The Impact of a Pay-for-Performance Scheme on Prescription Quality in Rural China

New evidence on supplier-induced demand in China's public tertiary hospitals: is the cost of hospitalization higher in the off-season?

Supplier-induced demand (SID) is a long-standing concern in health economics and health system studies; however, empirical evidence on SID-critical to the development of health policy-is difficult to obtain, especially from China. This study, therefore, aims to add new evidence on SID in China's public tertiary hospitals and facilitates the development of evidence-based health policies in China and other countries with similar healthcare systems. For this study, we used patient-level electronic medical records (EMRs) collected from the information systems of tertiary hospitals in a western province in China. From 11 tertiary hospitals, we collected 274,811 hospitalization records dated between 15 February and 30 November 2019. Total expenditure on hospitalization and length of admission of each patient were the primary metrics for measuring SID. We constructed a character indicator to measure the high-season or off-season status of hospitals, and log-linear estimations were applied to estimate the "off-season effect" on hospitalized expenditures and length of admission. We find that the cost of hospitalization is indeed higher in the off-season in China's public tertiary hospitals; specifically, expenditures for patients admitted in the off-season increased by an average of 5.3-7.9% compared to patients admitted in the peak season, while the length of admission in the hospital increased by an average of 6.8% to 10.2%. We also checked the robustness of our findings by performing subgroup analyses of EMRs in the city-level hospitals and surgical group. We name this phenomenon the "hospital off-season effect" and suggest that the main reason for it is inappropriate financial incentives combined with a Fee-For-Services payment method. We suggest that China should work to reform inappropriate financial incentives in public hospitals to eliminate SID by changing its payment and financing compensation system.

Health and health system impacts of China's comprehensive primary healthcare reforms: a systematic review

China's comprehensive primary healthcare (PHC) reforms since 2009 aimed to deliver accessible, efficient, equitable and high-quality healthcare services. However, knowledge on the system-wide effectiveness of these reforms is limited. This systematic review synthesizes evidence on the reforms' health and health system impacts. In 13 August 2022, international databases and three Chinese databases were searched for randomized controlled trials, quasi-experimental studies and controlled before-after studies. Included studies assessed large-scale PHC policies since 2009; had a temporal comparator and a control group and assessed impacts on expenditures, utilization, care quality and health outcomes. Study quality was assessed using Risk of Bias In Non-randomized Studies of Interventions, and results were synthesized narratively. From 49 174 identified records, 42 studies were included-all with quasi-experimental designs, except for one randomized control trial. Nine studies were assessed as at low risk of bias. Only five low- to moderate-quality studies assessed the comprehensive reforms as a whole and found associated increases in health service utilization, whilst the other 37 studies examined single-component policies. The National Essential Medicine Policy (N = 15) and financing reforms (N = 11) were the most studied policies, whilst policies on primary care provision (i.e. family physician policy and the National Essential Public Health Services) were poorly evaluated. The PHC reforms were associated with increased primary care utilization (N = 17) and improved health outcomes in people with non-communicable diseases (N = 8). Evidence on healthcare costs was unclear, and impacts on patients' financial burden and care quality were understudied. Some studies showed disadvantaged regions and groups that accrued greater benefits (N = 8). China's comprehensive PHC reforms have made some progress in achieving their policy objectives including increasing primary care utilization, improving some health outcomes and reducing health inequalities. However, China's health system remains largely hospital-centric and further PHC strengthening is needed to advance universal health coverage.

Comparison of pay-for-performance (P4P) programs in primary care of selected countries: a comparative study

BACKGROUND

Pay for performance (P4P) schemes provide financial incentives or facilities to health workers based on the achievement of predetermined performance goals. Various P4P programs have been implemented around the world. There is a question of which model is suitable for p4p implementation to achieve better results. The purpose of this study is to compare pay for performance models in different countries.

METHODS

This is a descriptive-comparative study comparing the P4P model in selected countries in 2022. Data for each country are collected from reliable databases and are tabulated to compare their payment models. the standard framework of the P4P model is used for data analysis.

RESULTS

we used the standard P4P model framework to compare pay for performance programs in the primary care sector of selected countries because this framework can demonstrate all the necessary features of payment programs, including performance domains and measures, basis for reward or penalty, nature of the reward or penalty, and data reporting. The results of this study show that although the principles of P4P are almost similar in the selected countries, the biggest difference is in the definition of performance domains and measures.

