Podcast: Paying for performance to improve the delivery of healthcare services in low- and middle-income countries

Alongside the thousands of Cochrane Reviews of the effects of healthcare interventions, there are many that look at how to organise and deliver health care. One of these, on the use of a strategy called “paying for performance” was updated in May 2021. Here's one of the authors, Sophie Witter from Queen Margaret University in Edinburgh in Scotland, to tell us about the strategy and its effectiveness.

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Mike: Hello, I'm Mike Clarke, podcast editor for the Cochrane Library. Alongside the thousands of Cochrane Reviews of the effects of healthcare interventions, there are many that look at how to organise and deliver health care. One of these, on the use of a strategy called “paying for performance” was updated in May 2021. Here's one of the authors, Sophie Witter from Queen Margaret University in Edinburgh in Scotland, to tell us about the strategy and its effectiveness.

Sophie: Paying for performance, or P4P, means providing money or other kinds of rewards to healthcare workers, health facilities or other parts of the health system when they provide specific services or achieve specific results. Payment is made after checking of the targeted service or result and may be modified after a quality assessment. The approach has become increasingly common over the past decade in low- and middle-income countries and we did our review to identify and synthesise evidence on whether it's effective. This is important because paying for performance may cause harm as well as bring benefits to health services and this update was needed because the earlier review found limited evidence but a large amount of new evidence has appeared since it was done.
In the current review, we were able to use data from 59 studies, 50 more than last time. Most of the studies looked at payments made at facility level, generally in public sector or private not for profit facilities, and most of the indicators use to assess effectiveness were related to reproductive, maternal and child health.
In general, the evidence for whether paying for performance increases the use of health services or improves service delivery is mixed. There is some evidence that P4P can improve quality of care, especially in terms of availability of medicines, but the evidence for improved processes of care is less clear. For health outcomes, there is evidence of small improvements, but these may be due to the additional resources provided by P4P and most of the apparent benefits are lost when studies adjusted for additional resources. The effects for some important aspects that paying for performance was hoped to benefit, such as staff motivation, equity and user fees charged to patients, are also mixed or certain.
We also looked at different designs for P4P, and although it's difficult to be conclusive because of the numbers of studies in different categories, there is some evidence that schemes which adjust payments for quality and for equity have more impact on service use.
In general, we can still not draw definitive conclusions about the effects of paying for performance because, even though the number of studies has increased, these included a wide range of programme designs, settings and implementation, and the varying amounts of funding and supporting elements also influence the outcomes. This means that average effects can mask different impacts on population groups and facility types. Therefore, as the evidence base continues to grow, it will be important to examine paying for performance in a more disaggregated way, allowing for all of these differences to be explored.

Mike: If you'd like to read this latest version of the review and watch for further updates as more evidence becomes available, you can find it online. Just go to Cochrane Library dot com and search 'paying for performance in LMIC'.

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