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Although performance-based financing (PBF) receives increasing attention in the literature, a lot remains unknown about the exact mechanisms triggered by PBF arrangements. This article aims to summarize current knowledge on how PBF works, set out what still needs to be investigated and formulate recommendations for researchers and policymakers from donor and recipient countries alike. Drawing on an extensive systematic literature review of peer-reviewed journals, we analysed 35 relevant articles. To guide us through this variety of studies, point out relevant issues and structure findings, we use a comprehensive analytical framework based on eight dimensions. The review inter alia indicates that PBF is generally welcomed by the main actors (patients, health workers and health managers), yet what PBF actually entails is less straightforward. More research is needed on the exact mechanisms through which not only incentives but also ancillary components operate. This knowledge is essential if we really want to appreciate the effectiveness, desirability and appropriate format of PBF as one of the possible answers to the challenges in the health sector of low-and lower middle-income countries. A clear definition of the research constructs is a primordial starting point for such research. Même si le financement basé sur les résultats (PBF) bénéficie d’une attention croissante dans la littérature, il reste encore beaucoup à découvrir sur les mécanismes exacts déclenchés par des accords PBF. Le présent article vise à résumer les connaissances actuelles relatives au fonctionnement des accords PBF, déterminer ce qui doit encore être étudié et formuler des recommandations pour les chercheurs et les décideurs aussi bien des pays donateurs que des pays bénéficiaires. Partant d’un examen approfondi systématique des revues à comité de lecture, nous avons analysé 35 articles pertinents. Pour nous guider à travers cette série d’études, relever les questions pertinentes et structurer les conclusions, nous utilisons un cadre analytique complet basé sur huit dimensions. L’examen indique entre autres, que l’accord PBF est généralement bien accueilli par les principaux acteurs (patients, professionnels de la santé et gestionnaires de la santé), mais la véritable implication de l’accord PBF n’est pas aussi facilement perceptible. Il faut faire davantage de recherches sur les mécanismes exacts de fonctionnement, non seulement des mesures incitatives mais aussi des composants périphériques. Cette connaissance est essentielle si nous voulons vraiment apprécier l’efficacité, l’opportunité et la spécificité du format de l’accord PBF en tant qu’une des réponses possibles aux défis du secteur de la santé dans les pays à revenu faible ou intermédiaire de la tranche inférieure. Une définition claire des éléments de la recherche est un point de départ essentiel pour de telles recherches. Aunque el financiamiento basado en el rendimiento (FBR) recibe creciente atención en la literatura, poco se sabe sobre los mecanismos exactos que son desencadenados por la organización del FBR. Este articulo tiene como objetivo resumir el conocimiento actual sobre cómo funciona el FBR, describir que necesita ser investigado y formular recomendaciones para los investigadores y creadores de políticas por parte de los donantes y países receptores. Utilizando un resumen extensivo de la literatura de las revistas evaluadas por pares, analizamos 35 artículos relevantes. Para guiarnos a través de esta variedad de artículos, destacar los temas relevantes y estructurar los hallazgos relevantes, usamos un marco analítico amplio basado en ocho dimensiones. El resumen, entre otras cosas, indica que el FBR es generalmente bienvenido por los actores principales (pacientes, trabajadores de salud y gerentes de salud), pero lo que el FBR conlleva no es claro. Se necesita más investigación sobre los mecanismos exactos a través de los cuales operan los objetivos y los componentes complementarios. Este conocimiento es esencial si queremos realmente entender la efectividad, el atractivo y el formato apropiado para el FBR como una de las posibles respuestas a los retos en el sector de salud en los países de ingresos bajos y medios. Una definición clara de la construcción de la investigación es un punto de partida primordial para este tipo de investigación. 尽管绩效融资得到文献研究的日益关注, 但是现有研究对绩效 融资安排产生的具体的机制知之甚少。本文旨在总结现有关于 绩效融资运作方式的知识, 设置仍需被调查的方面, 为来自类似 的投资国和融资国研究者和政策制定者提出建议。根据对相关 回顾性期刊的扩展系统性文献综述, 我们分析了35篇相关文 章。为了指导我们了解这一系列的研究, 指出相关问题和结构 性结论, 我们使用了一个基于8个层面的综合性分析结构。本研 究综述特别指出绩效融资受到关键行为主体 （病人、医疗工作 者和医疗主管） 的广泛欢迎, 但是绩效融资赋予的东西并没有 那么直接。需要更多的研究探讨具体机制, 通过该机制激励和 辅助部分同时运转。如果我们真的想要理解绩效融资作为中低 收入国家医疗部门面对挑战潜在解决方案的有效性、受欢迎程 度和合适的形式, 那么该知识是关键。对于这样的研究来说首 要的入手点在于一个明确的研究结构定义。