CONCLUSIONS

Designing an effective P4P program is very complex, and its success depends on a variety of factors, from the socioeconomic and cultural context and the healthcare goals of governments to the personal characteristics of the healthcare provider. considering these factors and the general framework of the features of P4P programs are critical to the success of the p4p design and implementation.

Effects of performance-based capitation payment on the use of public primary health care services in Indonesia

The Indonesian national health insurance agency BPJS Kesehatan, the largest single-payer system in the world, is among the first to combine capitation-based payments with performance-based financing. The Kapitasi Berbasis Komitmen (KBK) scheme for puskesmas (community health centres) was implemented in province capitals between August 2015 and May 2016. Its main goal was to incentivize the substitution of secondary by primary care use. We evaluate its effect on its three incentivized outcomes: the fraction of insured visiting the puskesmas, the fraction of chronically ill with a puskesmas visit and the hospital referral rate for insured with a non-specialistic condition. We use BPJS Kesehatan claims data from 2015 to 2016 from a stratified one percent sample of its members. Comparable control districts were identified using coarsened exact matching. We adopt a Difference-in-Differences (DID) study design and estimate a two-way fixed effects regression model to compare 27 intervention districts to 300 comparable non-capital control districts. We find that KBK payment increased the monthly percentage of enrolees contacting a puskesmas with 0.578 percentage points. This is a sizeable increase of 48 percent compared to the baseline rate of just 1.2% but it still leaves most puskesmas far below the "sufficient" KBK threshold of 15%. For chronically ill patients, a small increase of 1.15 percentage points was estimated, but it leaves the rate even further below the program's "sufficient" threshold of 50%. We find no statistically significant effect on referral rates to hospitals for conditions not requiring specialist care. While we find positive effects of KBK on two out of three outcomes, all estimated effect sizes leave the actual rates far below the program targets. Our findings suggest that the KBK performance-based capitation reform has not been very successful in substituting secondary care use by greater primary care use.

Paying for performance to improve the delivery of health interventions in low- and middle-income countries

BACKGROUND

There is growing interest in paying for performance (P4P) as a means to align the incentives of healthcare providers with public health goals. Rigorous evidence on the effectiveness of these strategies in improving health care and health in low- and middle-income countries (LMICs) is lacking; this is an update of the 2012 review on this topic.

OBJECTIVES

To assess the effects of paying for performance on the provision of health care and health outcomes in low- and middle-income countries.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and 10 other databases between April and June 2018. We also searched two trial registries, websites, online resources of international agencies, organizations and universities, and contacted experts in the field. Studies identified from rerunning searches in 2020 are under 'Studies awaiting classification.'

SELECTION CRITERIA

We included randomized or non-randomized trials, controlled before-after studies, or interrupted time series studies conducted in LMICs (as defined by the World Bank in 2018). P4P refers to the transfer of money or material goods conditional on taking a measurable action or achieving a predetermined performance target. To be included, a study had to report at least one of the following outcomes: patient health outcomes, changes in targeted measures of provider performance (such as the delivery of healthcare services), unintended effects, or changes in resource use.

DATA COLLECTION AND ANALYSIS

We extracted data as per original review protocol and narratively synthesised findings. We used standard methodological procedures expected by Cochrane. Given diversity and variability in intervention types, patient populations, analyses and outcome reporting, we deemed meta-analysis inappropriate. We noted the range of effects associated with P4P against each outcome of interest. Based on intervention descriptions provided in documents, we classified design schemes and explored variation in effect by scheme design.

