Background There is growing interest in paying for performance (P4P) as a means to align the incentives of healthcare providers with public health goals. Rigorous evidence on the effectiveness of these strategies in improving health care and health in low‐ and middle‐income countries (LMICs) is lacking; this is an update of the 2012 review on this topic. Objectives To assess 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 CENTRAL, MEDLINE, Embase, and 10 other databases between April and June 2018. We also searched two trial registries, websites, online resources of international agencies, organizations and universities, and contacted experts in the field. Studies identified from rerunning searches in 2020 are under 'Studies awaiting classification.' Selection criteria We included randomized or non‐randomized trials, controlled before‐after studies, or interrupted time series studies conducted in LMICs (as defined by the World Bank in 2018). P4P 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: patient health outcomes, changes in targeted measures of provider performance (such as the delivery of healthcare services), unintended effects, or changes in resource use. Data collection and analysis We extracted data as per original review protocol and narratively synthesised findings. We used standard methodological procedures expected by Cochrane. Given diversity and variability in intervention types, patient populations, analyses and outcome reporting, we deemed meta‐analysis inappropriate. We noted the range of effects associated with P4P against each outcome of interest. Based on intervention descriptions provided in documents, we classified design schemes and explored variation in effect by scheme design. Main results We included 59 studies: controlled before‐after studies (19), non‐randomized (16) or cluster randomized trials (14);  and interrupted time‐series studies (9). One study included both an interrupted time series and a controlled before‐after study. Studies focused on a wide range of P4P interventions, including target payments and payment for outputs as modified by quality (or quality and equity assessments). Only one study assessed results‐based aid. Many schemes were funded by national governments (23 studies) with the World Bank funding most externally funded schemes (11 studies). Targeted services varied; however, most interventions focused on reproductive, maternal and child health indicators. Participants were predominantly located in public or in a mix of public, non‐governmental and faith‐based facilities (54 studies). P4P was assesse...

Objective To perform a European survey of the evidence needs and training demands of insurance medicine professionals related to professional tasks and evidence-based practice. Design International survey. Subjects Professionals working in insurance medicine. Methods Experts designed an online questionnaire including 26 questions related to 4 themes: evidence needs; training demands; evidence-seeking behaviour; and attitudes towards evidence-based medicine. Descriptive statistics were presented by country/conference and the total sample. Results A total of 782 participants responded. Three-quarter of participants experienced evidence needs at least once a week, related to mental disorders (79%), musculoskeletal disorders (67%) and occupational health (65%). Guidelines (76%) and systematic reviews (60%) were the preferred types of evidence and were requested for assessment of work capacity (64%) and prognosis of return-to-work (51%). Evidence-based medicine was thought to facilitate decision-making in insurance medicine (95%). Fifty-two percent of participants felt comfortable finding, reading, interpreting, and applying evidence. Countries expressed similar needs for reviews on typical topics. Conclusion This study reveals evidence gaps in key areas of insurance medicine, supporting the need for further research, guidelines and training in evidence-based insurance medicine. Importantly, insurance medicine professionals should recognize that evidence-based practice is crucial in producing high-quality assessments. LAY ABSTRACT Evidence-based medicine (EBM) means the consideration of research findings when taking decisions in clinical medicine. This approach has become standard in health and social care. Since it is less clear to what degree EBM is applied in insurance medicine, European insurance physicians performed a joint survey among colleagues in 8 countries and 2 conferences. More than 700 professionals participated. Half of respondents experienced a need at least once a week to look for guidelines and systematic reviews about work capacity assessments related to mental or musculoskeletal disorders. Almost all thought that EBM would facilitate decision-making. Not all felt competent in finding, reading, interpreting, and applying research evidence. Overall, findings were similar across countries. These results illustrate important evidence gaps in insurance medicine, supporting the need for further research and guidelines. Importantly, professionals should recognize that evidence-based practice is crucial in producing high-quality assessments.

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