Paying for performance to improve the delivery of health interventions in low- and middle-income countries

Abstract BACKGROUND: There is a growing interest in paying for performance as a means to align the incentives of health workers and health providers with public health goals. However, there is currently a lack of rigorous evidence on the effectiveness of these strategies in improving health care and health, particularly in low- and middle-income countries. Moreover, paying for performance is a complex intervention with uncertain benefits and potential harms. A review of evidence on effectiveness is therefore timely, especially as this is an area of growing interest for funders and governments. OBJECTIVES: To assess the current evidence for the effects of paying for performance on the provision of health care and health outcomes in low- and middle-income countries. SEARCH METHODS: We searched more than 15 databases in 2009, including the Cochrane Effective Practice and Organisation of Care Group Specialised Register (searched 3 March 2009), CENTRAL (2009, Issue 1) (searched 3 March 2009), MEDLINE, Ovid (1948 to present) (searched 24 June 2011), EMBASE, Ovid (1980 to 2009 Week 09) (searched 2 March 2009), EconLit, Ovid (1969 to February 2009) (searched 5 March 2009), as well as the Social Sciences Citation Index, ISI Web of Science (1975 to present) (searched 8 September 2010). We also searched the websites and online resources of numerous international agencies, organisations and universities to find relevant grey literature and contacted experts in the field. We carried out an updated search on the Results-Based Financing website in April 2011, and re-ran the MEDLINE search in June 2011. SELECTION CRITERIA: Pay for performance refers to the transfer of money or material goods conditional on taking a measurable action or achieving a predetermined performance target. To be included, a study had to report at least one of the following outcomes: changes in targeted measures of provider performance, such as the delivery or utilisation of healthcare services, or patient outcomes, unintended effects and/or changes in resource use. Studies also needed to use one of the following study designs: randomised trial, non-randomised trial, controlled before-after study or interrupted time series study, and had to have been conducted in low- or middle-income countries (as defined by the World Bank). DATA COLLECTION AND ANALYSIS: We aimed to present a meta-analysis of results. However, due to the limited number of studies in each category, the diversity of intervention designs and study methods, as well as important contextual differences, we present a narrative synthesis with separate results from each study. MAIN RESULTS: Nine studies were included in the review: one randomised trial, six controlled before-after studies and two interrupted time series studies (or studies which could be re-analysed as such). The interventions were varied: one used target payments linked to quality of care (in the Philippines). Two used target payments linked to coverage indicators (in Tanzania and Zambia). Three used conditional cash transfers, modified by quality measurements (in Rwanda, Burundi and the Democratic Republic of Congo). Two used conditional cash transfers without quality measures (in Rwanda and Vietnam). One used a mix of conditional cash transfers and target payments (China). Targeted services also varied. Most of the interventions used a wide range of targets covering inpatient, outpatient and preventive care, including a strong emphasis on services for women and children. However, one focused specifically on tuberculosis (the main outcome measure was cases detected); one on hospital revenues; and one on improved treatment of common illnesses in under-sixes. Participants were in most cases in a mix of public and faith-based facilities (dispensaries, health posts, health centres and hospitals), though districts were also involved and in one case payments were made direct to individual private practitioners.One study was considered to have low risk of bias and one a moderate risk of bias. The other seven