Objectives To investigate the effect of withdrawing incentives on recorded quality of care, in the context of the UK Quality and Outcomes Framework pay for performance scheme.Design Retrospective longitudinal study.Setting Data for 644 general practices, from 2004/05 to 2011/12, extracted from the Clinical Practice Research Datalink.Participants All patients registered with any of the practices over the study period—13 772 992 in total.Intervention Removal of financial incentives for aspects of care for patients with asthma, coronary heart disease, diabetes, stroke, and psychosis.Main outcome measures Performance on eight clinical quality indicators withdrawn from a national incentive scheme: influenza immunisation (asthma) and lithium treatment monitoring (psychosis), removed in April 2006; blood pressure monitoring (coronary heart disease, diabetes, stroke), cholesterol concentration monitoring (coronary heart disease, diabetes), and blood glucose monitoring (diabetes), removed in April 2011. Multilevel mixed effects multiple linear regression models were used to quantify the effect of incentive withdrawal.Results Mean levels of performance were generally stable after the removal of the incentives, in both the short and long term. For the two indicators removed in April 2006, levels in 2011/12 were very close to 2005/06 levels, although a small but statistically significant drop was estimated for influenza immunisation. For five of the six indicators withdrawn from April 2011, no significant effect on performance was seen following removal and differences between predicted and observed scores were small. Performance on related outcome indicators retained in the scheme (such as blood pressure control) was generally unaffected.Conclusions Following the removal of incentives, levels of performance across a range of clinical activities generally remained stable. This indicates that health benefits from incentive schemes can potentially be increased by periodically replacing existing indicators with new indicators relating to alternative aspects of care. However, all aspects of care investigated remained indirectly or partly incentivised in other indicators, and further work is needed to assess the generalisability of the findings when incentives are fully withdrawn.

In 2015 the Medicare Hospital Value-Based Purchasing (VBP) program paid hospitals $1.4 billion in performance-based incentives; 30 percent of a hospital's VBP Total Performance Score was based on performance on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) measures of the patient experience of care. Hospitals receive patient experience points based on three components: achievement, improvement, and consistency. For 2015 we examined how the three components affected reimbursement for 3,152 hospitals, including their impact on low-performing and high-minority hospitals. Achievement accounted for 96 percent of the differences among hospitals in total HCAHPS points. Although achievement had the biggest influence on payments, payments related to improvement and consistency were more beneficial for low-performing hospitals that disproportionately served minority patients. The findings highlight the important inducement that paying for improvement provides to initially low-performing hospitals to improve care and the role this incentive structure plays in minimizing resource redistributions away from hospitals serving minority populations. Additional emphasis on improvement points could benefit hospitals serving disadvantaged patients.

Background Pay for performance (P4P) schemes provide financial incentives to health workers or facilities based on the achievement of pre-specified performance targets and have been widely implemented in health systems across low and middle-income countries (LMICs). The growing evidence base on P4P highlights that (i) there is substantial variation in the effect of P4P schemes on outcomes and (ii) there appears to be heterogeneity in incentive design. Even though scheme design is likely a key determinant of scheme effectiveness, we currently lack systematic evidence on how P4P schemes are designed in LMICs. Methods We develop a typology to classify the design of P4P schemes in LMICs, which highlights different design features that are a priori likely to affect the behaviour of incentivised actors. We then use results from a systematic literature review to classify and describe the design of P4P schemes that have been evaluated in LMICs. To capture academic publications, Medline, Embase, and EconLit databases were searched. To include relevant grey literature, Google Scholar, Emerald Insight, and websites of the World Bank, WHO, Cordaid, Norad, DfID, USAID and PEPFAR were searched. Results We identify 41 different P4P schemes implemented in 29 LMICs. We find that there is substantial heterogeneity in the design of P4P schemes in LMICs and pinpoint precisely how scheme design varies across settings. Our results also highlight that incentive design is not adequately being reported on in the literature – with many studies failing to report key design features. Conclusions We encourage authors to make a greater effort to report information on P4P scheme design in the future and suggest using the typology laid out in this paper as a starting point.

