Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
Soc Sci Med. 2021 Feb;270:113624. doi: 10.1016/j.socscimed.2020.113624. Epub 2020 Dec 18.
Pay for performance (P4P) programmes are popular health system-focused interventions aiming to improve health outcomes in low-and middle-income countries (LMICs). This realist review aims to understand how, why and under what circumstance P4P works in LMICs.We systematically searched peer-reviewed and grey literature databases, and examined the mechanisms underpinning P4P effects on: utilisation of services, patient satisfaction, provider productivity and broader health system, and contextual factors moderating these. This evidence was then used to construct a causal loop diagram.We included 112 records (19 grey literature; 93 peer-reviewed articles) assessing P4P schemes in 36 countries. Although we found mixed evidence of P4P's effects on identified outcomes, common pathways to improved outcomes include: community outreach; adherence to clinical guidelines, patient-provider interactions, patient trust, facility improvements, access to drugs and equipment, facility autonomy, and lower user fees. Contextual factors shaping the system response to P4P include: degree of facility autonomy, efficiency of banking, role of user charges in financing public services; staffing levels; staff training and motivation, quality of facility infrastructure and community social norms. Programme design features supporting or impeding health system effects of P4P included: scope of incentivised indicators, fairness and reach of incentives, timely payments and a supportive, robust verification system that does not overburden staff. Facility bonuses are a key element of P4P, but rely on provider autonomy for maximum effect. If health system inputs are vastly underperforming pre-P4P, they are unlikely to improve only due to P4P. This is the first realist review describing how and why P4P initiatives work (or fail) in different LMIC contexts by exploring the underlying mechanisms and contextual and programme design moderators. Future studies should systematically examine health system pathways to outcomes for P4P and other health system strengthening initiatives, and offer more understanding of how programme design shapes mechanisms and effects.
按服务付费（P4P）计划是一种以卫生系统为重点的干预措施，旨在改善中低收入国家（LMICs）的卫生结果。本真实主义审查旨在了解 P4P 在 LMICs 中如何、为何以及在何种情况下发挥作用。我们系统地搜索了同行评议和灰色文献数据库，并检查了 P4P 对以下方面的影响的潜在机制：服务利用、患者满意度、提供者生产力和更广泛的卫生系统，以及调节这些因素的背景因素。然后，我们使用这些证据构建了一个因果循环图。我们纳入了 112 项记录（19 项灰色文献；93 项同行评议文章），评估了 36 个国家的 P4P 计划。尽管我们发现 P4P 对确定结果的影响存在混合证据，但改善结果的常见途径包括：社区外展；遵守临床指南、医患互动、患者信任、设施改善、获得药物和设备、设施自主权以及降低用户费用。影响系统对 P4P 反应的背景因素包括：设施自主权程度、银行业效率、用户收费在公共服务融资中的作用；人员配备水平；员工培训和激励、设施基础设施质量和社区社会规范。支持或阻碍 P4P 对卫生系统影响的方案设计特征包括：激励指标的范围、激励的公平性和覆盖面、及时付款以及支持性强、稳健的验证系统，不会给员工带来过重负担。设施奖金是 P4P 的关键要素，但要发挥最大效果，还依赖于提供者的自主权。如果卫生系统投入在 P4P 之前表现严重不佳，那么仅依靠 P4P 不太可能改善。这是第一份真实主义审查，通过探索潜在机制以及背景和方案设计调节因素，描述了 P4P 计划如何以及为何在不同的 LMIC 背景下发挥作用（或失败）。未来的研究应系统地检查 P4P 和其他卫生系统强化计划对结果的卫生系统途径，并提供更多关于方案设计如何塑造机制和效果的理解。