MAIN RESULTS

We included 59 studies: controlled before-after studies (19), non-randomized (16) or cluster randomized trials (14);  and interrupted time-series studies (9). One study included both an interrupted time series and a controlled before-after study. Studies focused on a wide range of P4P interventions, including target payments and payment for outputs as modified by quality (or quality and equity assessments). Only one study assessed results-based aid. Many schemes were funded by national governments (23 studies) with the World Bank funding most externally funded schemes (11 studies). Targeted services varied; however, most interventions focused on reproductive, maternal and child health indicators. Participants were predominantly located in public or in a mix of public, non-governmental and faith-based facilities (54 studies). P4P was assessed predominantly at health facility level, though districts and other levels were also involved. Most studies assessed the effects of P4P against a status quo control (49 studies); however, some studies assessed effects against comparator interventions (predominantly enhanced financing intended to match P4P funds (17 studies)). Four studies reported intervention effects against both comparator and status quo. Controlled before-after studies were at higher risk of bias than other study designs. However, some randomised trials were also downgraded due to risk of bias. The interrupted time-series studies provided insufficient information on other concurrent changes in the study context. P4P compared to a status quo control For health services that are specifically targeted, P4P may slightly improve health outcomes (low certainty evidence), but few studies assessed this. P4P may also improve service quality overall (low certainty evidence); and probably increases the availability of health workers, medicines and well-functioning infrastructure and equipment (moderate certainty evidence). P4P may have mixed effects on the delivery and use of services (low certainty evidence) and may have few or no distorting unintended effects on outcomes that were not targeted (low-certainty evidence), but few studies assessed these. For secondary outcomes, P4P may make little or no difference to provider absenteeism, motivation or satisfaction (low certainty evidence); but may improve patient satisfaction and acceptability (low certainty evidence); and may positively affect facility managerial autonomy (low certainty evidence). P4P probably makes little to no difference to management quality or facility governance (low certainty evidence). Impacts on equity were mixed (low certainty evidence). For health services that are untargeted, P4P probably improves some health outcomes (moderate certainty evidence); may improve the delivery, use and quality of some health services but may make little or no difference to others (low certainty evidence); and may have few or no distorting unintended effects (low certainty evidence). The effects of P4P on the availability of medicines and other resources are uncertain (very low certainty evidence). P4P compared to other strategies For health outcomes and services that are specifically targeted, P4P may make little or no difference to health outcomes (low certainty evidence), but few studies assessed this. P4P may improve service quality (low certainty evidence); and may have mixed effects on the delivery and use of health services and on the availability of equipment and medicines (low certainty evidence). For health outcomes and services that are untargeted, P4P may make little or no difference to health outcomes and to the delivery and use of health services (low certainty evidence). The effects of P4P on service quality, resource availability and unintended effects are uncertain (very low certainty evidence). Findings of subgroup analyses Results-based aid, and schemes using payment per output adjusted for service quality, appeared to yield the greatest positive effects on outcomes. However, only one study evaluated results-based aid, so the effects may be spurious. Overall, schemes adjusting both for quality of service and rewarding equitable delivery of services appeared to perform best in relation to service utilization outcomes.

AUTHORS' CONCLUSIONS

The evidence base on the impacts of P4P schemes has grown considerably, with study quality gradually increasing. P4P schemes may have mixed effects on outcomes of interest, and there is high heterogeneity in the types of schemes implemented and evaluations conducted. P4P is not a uniform intervention, but rather a range of approaches. Its effects depend on the interaction of several variables, including the design of the intervention (e.g., who receives payments ), the amount of additional funding,  ancillary components (such as technical support) and contextual factors (including organizational context).

Is the evidence on the effectiveness of pay for performance schemes in healthcare changing? Evidence from a meta-regression analysis

BACKGROUND

This study investigated if the evidence on the success of the Pay for Performance (P4P) schemes in healthcare is changing as the schemes continue to evolve by updating a previous systematic review.

METHODS

A meta-regression analysis using 116 studies evaluating P4P schemes published between January 2010 to February 2018. The effects of the research design, incentive schemes, use of incentives, and the size of the payment to revenue ratio on the proportion of statically significant effects in each study were examined.

RESULTS

There was evidence of an increase in the range of countries adopting P4P schemes and weak evidence that the proportion of studies with statistically significant effects have increased. Factors hypothesized to influence the success of schemes have not changed. Studies evaluating P4P schemes which made payments for improvement over time, were associated with a lower proportion of statistically significant effects. There was weak evidence of a positive association between the incentives' size and the proportion of statistically significant effects.

CONCLUSION

The evidence on the effectiveness of P4P schemes is evolving slowly, with little evidence that lessons are being learned concerning the design and evaluation of P4P schemes.

Payment methods for healthcare providers working in outpatient healthcare settings

BACKGROUND

Changes to the method of payment for healthcare providers, including pay-for-performance schemes, are increasingly being used by governments, health insurers, and employers to help align financial incentives with health system goals. In this review we focused on changes to the method and level of payment for all types of healthcare providers in outpatient healthcare settings. Outpatient healthcare settings, broadly defined as 'out of hospital' care including primary care, are important for health systems in reducing the use of more expensive hospital services.

