August, 2016 - SUPPORT Summary of a systematic review | print this article |

Does pay for performance improve the delivery of health interventions in low and middle income countries?

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.

 

Key messages

 

  • It is uncertain whether pay for performance improves provider performance, the utilisation of services, patient outcomes or resource use in low and middle income countries.
  • Unintended effects of pay for performance schemes might include:

-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)

 

  • There is a lack of evidence about the economic consequences of pay for performance schemes in low and middle income countries.

 

Background

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.




About the systematic review underlying this summary

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.

Summary of findings

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.

 

  • It is uncertain whether paying for performance improves provider performance, the utilisation of services, patient outcomes, or resource use because the certainty of this evidence is very low.

Pay for performance compared with no conditional incentives

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
Outcomes Impact Certainty of the evidence
(GRADE)

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

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

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

GRADE: GRADE Working Group grades of evidence (see above and last page)

P4P: Pay for performance

 

 

 

Relevance of the review for low-income countries

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.

 

  • Pay for performance schemes in low and middle income countries may be affected by factors such as:

-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.

 

  • Because of uncertainty about the differential effects of financial incentives on high versus low performing providers, it is possible that financial incentives could have differential effects on disadvantaged populations served by low performers. Rewarding improvement compared to previous results (baseline) and not only absolute achievement might reduce the risk of undesirable differential effects on high versus low performers.
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.

 

  • Economic evaluations of pay for performance schemes are needed.

 


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.

 

  • Pay for performance schemes need to monitor unintended effects, including the adverse selection of patients and the adverse effects of P4P schemes on processes that are not rewarded with financial incentives. Schemes also need to monitor whether reported improvements are a consequence of changes in the documentation of care or due to actual improvements in practice.
  • Patient/user opinions should be considered during evaluation.

 


*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

 

Additional information

Related literature

Oxman AD, Fretheim A. An overview of research on the effects of results based financing. Report Nr 16-2008. Os-lo: Nasjonalt kunnskapssenter for helsetjenesten, 2008.

 

Eichler R. Can ”Pay for Performance” Increase Utilization by the Poor and Improve the Quality of Health Services? Discussion paper for the first meeting of the Working Group on Performance Based Incentives. Washington DC: Center for Global Development, 2006; 5.

 

Mannion R, Davies HTO. Payment for performance in health care. BMJ 2008;336:306-308.

 

Doran T, Fullwood C, Gravelle H, Reeves D, Konropantelis E, Hiroeh U, Roland M. Pay for Performance Programs in Family Practices in the United Kingdom. N Engl J Med 2006;355:375-84.

 

Scott A, Sivey P, Ait Ouakrim D, Willenberg L, Naccarella L, Furler J, Young D. The effect of financial incentives on the quality of health care provided by primary care physicians. Cochrane Database of Systematic Reviews 2011, Issue 9.

 

Van Herck P, De Smedt D, Annemans L, Remmen R, Rosenthal MB, Sermeus W. Systematic review: Effects, design choices, and context of pay for performance in health care. BMC Health Services Research 2010, 10:247

 

Petersen LA, Woodard LD, Urech T, Daw C, Sookanan S. Does pay for performance improve the quality of health care? Ann Intern Med. 2006 Aug 15;145(4):265-72.

 

Chaix Couturier C, Durand Zaleski I, Jolly D, Durieux P. Effects of financial incentives on medical practice:

results from a systematic review of the literature and methodological issues. International Journal for

Quality in Health Care 2000;12(2):133-42.

 

Rosenthal MB, Frank RG. What is the empirical basis for paying for quality in health care? Medical Care

Research and Review 2006;63(2):135-57

 

This summary was prepared by

Cristian Herrera, Unit for Health Policy and Systems Research, School of Medicine, Pontificia Universidad Católica de Chile, Chile

 

Conflict of interest

None declared. For details, see: www.supportsummaries.org/coi

 

Acknowledgements

This summary has been peer reviewed by: David Yondo, Sophie Witter, Simon Goudie, and Hanna Bergman.

 

This review should be cited as

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.

 

The summary should be cited as

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

 

Keywords

 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

 

 

 

 

 

 

 

 



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