Background: Since 2010, Israel has expanded the adoption of procedure-related group (PRG) based payments for hospitals. While there is a rich quantitative literature that assesses the effects of payment reforms on efficiency or quality of care, very few qualitative studies have focused on the impacts of diagnosis-related group (DRG)-like payments on hospitals from the perspective of hospital workers as change agents. Methods: We used a qualitative, thematic analysis based on 33 semi-structured in-depth interviews with chief executive officers (CEOs), chief financial officers (CFOs), ward directors and physicians conducted in five public hospitals in Israel, sampled by maximum variation according to hospital characteristics. Results: Interviewees reported that the payment reform led to organizational changes such as increased transparency and enhanced supervision. Interviewees also reported several actions in response to the economic incentives of PRGbased payment. These included (1) shifting activities to afterhours and using operating rooms (ORs) more efficiently to enable increased surgical volumes; (2) reducing costs by shortening lengths of stay and increasing cost-consciousness in procurement; and (3) increasing revenues by improving coding and selecting procedures. Moderating factors reduced the effects of the reform. For example, organizational factors such as the public nature of hospitals or the (un)availability of healthcare resources did not always allow hospitals to increase the number of cases treated. Also, conflicting incentives such as multiple payment mechanisms or underpricing of procedures blurred the incentives of the reform. Finally, managers and physicians have many other considerations that outweigh the economic ones. Conclusion: PRG payments affected the organizational dynamics of hospitals and changed decision-making about admission and treatment policies. However, such effects were moderated by many other factors that should be considered when shaping and analyzing hospital payment reforms.

Background In 2010, Israel intensified its adoption of Procedure-Related Group (PRG) based hospital payments, a local version of DRG (Diagnosis-related group). PRGs were created for certain procedures by clinical fields such as urology, orthopedics, and ophthalmology. Non-procedural hospitalizations and other specific procedures continued to be paid for as per-diems (PD). Whether this payment reform affected inpatient activities, measured by the number of discharges and average length of stay (ALoS), is unclear. Methods We analyzed inpatient data provided by the Ministry of Health from all 29 public hospitals in Israel. Our observations were hospital wards for the years 2008–2015, as proxies to clinical fields. We investigated the impact of this reform at the ward level using difference-in-differences analyses among procedural wards. Those for which PRG codes were created were treatment wards, other procedural wards served as controls. We further refined the analysis of effects on each ward separately. Results Discharges increased more in the wards that were part of the control group than in the treatment wards as a group. However, a refined analysis of each treated ward separately reveals that discharges increased in some, but decreased in other wards. ALoS decreased more in treatment wards. Difference-in-differences results could not suggest causality between the PRG payment reform and changes in inpatient activity. Conclusions Factors that may have hampered the effects of the reform are inadequate pricing of procedures, conflicting incentives created by other co-existing hospital-payment components, such as caps and retrospective subsidies, and the lack of resources to increase productivity. Payment reforms for health providers such as hospitals need to take into consideration the entire provider market, available resources, other – potentially conflicting – payment components, and the various parties involved and their interests.

BackgroundWhile poor countries have made progress attaining the The Joint United Nations Programme on HIV/AIDS (UNAIDS) goals for 2025, continued progress depends on continued accessibility of program services, as well as continued improvements in compliant behavior by HIV positive populations. This paper examines household survey data in four African countries pertaining to those critical behaviors and identifies the key population barriers for attaining UNAIDS goals. MethodsThis study used Population-based HIV Impact Assessment (PHIA) survey data for Zambia, Malawi, Eswatini, and Tanzania to examine household and other influences associated with effectively managing HIV-infected adults using three key outcomes: (i) self-awareness of HIV status, (ii) antiretroviral therapy adherence, and (iii) rate of viral load suppression (VLS). ResultsFactors found to increase HIV risk also posed barriers to awareness and viral suppression, such as being young, having multiple partners, and having a job outside the home. Additional barriers to awareness and viral suppression were low education, low wealth, low knowledge of HIV, and the HIV status and gender of the household head. The most consistent factor influencing awareness and viral load suppression was the gender of the individual. Women were much more likely to be aware of their HIV status and more likely to be virally suppressed at rates almost twice as high as comparable men. Our analysis shows that the gender differential for awareness seems primarily due the testing and other services provided for women giving birth. We also found that the VLS gender gap was not related birthing-related services. ConclusionsThe most substantial barrier to achieving UNAIDS goals appears to be poorer compliance by men regarding testing and sustained VLS. Routinely providing HIV testing and other HIV information during antenatal care (ANC) may have contributed to improved rates of HIV-status awareness of birthing-age women. New programs to routinely integrate HIV testing into men's health care in workplaces or other settings could improve men's awareness and compliance with treatment. Also needed are more effective interventions to target sectors of the population that are less likely to adhere to treatment regimens, such as persons with low-education levels, low wealth, and/or low knowledge of HIV.This study examines Population-based HIV Impact Assessment (PHIA) household survey data in four sub-Saharan African (SSA) countries to understand the personal, household and community factors that are associated with awareness of human immunodeficiency virus (HIV) status and continued viral load suppression (VLS) among HIV-positive individuals. The Joint United Nations Programme on HIV/ AIDS (UNAIDS) 95-95-95 cascade goals for 2025 depend critically on both accessibility of program activities as well as compliant behavior of households. 1 Specifically, current UNAIDS targets are the following:1. 95% of HIV positive persons should be aware of their positive status. This requires testing and ...

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