Background Pay-for-performance (P4P) is one of the primary tools used to support healthcare delivery reform. Substantial heterogeneity exists in the development and implementation of P4P in health care and its effects. This paper summarizes evidence, obtained from studies published between January 1990 and July 2009, concerning P4P effects, as well as evidence on the impact of design choices and contextual mediators on these effects. Effect domains include clinical effectiveness, access and equity, coordination and continuity, patient-centeredness, and cost-effectiveness. Methods The systematic review made use of electronic database searching, reference screening, forward citation tracking and expert consultation. The following databases were searched: Cochrane Library, EconLit, Embase, Medline, PsychINFO, and Web of Science. Studies that evaluate P4P effects in primary care or acute hospital care medicine were included. Papers concerning other target groups or settings, having no empirical evaluation design or not complying with the P4P definition were excluded. According to study design nine validated quality appraisal tools and reporting statements were applied. Data were extracted and summarized into evidence tables independently by two reviewers. Results One hundred twenty-eight evaluation studies provide a large body of evidence -to be interpreted with caution- concerning the effects of P4P on clinical effectiveness and equity of care. However, less evidence on the impact on coordination, continuity, patient-centeredness and cost-effectiveness was found. P4P effects can be judged to be encouraging or disappointing, depending on the primary mission of the P4P program: supporting minimal quality standards and/or boosting quality improvement. Moreover, the effects of P4P interventions varied according to design choices and characteristics of the context in which it was introduced. Future P4P programs should (1) select and define P4P targets on the basis of baseline room for improvement, (2) make use of process and (intermediary) outcome indicators as target measures, (3) involve stakeholders and communicate information about the programs thoroughly and directly, (4) implement a uniform P4P design across payers, (5) focus on both quality improvement and achievement, and (6) distribute incentives to the individual and/or team level. Conclusions P4P programs result in the full spectrum of possible effects for specific targets, from absent or negligible to strongly beneficial. Based on the evidence the review has provided further indications on how effect findings are likely to relate to P4P design choices and context. The provided best practice hypotheses should be tested in future research.

BackgroundWhile both administrators of pay-for-performance programs and practicing physicians strive to improve healthcare quality, they sometimes disagree on the best approach. The Medicare Access and CHIP Reauthorization Act of 2015 mandated the creation of the Merit-Based Incentive Payment System (MIPS), a program that incentivizes more than 700,000 physician participants to report on four domains of care, including healthcare quality. While MIPS performance scores were recently released, little is known about how primary care physicians (PCPs) and their practices are being affected by the program and what actions they are taking in response to MIPS.ObjectivesTo (1) describe PCP perspectives and self-reported practice changes related to quality measurement under MIPS and (2) disseminate PCP suggestions for improving the program.DesignQualitative study employing semi-structured interviews.ParticipantsTwenty PCPs trained in internal medicine or family medicine who were expected to report under MIPS for calendar year 2017 were interviewed between October 2017 and June 2018. Eight PCPs self-reported to be knowledgeable about MIPS. Seven PCPs worked in small practices.Key ResultsMost PCPs identified advantages of quality measurement under MIPS, including the creation of practice-level systems for quality improvement. However, they also cited disadvantages, including administrative burdens and fears that practices serving vulnerable patients could be penalized. Many participants reported using technology or altering staffing to help with data collection and performance improvement. A few participants were considering selling small practices or joining larger ones to avoid administrative tasks. Suggestions for improving MIPS included simplifying the program to reduce administrative burdens, protecting practices serving vulnerable populations, and improving communication between program administrators and PCPs.ConclusionsMIPS is succeeding in nudging PCPs to develop quality measurement and improvement systems, but PCPs are concerned that administrative burdens are leading to the diversion of clinical resources away from patient-centered care and negatively impacting patient and clinician satisfaction. Program administrators should improve communication with participants and consider simplifying the program to make it less burdensome. Future work should be done to investigate how technical assistance programs can target PCPs that serve vulnerable patient populations and are having difficulty adapting to MIPS.

