Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, E8622, Baltimore, MD 21205, USA.
Department of Civil Engineering, Johns Hopkins University, 3400 N Charles Street, Baltimore, MD 21218, USA.
Health Policy Plan. 2017 Dec 1;32(10):1417-1426. doi: 10.1093/heapol/czx122.
System dynamics methods were used to explore effective implementation pathways for improving health systems performance through pay-for-performance (P4P) schemes. A causal loop diagram was developed to delineate primary causal relationships for service delivery within primary health facilities. A quantitative stock-and-flow model was developed next. The stock-and-flow model was then used to simulate the impact of various P4P implementation scenarios on quality and volume of services. Data from the Afghanistan national facility survey in 2012 was used to calibrate the model. The models show that P4P bonuses could increase health workers' motivation leading to higher levels of quality and volume of services. Gaming could reduce or even reverse this desired effect, leading to levels of quality and volume of services that are below baseline levels. Implementation issues, such as delays in the disbursement of P4P bonuses and low levels of P4P bonuses, also reduce the desired effect of P4P on quality and volume, but they do not cause the outputs to fall below baseline levels. Optimal effect of P4P on quality and volume of services is obtained when P4P bonuses are distributed per the health workers' contributions to the services that triggered the payments. Other distribution algorithms such as equal allocation or allocations proportionate to salaries resulted in quality and volume levels that were substantially lower, sometimes below baseline. The system dynamics models served to inform, with quantitative results, the theory of change underlying P4P intervention. Specific implementation strategies, such as prompt disbursement of adequate levels of performance bonus distributed per health workers' contribution to service, increase the likelihood of P4P success. Poorly designed P4P schemes, such as those without an optimal algorithm for distributing performance bonuses and adequate safeguards for gaming, can have a negative overall impact on health service delivery systems.
系统动力学方法被用于探索通过绩效薪酬（P4P）方案改善卫生系统绩效的有效实施途径。因果关系图被开发出来，以描绘基层卫生机构内服务提供的主要因果关系。接下来，开发了一个定量的存量-流量模型。然后，使用存量-流量模型模拟各种 P4P 实施场景对服务质量和数量的影响。2012 年阿富汗国家设施调查的数据被用于校准模型。模型表明，P4P 奖金可以提高卫生工作者的积极性，从而提高服务的质量和数量。博弈可能会降低甚至逆转这种预期效果，导致服务的质量和数量低于基线水平。实施问题，如 P4P 奖金的延迟发放和 P4P 奖金的低水平，也会降低 P4P 对服务质量和数量的预期效果，但不会导致产出低于基线水平。当 P4P 奖金根据触发支付的服务中卫生工作者的贡献进行分配时，P4P 对服务质量和数量的最佳效果得以实现。其他分配算法，如等额分配或按工资比例分配，导致的质量和数量水平要低得多，有时甚至低于基线。系统动力学模型以定量结果为依据，为 P4P 干预的变革理论提供信息。具体的实施策略，如及时发放根据卫生工作者对服务的贡献分配的足够水平的绩效奖金，可以增加 P4P 成功的可能性。设计不佳的 P4P 方案，如没有最优的绩效奖金分配算法和充分的博弈防范措施的方案，可能会对卫生服务提供系统产生负面影响。