OBJECTIVES

To assess the impact of different payment methods for healthcare providers working in outpatient healthcare settings on the quantity and quality of health service provision, patient outcomes, healthcare provider outcomes, cost of service provision, and adverse effects.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase (searched 5 March 2019), and several other databases. In addition, we searched clinical trials platforms, grey literature, screened reference lists of included studies, did a cited reference search for included studies, and contacted study authors to identify additional studies. We screened records from an updated search in August 2020, with any potentially relevant studies categorised as awaiting classification.

SELECTION CRITERIA

Randomised trials, non-randomised trials, controlled before-after studies, interrupted time series, and repeated measures studies that compared different payment methods for healthcare providers working in outpatient care settings.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We conducted a structured synthesis. We first categorised the payment methods comparisons and outcomes, and then described the effects of different types of payment methods on different outcome categories. Where feasible, we used meta-analysis to synthesise the effects of payment interventions under the same category. Where it was not possible to perform meta-analysis, we have reported means/medians and full ranges of the available point estimates. We have reported the risk ratio (RR) for dichotomous outcomes and the relative difference (as per cent change or mean difference (MD)) for continuous outcomes.

MAIN RESULTS

We included 27 studies in the review: 12 randomised trials, 13 controlled before-and-after studies, one interrupted time series, and one repeated measure study. Most healthcare providers were primary care physicians. Most of the payment methods were implemented by health insurance schemes in high-income countries, with only one study from a low- or middle-income country. The included studies were categorised into four groups based on comparisons of different payment methods. (1) Pay for performance (P4P) plus existing payment methods compared with existing payment methods for healthcare providers working in outpatient healthcare settings P4P incentives probably improve child immunisation status (RR 1.27, 95% confidence interval (CI) 1.19 to 1.36; 3760 patients; moderate-certainty evidence) and may slightly increase the number of patients who are asked more detailed questions on their disease by their pharmacist (MD 1.24, 95% CI 0.93 to 1.54; 454 patients; low-certainty evidence). P4P may slightly improve primary care physicians' prescribing of guideline-recommended antihypertensive medicines compared with an existing payment method (RR 1.07, 95% CI 1.02 to 1.12; 362 patients; low-certainty evidence). We are uncertain about the effects of extra P4P incentives on mean blood pressure reduction for patients and costs for providing services compared with an existing payment method (very low-certainty evidence). Outcomes related to workload or other health professional outcomes were not reported in the included studies. One randomised trial found that compared to the control group, the performance of incentivised professionals was not sustained after the P4P intervention had ended. (2) Fee for service (FFS) compared with existing payment methods for healthcare providers working in outpatient healthcare settings We are uncertain about the effect of FFS on the quantity of health services delivered (outpatient visits and hospitalisations), patient health outcomes, and total drugs cost compared to an existing payment method due to very low-certainty evidence. The quality of service provision and health professional outcomes were not reported in the included studies. One randomised trial reported that physicians paid via FFS may see more well patients than salaried physicians (low-certainty evidence), possibly implying that more unnecessary services were delivered through FFS. (3) FFS mixed with existing payment methods compared with existing payment methods for healthcare providers working in outpatient healthcare settings FFS mixed payment method may increase the quantity of health services provided compared with an existing payment method (RR 1.37, 95% CI 1.07 to 1.76; low-certainty evidence). We are uncertain about the effect of FFS mixed payment on quality of services provided, patient health outcomes, and health professional outcomes compared with an existing payment method due to very low-certainty evidence. Cost outcomes and adverse effects were not reported in the included studies. (4) Enhanced FFS compared with FFS for healthcare providers working in outpatient healthcare settings Enhanced FFS (higher FFS payment) probably increases child immunisation rates (RR 1.25, 95% CI 1.06 to 1.48; moderate-certainty evidence). We are uncertain whether higher FFS payment results in more primary care visits and about the effect of enhanced FFS on the net expenditure per year on covered children with regular FFS (very low-certainty evidence). Quality of service provision, patient outcomes, health professional outcomes, and adverse effects were not reported in the included studies.

AUTHORS' CONCLUSIONS

For healthcare providers working in outpatient healthcare settings, P4P or an increase in FFS payment level probably increases the quantity of health service provision (moderate-certainty evidence), and P4P may slightly improve the quality of service provision for targeted conditions (low-certainty evidence). The effects of changes in payment methods on health outcomes is uncertain due to very low-certainty evidence. Information to explore the influence of specific payment method design features, such as the size of incentives and type of performance measures, was insufficient. Furthermore, due to limited and very low-certainty evidence, it is uncertain if changing payment models without including additional funding for professionals would have similar effects. There is a need for further well-conducted research on payment methods for healthcare providers working in outpatient healthcare settings in low- and middle-income countries; more studies comparing the impacts of different designs of the same payment method; and studies that consider the unintended consequences of payment interventions.

