Reviewing the evidence on health financing for effective coverage: do financial incentives work?

Impact of health system governance on healthcare quality in low-income and middle-income countries: a scoping review

INTRODUCTION

Improving healthcare quality in low-/middle-income countries (LMICs) is a critical step in the pathway to Universal Health Coverage and health-related sustainable development goals. This study aimed to map the available evidence on the impacts of health system governance interventions on the quality of healthcare services in LMICs.

METHODS

We conducted a scoping review of the literature. The search strategy used a combination of keywords and phrases relevant to health system governance, quality of healthcare and LMICs. Studies published in English until August 2023, with no start date limitation, were searched on PubMed, Cochrane Library, CINAHL, Web of Science, Scopus, Google Scholar and ProQuest. Additional publications were identified by snowballing. The effects reported by the studies on processes of care and quality impacts were reviewed.

RESULTS

The findings from 201 primary studies were grouped under (1) leadership, (2) system design, (3) accountability and transparency, (4) financing, (5) private sector partnerships, (6) information and monitoring; (7) participation and engagement and (8) regulation.

CONCLUSIONS

We identified a stronger evidence base linking improved quality of care with health financing, private sector partnerships and community participation and engagement strategies. The evidence related to leadership, system design, information and monitoring, and accountability and transparency is limited.

The effectiveness of pay-for-performance contracts with non-governmental organizations in Afghanistan - results of a controlled interrupted time series analysis

BACKGROUND

In many contexts, including fragile settings like Afghanistan, the coverage of basic health services is low. To address these challenges there has been considerable interest in working with NGOs and examining the effect of financial incentives on service providers. The Government of Afghanistan has used contracting with NGOs for more than 15 years and in 2019 introduced pay-for-performance (P4P) into the contracts. This study examines the impact of P4P on health service delivery in Afghanistan.

METHODS

We conducted an interrupted time series (ITS) analysis with a non-randomized comparison group that employed segmented regression models and used independently verified health management information system (HMIS) data from 2015 to 2021. We compared 31 provinces with P4P contracts to 3 provinces where the Ministry of Public Health (MOPH) continued to deliver services without P4P. We used data from annual health facility surveys to assess the quality of care.

FINDINGS

Independent verification of the HMIS data found that consistency and accuracy was greater than 90% in the contracted provinces. The introduction of P4P increased the 10 P4P-compensated service delivery outcomes by a median of 22.1 percentage points (range 10.2 to 43.8) for the two-arm analysis and 19.9 percentage points (range: - 8.3 to 56.1) for the one-arm analysis. There was a small decrease in quality of care initially, but it was short-lived. We found few other unintended consequences.

INTERPRETATION

P4P contracts with NGOs led to a substantial improvement in service delivery at lower cost despite a very difficult security situation. The promising results from this large-scale experience warrant more extensive application of P4P contracts in other fragile settings or wherever coverage remains low.