studies had a high risk of bias. Only one study included any patient health indicators. Of the four outcome measures, two showed significant improvement for the intervention group (wasting and self reported health by parents of the under-fives), while two showed no significant difference (being C-reactive protein (CRP)-negative and not anaemic). The two more robust studies both found mixed results - gains for some indicators but no improvement for others. Almost all dimensions of potential impact remain under-studied, including intended and unintended impact on health outcomes, equity, organisational change, user payments and satisfaction, resource use and staff satisfaction. AUTHORS' CONCLUSIONS: The current evidence base is too weak to draw general conclusions; more robust and also comprehensive studies are needed. Performance-based funding is not a uniform intervention, but rather a range of approaches. Its effects depend on the interaction of several variables, including the design of the intervention (e.g. who receives payments, the magnitude of the incentives, the targets and how they are measured), the amount of additional funding, other ancillary components such as technical support, and contextual factors, including the organisational context in which it is implemented.sch_iihReferences to studies included in this review Basinga 2010 {published data only} Basinga P, Gertler P, Binagwaho A, Soucat A, Sturdy J, Vermeersch C. Paying primary health centres for performance in Rwanda. World Bank, Washington, DC, Policy research working paper 5190. Canavan 2008 {unpublished data only} Canavan A, Swai G. Payment for Performance (P4P) Evaluation: Tanzania Country Report for Cordaid Godfrey Swai, National Consultant Width 1. KIT, Amsterdam. Liu 2003 {published data only} Liu X, Mills A. The influence of bonus payments to doctors on hospital revenue: results of a quasi-experimental study. Applied Health Economics & Health Policy 2003;2:91-8. Peabody 2010 {unpublished data only} Peabody J, Shimkhada R, Quimbo S, Solon O, Javier X, McCulloch C. Linkage between measurement and incentive payments and health outcomes: experimental data from a policy experiment in the Philippines. Submitted for publication to JAMA. Peabody JW, Florentino J, Shimkhada R, Solon O, Quimbo S. Quality variation and its impact on costs and satisfaction: evidence from the QIDS study. Medical Care 2010;48: 25-30. Quy 2003 {published data only} Quy H, Lan N, Lonnroth K, Buu T, Dieu T, Hai T. Publicprivate mix for improved TB control in Ho Chi Minh City, Vietnam: an assessment of its impact on case detection. International Journal for Tuberculosis and Lung Disease 2003; 7:464-71. Soeters 2005 {unpublished data only} Soeters R, Musango L, Meessen B. Comparison of two output based schemes in Butare and Cyangugu provinces with two control provinces in Rwanda. GBPOA, World Bank, Ministry of Health Rwanda 2005. Soeters 2008 {unpublished data only} Soeters R, Kimakuka C. Rsultats de l'enqute mnage, l'enqute qualit, et l'enqute infirmiers titulaires. Pour le Programme Achat de Performance dans les Zones de Sant du District Sanitaire Nord du Sud Kivu February 2008. Soeters 2009 {unpublished data only} Soeters R, Kiwanuka C. [Rapport de l'Etude d'Evaluation du programme Achat de Performance dans les Provinces Bubanza et Cankuzo, bas sur les rsultats des enqutes mnages, qualit et infirmiers titulaires ralises en 2006 et 2008]. Report for Cordaid 2009. Vergeer 2008 {unpublished data only} Vergeer P, Chansa C. Payment for Performance (P4P) Evaluation: Zambia Country Report for Cordaid. KIT, Amsterdam. References to studies excluded from this review Bhushan 2002 {published data only} Bhushan I, Keller S, Schwartz B. Achieving the twin objectives of efficiency and equity: contracting health services in Cambodia. ERD Policy Brief Series: Economics and Research Department - Number 6. Asian Development Bank, 2002. Biai 2007 {published data only} Biai S, Rodrigues A, Gomes M, Ribeiro I, Sodemann M, Alves F, et al.Reduced in-hospital mortality after improved management of children under 5 years admitted to hospital with malaria: randomised trial. BMJ 