A realist review to assess for whom, under what conditions and how pay for performance programmes work in low- and middle-income countries

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.

The Impact of Physicians' Working Hours on Inappropriate Use of Outpatient Medicine in a Tertiary Hospital in China

BACKGROUND

Inappropriate prescribing is an important health system problem in China. Several studies have identified critical factors influencing prescription quality, but the impact of physicians' working hours remains unknown. In China, tertiary hospitals face ever-increasing outpatient volumes. Physicians are asked to work long hours and the impact of shift duration on prescription quality is unknown.

OBJECTIVE

We aimed to investigate the association between consecutive working hours and the quality of physicians' prescriptions in a Chinese tertiary hospital.

METHODS

We obtained all outpatient electronic health records from the hospital information system (HIS) of a tertiary hospital in Beijing, China from 1 July to 30 November 2015. Prescriptions made during two periods were analyzed: a morning shift from 7:30 to 12:30, and an afternoon shift from 13:30 to 18:30. The time when a physician issued the first prescription was considered the beginning of the work shift and prescriptions within the next 4 consecutive hours were included. Potentially inappropriate prescriptions were based on the Rational Drug Use (RDU) system that was developed and validated for this study. We used multivariable logistic regression to examine the impact of shift duration and other clinical and physician factors on potentially inappropriate prescribing.

RESULTS

Of the total 560,529 prescriptions, 15.3% were classified as inappropriate by the RDU system. Physicians' inappropriate prescribing increased in the last hour in each work shift (odds ratio (OR) for the fourth hour compared to the first = 1.12 (95% CI, 1.09-1.15)). We also found that physicians who worked all day had a higher rate of inappropriate prescribing than those who only worked half a day (OR = 1.05 (95% CI, 1.04-1.07)).

CONCLUSIONS

Longer working hours are a risk factor for inappropriate prescribing. Relevant interventions are urgently needed to establish working hour limits in China to reduce the likelihood of inappropriate prescribing by physicians.

The impact of global budget on expenditure, service volume, and quality of care among patients with pneumonia in a secondary hospital in China: a retrospective study

BACKGROUND

The Chinese government has begun to dampen the growth of health expenditure by implementing Global Budgets (GB). Concerns were raised about whether reductions in expenditure would lead to a deterioration of quality of care. This paper aims to evaluate the impact of GB on health expenditure, service volume and quality of care among Chinese pneumonia patients.

METHODS

A secondary hospital that replaced Fee-For-Service (FFS) with GB in China in 2016 was sampled. We used daily expenditure to assess health expenditure; monthly admission, length of stay (LOS), number of drugs per record and record containing antibiotics to evaluate service volume; record with multiple antibiotics and readmission to assess quality of care. Descriptive analyses were adopted to evaluate changes after the reform, logistic regression and multivariable linear regressions were used to analyze changes associated with the reform.

RESULTS

In 2015 and 2016, 3400 admissions from 3173 inpatients and 2342 admissions from 2246 inpatients were admitted, respectively. According to regression analyses, daily expenditure, LOS, readmission, and records with multiple antibiotic usages significantly declined after the reform. However, no significant relation was observed between GB and the number of drugs per record or record containing antibiotics.

CONCLUSIONS

When compared with FFS, GB can curtail health expenditure and improve quality of care. As far as service volume was concerned, LOS and monthly admission declined, while number of drugs per record and record containing antibiotics were not affected.

The impact of global budget on expenditure, service volume, and quality of care among patients with pneumonia in a secondary hospital in China: a retrospective study

BACKGROUND

The Chinese government has begun to dampen the growth of health expenditure by implementing Global Budgets (GB). Concerns were raised about whether reductions in expenditure would lead to a deterioration of quality of care. This paper aims to evaluate the impact of GB on health expenditure, service volume and quality of care among Chinese pneumonia patients.

METHODS

A secondary hospital that replaced Fee-For-Service (FFS) with GB in China in 2016 was sampled. We used daily expenditure to assess health expenditure; monthly admission, length of stay (LOS), number of drugs per record and record containing antibiotics to evaluate service volume; record with multiple antibiotics and readmission to assess quality of care. Descriptive analyses were adopted to evaluate changes after the reform, logistic regression and multivariable linear regressions were used to analyze changes associated with the reform.

