Pay for Performance: A Reflection on How a Global Perspective Could Enhance Policy and Research

Anselmi, Laura; Borghi, Josephine; Brown, Garrett Wallace; Fichera, Eleonora; Hanson, Kara; Kadungure, Artwell; Kovacs, Roxanne; Kristensen, Søren Rud; Singh, Neha; Sutton, Matt

doi:10.34172/ijhpm.2020.23

Cited by 11 publications

(13 citation statements)

References 45 publications

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“…BMJ Global Health utilisation of services, patient outcomes and resource use. [1][2][3] Moreover, evidence from LMICs is skewed towards donor-oriented approaches, since most P4P schemes have been driven and funded by international organisations, 4 often implemented disassociated from existing health system institutions. 5 6 Additionally, the effects of P4P schemes have typically been assessed at only one point in time.…”

Section: Key Questionsmentioning

confidence: 99%

“…5 6 Additionally, the effects of P4P schemes have typically been assessed at only one point in time. 4 After nearly two decades of continuing reforms and strengthening of PHC, 7 Brazil introduced its first national-level P4P scheme, called the Brazilian National Programme for Improving Primary Care Access and Quality (PMAQ, acronym in Portuguese) in 2011. PMAQ was rolled out over three rounds of implementation: round 1 (November 2011-Mar 2013), round 2 (April 2013-September 2015) and round 3 (October 2015-December 2019).…”

Section: Key Questionsmentioning

confidence: 99%

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Pay for performance in primary care: the contribution of the Programme for Improving Access and Quality of Primary Care (PMAQ) on avoidable hospitalisations in Brazil, 2009–2018

et al. 2021

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BackgroundEvidence on the effect of pay-for-performance (P4P) schemes on provider performance is mixed in low-income and middle-income countries. Brazil introduced its first national-level P4P scheme in 2011 (PMAQ-Brazilian National Programme for Improving Primary Care Access and Quality). PMAQ is likely one of the largest P4P schemes in the world. We estimate the association between PMAQ and hospitalisations for ambulatory care sensitive conditions (ACSCs) based on a panel of 5564 municipalities.MethodsWe conducted a fixed effect panel data analysis over the period of 2009–2018, controlling for coverage of primary healthcare, hospital beds per 10 000 population, education, real gross domestic product per capita and population density. The outcome is the hospitalisation rate for ACSCs among people aged 64 years and under per 10 000 population. Our exposure variable is defined as the percentage of family health teams participating in PMAQ, which captures the roll-out of PMAQ over time. We also provided several sensitivity analyses, by using alternative measures of the exposure and outcome variables, and a placebo test using transport accident hospitalisations instead of ACSCs.ResultsThe results show a negative and statistically significant association between the rollout of PMAQ and ACSC rates for all age groups. An increase in PMAQ participating of one percentage point decreased the hospitalisation rate for ACSC by 0.0356 (SE 0.0123, p=0.004) per 10 000 population (aged 0–64 years). This corresponds to a reduction of approximately 60 829 hospitalisations in 2018. The impact is stronger for children under 5 years (−0.0940, SE 0.0375, p=0.012), representing a reduction of around 11 936 hospitalisations. Our placebo test shows that the association of PMAQ on the hospitalisation rate for transport accidents is not statistically significant, as expected.ConclusionWe find that PMAQ was associated with a modest reduction in hospitalisation for ACSCs.

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Section: Key Questionsmentioning

confidence: 99%

Section: Key Questionsmentioning

confidence: 99%

Pay for performance in primary care: the contribution of the Programme for Improving Access and Quality of Primary Care (PMAQ) on avoidable hospitalisations in Brazil, 2009–2018

et al. 2021

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“…Finally, we encourage the evaluation of reforms such as P4P in a comprehensive manner, in terms of changes in inputs, outputs and efficiency at the provider level, but also costeffectiveness and efficiency of the reform itself. 83 This study has some limitations. First, our focus has been on technical efficiency and scale efficiency, as opposite to allocative efficiency due to the lack of data on input prices.…”

Section: Discussionmentioning

confidence: 91%

Understanding efficiency and the effect of pay-for-performance across health facilities in Tanzania