Background Financial incentives are widely used strategies to alleviate poverty, foster development, and improve health. Cash transfer programs, microcredit, user fee removal policies and voucher schemes that provide direct or indirect monetary incentives to households have been used for decades in Latin America, Sub-Saharan Africa, and more recently in Southeast Asia. Until now, no systematic review of the impact of financial incentives on coverage and uptake of health interventions targeting children under 5 years of age has been conducted. The objective of this review is to provide estimates on the effect of six types of financial incentive programs: (i) Unconditional cash transfers (CT), (ii) Conditional cash transfers (CCT), (iii) Microcredit (MC), (iv) Conditional Microcredit (CMC), (v) Voucher schemes (VS) and (vi) User fee removal (UFR) on the uptake and coverage of health interventions targeting children under the age of five years. Methods We conducted systematic searches of a series of databases until September 1st, 2012, to identify relevant studies reporting on the impact of financial incentives on coverage of health interventions and behaviors targeting children under 5 years of age. The quality of the studies was assessed using the CHERG criteria. Meta-analyses were undertaken to estimate the effect when multiple studies meeting our inclusion criteria were available. Results Our searches resulted in 1671 titles identified 25 studies reporting on the impact of financial incentive programs on 5 groups of coverage indicators: breastfeeding practices (breastfeeding incidence, proportion of children receiving colostrum and early initiation of breastfeeding, exclusive breastfeeding for six months and duration of breastfeeding); vaccination (coverage of full immunization, partial immunization and specific antigens); health care use (seeking healthcare when child was ill, visits to health facilities for preventive reasons, visits to health facilities for any reason, visits for health check-up including growth control); management of diarrhoeal disease (ORS use during diarrhea episode, continued feeding during diarrhea, healthcare during diarrhea episode) and other preventive health interventions (iron supplementation, vitamin A, zinc supplementation, preventive deworming). The quality of evidence on the effect of financial incentives on breastfeeding practices was low but seems to indicate a potential positive impact on receiving colostrum, early initiation of breastfeeding, exclusive breastfeeding and mean duration of exclusive breastfeeding. There is no effect of financial incentives on immunization coverage although there was moderate quality evidence of conditional cash transfers leading to a small but non-significant increase in coverage of age-appropriate immunization. There was low quality evidence of impact of CCT on healthcare use by children under age 5 (Risk difference: 0.14 [95%CI: 0.03; 0.26]) as well as low quality evidence of an effect of user fee removal on use of curative health services (RD=0.62 [0.41; 0.82]). Conclusions Financial incentives may have potential to promote increased coverage of several important child health interventions, but the quality of evidence available is low. The more pronounced effects seem to be achieved by programs that directly removed user fees for access to health services. Some indication of effect were also observed for programs that conditioned financial incentives on participation in health education and attendance to health care visits. This finding suggest that the measured effect may be less a consequence of the financial incentive and more due to conditionalities addressing important informational barriers.

To evaluate the impact of a performance-based financing scheme on maternal and neonatal health service quality in Malawi. We conducted a non-randomized controlled before and after study to evaluate the effects of district- and facility-level performance incentives for health workers and management teams. We assessed changes in the facilities' essential drug stocks, equipment maintenance and clinical obstetric care processes. Difference-in-difference regression models were used to analyse effects of the scheme on adherence to obstetric care treatment protocols and provision of essential drugs, supplies and equipment. We observed 33 health facilities, 23 intervention facilities and 10 control facilities and 401 pregnant women across four districts. The scheme improved the availability of both functional equipment and essential drug stocks in the intervention facilities. We observed positive effects in respect to drug procurement and clinical care activities at non-intervention facilities, likely in response to improved district management performance. Birth assistants' adherence to clinical protocols improved across all studied facilities as district health managers supervised and coached clinical staff more actively. Despite nation-wide stock-outs and extreme health worker shortages, facilities in the study districts managed to improve maternal and neonatal health service quality by overcoming bottlenecks related to supply procurement, equipment maintenance and clinical performance. To strengthen and reform health management structures, performance-based financing may be a promising approach to sustainable improvements in quality of health care.

Pay for performance (P4P) is increasingly being used to stimulate healthcare providers to improve their performance. However, evidence on P4P effectiveness remains inconclusive. Flaws in program design may have contributed to this limited success. Based on a synthesis of relevant theoretical and empirical literature, this paper discusses key issues in P4P-program design. The analysis reveals that designing a fair and effective program is a complex undertaking. The following tentative conclusions are made: (1) performance is ideally defined broadly, provided that the set of measures remains comprehensible, (2) concerns that P4P encourages \"selection\" and \"teaching to the test\" should not be dismissed, (3) sophisticated risk adjustment is important, especially in outcome and resource use measures, (4) involving providers in program design is vital, (5) on balance, group incentives are preferred over individual incentives, (6) whether to use rewards or penalties is context-dependent, (7) payouts should be frequent and low-powered, (8) absolute targets are generally preferred over relative targets, (9) multiple targets are preferred over single targets, and (10) P4P should be a permanent component of provider compensation and is ideally \"decoupled\" form base payments. However, the design of P4P programs should be tailored to the specific setting of implementation, and empirical research is needed to confirm the conclusions.