2007;335(7625):862. Chee 2004 {published data only} Chee G, Fields R, Hsi N, Schott W. Evaluation of GAVI immunization services support funding. The Global Alliance for Vaccines and Immunization 2004. Chee 2007 {published data only} Chee G, Hsi N, Carlson K, Chankova S, Taylor P. Evaluation of the First Five Years of GAVI Immunization Services Support Funding. Bethesda, MD: ABT Associates Inc September 2007. Chee 2008 {published data only} Chee G, Molldrem V, Hsi N, Chankova S. Evaluation of the GAVI Phase 1 Performance (2000-2005). Bethesda, MD: ABT Associates Inc October 2008. Eichler 2007 {published data only} Eichler R, Auxila P, Antoine U, Desmangles B. Performance- Based Incentives for Health: Six Years of Results from Supply-Side Programs in Haiti. Center for Global Development, Working Papers #121 2007. Furth 2006 {published data only} Furth R. Zambia pilot study of performance-based incentives. USAID 2006. Gauri 2004 {published data only} Gauri V, Cercone J, Briceno R. Separating financing from provision: evidence from 10 years of partnership with health cooperatives in Costa Rica. Health Policy and Planning 2004;19(5):292-301. Keller 2001 {published data only} Keller S, Schwartz JB. Final evaluation report: contracting for health services pilot project (CHSPP) - a component of the basic health services project. ADB Loan No. 1447- CAM. Phnom Penh, Cambodia, 2001. Lim 2008 {published data only} Lim SS, Stein DB, Charrow A, Murray CJ. Tracking progress towards universal childhood immunisation and the impact of global initiatives: a systematic analysis of three-dose diphtheria, tetanus, and pertussis immunisation coverage. Lancet 2008;372(1474-547X (Electronic), 0140- 6736 (Linking), 9655):2031-46. Liu 2005 {published data only} Liu X, Mills A. The effect of performance-related pay of hospital doctors on hospital behaviour: a case study from Shandong, China. Human Resources for Health [Electronic Resource] 2005;3:11. Lu 2006 {published data only} Lu C, Michaud CM, Gakidou E, Khan K, Murray CJ. Effect of the Global Alliance for Vaccines and Immunisation on diphtheria, tetanus, and pertussis vaccine coverage: an independent assessment. Lancet 2006;368:1088-95. Mahmood 2007 {published data only} Mahmood J, AlamMN. Bangladesh: Urban Primary Health Care Project. Asian Development Bank 2007; Vol. 29033. Marek 1999 {published data only} Marek T, Diallo I, Ndiaye B, Rakotosalama J. Successful contracting of prevention services: fighting malnutrition in Senegal and Madagascar. Health Policy Plan 1999;14(0268- 1080 (Print), 0268-1080 (Linking), 4):382-9. Meessen 2006 {published data only} Meessen B, Musango L, Kashala JP, Lemlin J. Reviewing institutions of rural health centres: the Performance Initiative in Butare, Rwanda. Tropical Medicine and International Health 2006;11(8):1303-17. Meuwissen 2006 {published data only} Meuwissen LE, Gorter AC, Kester ADM, Knottnerus JA. Can a comprehensive voucher programme prompt changes in doctors' knowledge, attitudes and practices related to sexual and reproductive health care for adolescents? A case study from Latin America. Tropical Medicine and International Health 2006;11(6):889-98. Schwartz 2004 {published data only} Schwartz JB, Bhushan I. Improving immunization equity through a public-private partnership in Cambodia. Bulletin of the World Health Organization 2004;82(0042-9686 (Print), 0042-9686 (Linking), 9):661-7. Soeters 2003 {published data only} Soeters R, Griffiths F. Improving government health services through contract management: a case from Cambodia. Health Policy and Planning 2003;18(1):74-83. Sondorp 2009 {published data only} Sondorp E, Palmer N, Strong L, Wali A. Afghanistan: Paying NGOs for performance in a postconflict setting. Center for Global Development 2009. World Bank 2003 {published data only} World Bank. Partnerships within the public sector to achieve health objectives - Performance-based management in an evolving decentralized public health system in West Africa: the case of Burkina Faso. World Bank 2003. Yip 2001 {published data only} Yip W, Eggleston K. Provider payment reform in China: the case of hospital reimbursement