Binyaruka

Anselmi

2020

BMJ Glob Health

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BackgroundEnsuring efficient use and allocation of limited resources is crucial to achieving the UHC goal. Performance-based financing that provides financial incentives for health providers reaching predefined targets would be expected to enhance technical efficiency across facilities by promoting an output-oriented payment system. However, there is no study which has systematically assessed efficiency scores across facilities before and after the introduction of pay-for-performance (P4P). This paper seeks to fill this knowledge gap.MethodsWe used data of P4P evaluation related to healthcare inputs (staff, equipment, medicines) and outputs (outpatient consultations and institutional deliveries) from 75 health facilities implementing P4P in Pwani region, and 75 from comparison districts in Tanzania. We measured technical efficiency using Data Envelopment Analysis and obtained efficiency scores across facilities before and after P4P scheme. We analysed which factors influence technical efficiency by regressing the efficiency scores over a number of contextual factors. We also tested the impact of P4P on efficiency through a difference-in-differences regression analysis.ResultsThe overall technical efficiency scores ranged between 0.40 and 0.65 for hospitals and health centres, and around 0.20 for dispensaries. Only 21% of hospitals and health centres were efficient when outpatient consultations and deliveries were considered as output, and <3% out of all facilities were efficient when outpatient consultations only were considered as outputs. Higher efficiency scores were significantly associated with the level of care (hospital and health centre) and wealthier catchment populations. Despite no evidence of P4P effect on efficiency on average, P4P might have improved efficiency marginally among public facilities.ConclusionMost facilities were not operating at their full capacity indicating potential for improving resource usage. A better understanding of the production process at the facility level and of how different healthcare financing reforms affects efficiency is needed. Effective reforms should improve inputs, outputs but also efficiency.

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“…This design choice was intended to minimize the risk of measuring physicians’ ability to “game” the payment system rather than true performance; however, such concerns have also been raised in the United Kingdom, as regards P4P potentially reflecting distorted “embellishing” of patient diagnosis codes over the quality of care [ 57 ]. Performance pay as a mechanism to improve quality of care first emerged in high-income countries, and much of the research on P4P still tends to be siloed by income setting [ 58 ]. Given the proliferation of P4P schemes in low- and middle-income countries, coupled with weaker information systems and the more limited research on P4P effectiveness in many of these contexts [ 4 , 59 , 60 ], rigorous empirical assessments are needed of the relationships (if any) between the allocation of limited resources to performance-based payments and consequences for gender equity from countries at all levels of development.…”

Section: Discussionmentioning

confidence: 99%

The evidence gap on gendered impacts of performance-based financing among family physicians for chronic disease care: a systematic review reanalysis in contexts of single-payer universal coverage

Gupta

Ayles

2020

Hum Resour Health

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Background Although pay-for-performance (P4P) among primary care physicians for enhanced chronic disease management is increasingly common, the evidence base is fragmented in terms of socially equitable impacts in achieving the quadruple aim for healthcare improvement: better population health, reduced healthcare costs, and enhanced patient and provider experiences. This study aimed to assess the literature from a systematic review on how P4P for diabetes services impacts on gender equity in patient outcomes and the physician workforce. Methods A gender-based analysis was performed of studies retrieved through a systematic search of 10 abstract and citation databases plus grey literature sources for P4P impact assessments in multiple languages over the period January 2000 to April 2018, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The study was restricted to single-payer national health systems to minimize the risk of physicians sorting out of health organizations with a strong performance pay component. Two reviewers scored and synthesized the integration of sex and gender in assessing patient- and provider-oriented outcomes as well as the quality of the evidence. Findings Of the 2218 identified records, 39 studies covering eight P4P interventions in seven countries were included for analysis. Most (79%) of the studies reported having considered sex/gender in the design, but only 28% presented sex-disaggregated patient data in the results of the P4P assessment models, and none (0%) assessed the interaction of patients’ sex with the policy intervention. Few (15%) of the studies controlled for the provider’s sex, and none (0%) discussed impacts of P4P on the work life of providers from a gender perspective (e.g., pay equity). Conclusions There is a dearth of evidence on gender-based outcomes of publicly funded incentivizing physician payment schemes for chronic disease care. As the popularity of P4P to achieve health system goals continues to grow, so does the risk of unintended consequences. There is a critical need for research integrating gender concerns to help inform performance-based health workforce financing policy options in the era of the Sustainable Development Goals.

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Pay for Performance: A Reflection on How a Global Perspective Could Enhance Policy and Research

Cited by 11 publications

References 45 publications

Pay for performance in primary care: the contribution of the Programme for Improving Access and Quality of Primary Care (PMAQ) on avoidable hospitalisations in Brazil, 2009–2018

Pay for performance in primary care: the contribution of the Programme for Improving Access and Quality of Primary Care (PMAQ) on avoidable hospitalisations in Brazil, 2009–2018

Understanding efficiency and the effect of pay-for-performance across health facilities in Tanzania

The evidence gap on gendered impacts of performance-based financing among family physicians for chronic disease care: a systematic review reanalysis in contexts of single-payer universal coverage

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