophie Witter, Simon Goudie, and Hanna Bergman.
Witter S, Fretheim A, Kessy FL, Lindahl AK. Paying for performance to improve the delivery of health interventions in low and middle income countries. Cochrane Database of Systematic Reviews 2012, Issue 2. Art. No.: CD007899.
Herrera C. Does pay for performance improve the delivery of health interventions in low and middle income countries? A SUPPORT Summary of a systematic review. August 2016. www.supportsummaries.org
evidence informed health policy, evidence based, systematic review, health systems research, health care, low and middle income countries, developing countries, primary healthcare, pay for performance