in Hainan province. Health Economics 2001;10(4):325-39. References to studies awaiting assessment Huntingdon 2010 {published data only} Huntington D, Zaky HH, Shawky S, Fattah FA, El- Hadary E. Impact of a service provider incentive payment scheme on quality of reproductive and child-health services in Egypt. Journal of Health, Population & Nutrition 2010; 28:273-80. Lundberg 2007 {unpublished data only} Lundberg M, Marek T, Okwero P. Contracting Health Services in Uganda, Unpublished Report. World Bank 2007. Additional references Basinga 2009 Basinga P. Impact of performance-based financing on the quantity and quality of maternal health services in Rwanda. PhD Dissertation, School of Public Health and Tropical Medicine, Tulane University. Basinga 2011 Basinga P, Gertler P, Binagwaho A, Soucat A, Sturdy J, Vermeersch C. Effect on maternal and child health services in Rwanda of payment to primary health-care providers for performance: an impact evaluation. Lancet 2011;377: 1421-8. Christianson 2007 Christianson J, Leatherman S, Sutherland K. Financial incentives, health care providers and quality improvements: a review of the evidence. London: The Health Foundation, 2007. Deci 1999 Deci E, Ryan R, Koestner R. A meta-analytic review of experiments examining the effects of extrinsic rewards on intrinsic motivation. Psychological Bulletin 1999;125(6): 627-68. Eichler 2006 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. Eldridge 2009 Eldridge C, Palmer N. Performance-based payment: some reflections on the discourse, evidence and unanswered questions. Health Policy and Planning 2009. In press. Giuffrida 1999 Giuffrida A, Gosden T, Forland F, Kristiansen I, Sergison M, Leese B, et al.Target payments in primary care: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews 1999, Issue 4. 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Decline of the Public. The Hollowing Out of Citizenship. Polity Press, 2004. Meessen 2011 Meessen B, Soucat A, Sekabaraga C. Performancebased financing: just a donor fad or a catalyst towards comprehensive health-care reform?. Bulletin of the World Health Organization 2011;89:156. Morgan 2010 Morgan L. Some days are better than others: Lessons Learnt from Uganda's First Results Based Financing Pilot, Feature story. Washington DC: The World Bank 2010. Oxman 2008 Oxman AD, Fretheim A. An overview of research on the effects of results-based financing. Report No. 16-2008. Oslo: Norwegian Knowledge Centre for the Health Services 2008. Peabody 2011 Peabody J, Shimkhada R, Quimbo S, Florentino J, Bacate M, McCulloch C, et al.Financial incentives and measurement improved physicians' quality of care in the Philippines. Health Affairs 2011;30:773-81. Ramsay 2003 Ramsay CR, Matowe L, Grilli R, Grimshaw JM, Thomas RE. Interrupted time series design in health technology assessment: Lessons from two systematic reviews of behaviour change strategies.. International Journal of Technology Assessment in Health Care 2003;19:612-23. Savedoff 2010 Savedoff W. Basic Economics of Results-based Financing in Health. Bath, Maine (USA): Social Insight, 2010. Sheffler 2010 Sheffler R. Pay For Performance (P4P) programs in health services: what is the evidence?. World Health Report 2010 Background Paper 31, Geneva, WHO 2010. Soeters 2010 Soeters R, Basenya O, Kamana J, Nyarushatsi JP, Bossuyt M, Vroeg P. Delivering equitable and quality health services through performance based financing. An experiment - control study from Burundi. Submitted for publication to Health Policy and Planning. Soeters 2011 Soeters R, Peerenboom P, Mushagalusa P, Kimanuka C. Performance-Based Financing Experiment Improved Health Care In The Democratic Republic Of Congo. Health Affairs 2011;30:1518-27. Toonen 2009 Toonen J, Canavan A, Vergeer P, Elovainio R. Performance Based Financing: a synthesis report. KIT, in collaboration with Cordaid and WHO, Amsterdam 2009. Valera 2009 ValeraM, Quimbo S. A quality improvement demonstration study: a P4P experiment in the Philippines. Presentation to Asia Pay for Performance Workshop, Cebu, Philippines 2009. Indicates the major publication for the study Paying2pub2680pubCD007