RESULTS

In 2015 and 2016, 3400 admissions from 3173 inpatients and 2342 admissions from 2246 inpatients were admitted, respectively. According to regression analyses, daily expenditure, LOS, readmission, and records with multiple antibiotic usages significantly declined after the reform. However, no significant relation was observed between GB and the number of drugs per record or record containing antibiotics.

CONCLUSIONS

When compared with FFS, GB can curtail health expenditure and improve quality of care. As far as service volume was concerned, LOS and monthly admission declined, while number of drugs per record and record containing antibiotics were not affected.

Implementation of provider payment system reforms in the age of universal health coverage: a realist review of evidence from Asian developing countries

Objective

Launched to assist in achieving universal health coverage, provider payment reform (PPR) is one of the most important policy tools deployed to transform incentives within a health system that is plagued with allocative inefficiency and high out-of-pocket payments to one that is able to deliver basic services and be cost-efficient. However, the black box of such reform – that is, the contexts in which reform operates, the mechanisms by which it changes health systems and behaviour within health systems, and the outcome patterns that arise from – remains unexplored. This review aims to examine the implementation mechanisms underlying PPR in Asian developing countries.

Methods

A realist synthesis approach was employed to tease out the configurative elements of PPR in developing countries. A multimethod and retrospective search was conducted to locate the evidence. A programme theory and data extraction framework were developed. Data were analysed using thematic synthesis to inform an overarching realist synthesis, expressed as a set of synthesized context-mechanism-outcome configurations.

Results

This review found that the policy design of PPR, policy capacity, willingness of policy adoption at the local government level and provider autonomy are critical contextual factors that could trigger different policy mechanisms leading to either intended theoretical outcomes or perverse incentives.

Conclusions

Our findings, demonstrating the PPR implementation contexts and mechanisms that have worked in Asian countries, have implications in terms of policy learning for most developing countries that are contemplating rolling out similar reforms in the future.

Should performance-based incentives be used to motivate health care providers? Views of health sector managers in Cambodia, China and Pakistan

This study qualitatively investigates what factors apart from or in addition to financial incentives can encourage better performance of frontline health care providers. We interviewed health sector managers in Pakistan, Cambodia and China, and they highlighted many potential limitations in the applicability of financial incentives in their contexts. There was a consistent view that providers are not always primarily driven by monetary rewards and that non-monetary rewards - such as recognition from direct supervisors and career development - could have a greater influence on performance. Managers also highlighted several challenges related to the design and implementation of performance management schemes: supervisors may not have performance information necessary to determine which agents to reward; when performance information is available, organisational culture may value other attributes such as social ties or years of experience; finally, concentration of power at higher levels of the health system can reduce supervisors' ability to manage performance, rewards and accountability. Although health sector managers were enthusiastic about measures to improve performance of providers, our study indicated that specific social, cultural and health system factors may mean that non-monetary rewards and structural changes to support a more transparent and meritocratic working environment should also be considered.

Health Insurance and Payment System Reform in China

Payment system reform has become one of the primary targets of Chinese healthcare reform since 2009. This chapter describes the development of China’s insurance system, along with a review of the policy and impacts of payment reform from fee-for-service to alternative schemes, while focusing on capitation payments. In China, public programs presently cover most of the population; the participation of private insurance firms is limited. Studies to date have found no significant impact of capitation payment on total medical expenditure. The reason could be that providers are slow to respond. Also, the impact could have been diluted because reforms were implemented only on some insurance programs paying providers, but not all.

China's Health Reform Update

China experienced both economic and epistemological transitions within the past few decades, greatly increasing demand for accessible and affordable health care. These shifts put significant pressure on the existing outdated, highly centralized bureaucratic system. Adjusting to growing demands, the government has pursued a new round of health reforms since the late 2000s; the main goals are to reform health care financing, essential drug policies, and public hospitals. Health care financing reform led to universal basic medical insurance, whereas the public hospital reform required more complex measures ranging from changes in regulatory, operational, and service delivery settings to personnel management. This article reviews these major policy changes and the literature-based evidence of the effects of reforms on cost, access, and quality of care. It then highlights the outlook for future reforms. We argue that a better understanding of the unintended consequences of reform policies and of how practitioners’ and patients’ interests can be better aligned is essential for reforms to succeed.