Centre for International Health, University of Bergen, PO Box 7804, N-5020, Bergen, Norway.
Ifakara Health Institute, PO Box 78373, Dar es Salaam, Tanzania.
Int J Equity Health. 2018 Jan 29;17(1):14. doi: 10.1186/s12939-018-0728-x.
Payment for performance (P4P) strategies, which provide financial incentives to health workers and/or facilities for reaching pre-defined performance targets, can improve healthcare utilisation and quality. P4P may also reduce inequalities in healthcare use and access by enhancing universal access to care, for example, through reducing the financial barriers to accessing care. However, P4P may also enhance inequalities in healthcare if providers cherry-pick the easier-to-reach patients to meet their performance targets. In this study, we examine the heterogeneity of P4P effects on service utilisation across population subgroups and its implications for inequalities in Tanzania.
We used household data from an evaluation of a P4P programme in Tanzania. We surveyed about 3000 households with women who delivered in the last 12 months prior to the interview from seven intervention and four comparison districts in January 2012 and a similar number of households in 13 months later. The household data were used to generate the population subgroups and to measure the incentivised service utilisation outcomes. We focused on two outcomes that improved significantly under the P4P, i.e. institutional delivery rate and the uptake of antimalarials for pregnant women. We used a difference-in-differences linear regression model to estimate the effect of P4P on utilisation outcomes across the different population subgroups.
P4P led to a significant increase in the rate of institutional deliveries among women in poorest and in middle wealth status households, but not among women in least poor households. However, the differential effect was marginally greater among women in the middle wealth households compared to women in the least poor households (p = 0.094). The effect of P4P on institutional deliveries was also significantly higher among women in rural districts compared to women in urban districts (p = 0.028 for differential effect), and among uninsured women than insured women (p = 0.001 for differential effect). The effect of P4P on the uptake of antimalarials was equally distributed across population subgroups.
P4P can enhance equitable healthcare access and use especially when the demand-side barriers to access care such as user fees associated with drug purchase due to stock-outs have been reduced.
绩效支付（P4P）策略为达到预先设定的绩效目标的卫生工作者和/或医疗机构提供经济激励，可以改善医疗保健的利用和质量。P4P 还可以通过增强普遍获得医疗保健的机会，例如通过减少获得医疗保健的经济障碍，来减少医疗保健使用和获得方面的不平等。然而，如果提供者选择更容易达到的患者来达到他们的绩效目标，那么 P4P 也可能会加剧医疗保健方面的不平等。在这项研究中，我们研究了 P4P 对坦桑尼亚不同人群亚组的服务利用的异质性及其对不平等的影响。
我们使用了来自坦桑尼亚 P4P 计划评估的家庭数据。我们在 2012 年 1 月调查了来自七个干预区和四个对照区的最近 12 个月内分娩的约 3000 名妇女及其家庭，在 13 个月后调查了类似数量的家庭。家庭数据被用来生成人口亚组，并衡量激励性服务利用结果。我们重点关注了在 P4P 下显著改善的两个结果，即机构分娩率和孕妇抗疟药物的使用率。我们使用差异-差异线性回归模型来估计 P4P 对不同人群亚组利用结果的影响。
P4P 显著提高了最贫困和中等富裕家庭妇女的机构分娩率，但没有提高最不贫困家庭妇女的分娩率。然而，中间富裕家庭妇女的差异效应略高于最不贫困家庭妇女（p=0.094）。P4P 对农村地区妇女的机构分娩率的影响也明显高于城市地区妇女（差异效应 p=0.028），以及未保险妇女的机构分娩率高于保险妇女（差异效应 p=0.001）。P4P 对抗疟药物使用率的影响在人口亚组中分布均匀。
P4P 可以增强公平获得医疗保健的机会和利用，特别是当与药品购买相关的自付费用等获得医疗保健的需求方障碍已经减少时。
