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How Often Should I Review a Measure for Pay for Performance

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Issue of pay for performance to meliorate quality of maternal and child care in low- and middle-income countries: a systematic review

BMC Public Health volume 16, Article number:321 (2016) Cite this commodity

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Abstract

Background

Pay for Performance (P4P) mechanisms to health facilities and providers are currently beingness tested in several low- and heart-income countries (LMIC) to better maternal and child wellness (MCH). This paper reviews the existing evidence on the effect of P4P program on quality of MCH care in LMICs.

Methods

A systematic review of literature was conducted according to a registered protocol. MEDLINE, Spider web of Science, and Embase were searched using the key words maternal intendance, quality of care, ante natal intendance, emergency obstetric and neonatal care (EmONC) and child intendance. Of 4535 records retrieved, only eight papers met the inclusion criteria. Primary consequence of interest was quality of MCH disaggregated into structural quality, procedure quality and outcomes. Gamble of bias across studies was assessed through a customized quality checklist.

Results and word

There were four controlled earlier after intervention studies, 3 cluster randomized controlled trials and ane instance control with postal service-intervention comparing of P4P programs for MCH care in Burundi, Autonomous Democracy of Congo, Arab republic of egypt, the Philippines, and Rwanda. There is some bear witness of positive event of P4P only on process quality of MCH. The upshot of P4P on delivery, EmONC, postal service natal care and under-5 child care were non evaluated in these studies. There is weak prove for P4P's positive consequence on maternal and neonatal health outcomes and out-of-pocket expenses. P4P program had a few negative furnishings on structural quality.

Conclusion

P4P is constructive to improve procedure quality of ante natal care. However, further inquiry is needed to understand P4P's impact on MCH and their causal pathways in LMICs.

Trial registration

PROSPERO registration number CRD42014013077.

Peer Review reports

Background

Pay for performance (P4P) is an emerging health sector strategy to amend availability, quality and utilization of essential healthcare services. P4P aims at incentivizing performance of the providers and clients for uptake of key services and behavior changes [1]. P4P belongs to the category of innovative financing mechanisms that includes similar type of payment systems such as results based financing, performance-based financing, performance-based contracting, output-based help, conditional cash transfer and cash on commitment [1]. In supply-side P4P, incentives are provided to achieve a pre-agreed set of results (outputs and outcomes) by improving the performance of health workforce and health facilities [2] and involves a strict monitoring of results in a stipulated fourth dimension-frame. Typically, performance in a P4P program is measured through health outcomes, utilization of services, and quality of intendance [3]. Though P4P has been widely implemented in both high- and low-income settings, its primary focus and trajectory are context specific [3]. In low- and middle-income countries (LMICs), P4P is unremarkably used to reach unmet millennium development goals (MDG) 4 and v on maternal and child wellness (MCH) [iv]. However, the exiting knowledge on the effects of P4P is limited to utilization of a few services than quality of care [four]. Even in high-income countries, rigorous prove on the effect of P4P on quality of care is express [five–8].

Several LMICs in Asia and Africa have experimented P4P to amend MCH since 1990s, mainly to mitigate the brunt of maternal and child conditions [4, ix, 10]. Clinical bear witness indicates that quality of MCH intendance is a pre-requisite to reduce maternal and child mortalities [11]. An increased uptake of MCH services such as skilled nascence attendance and newborn care without acceptable quality cannot guarantee an improved MCH status [12]. Studies conducted in Kingdom of cambodia, Democratic Republic of Congo, Republic of burundi, Rwanda, Haiti have demonstrated improvements in maternal and child healthcare service utilization and to some extent amend financial and management capacities with health facilities [13]. At that place is no synthesized prove supporting the positive upshot of P4P on quality of care. In addition, a systematic review conducted on P4P in LMICs asserts that the testify is weak to conclude the bear upon of provider incentives on quality of care [4]. If P4P positively impacts only service utilization without corresponding improvements in quality of care, current investments on P4P in low-income countries may not exist cost-effective to improve MDGs 4 and v [3]. In this systematic review, nosotros assessed the effect of supply-side pay for performance on the quality of maternal and child health services in LMICs. While identifying the knowledge gaps in this expanse, we also explored the appropriateness of methods adopted past dissimilar studies to measure quality of MCH intendance under P4P.

Defining quality of healthcare: definition and measures

Constitute of Medicine (IOM) defines quality in healthcare as the "degree to which wellness services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional noesis" [fourteen]. Donabedian describes healthcare service delivery as a continuum which includes structures, processes, and outcomes and asserts quality of care is an end product when the structures are translated to outcomes through the processes [xv]. In the service delivery continuum, there is equal emphasis on each of the higher up mentioned aspects of quality. Structural quality consists of human being and cardinal material resources such every bit infrastructure, equipment, drugs and supplies, advice, and send. Apart from having the needful material resource, it is also essential that they are put to practice to provide services. To evangelize optimal quality of care, adequately skilled and motivated homo resources should exist available [15]. Process simply means whether services are provided optimally and safely post-obit the standards of service delivery through technical and not-technical operation [15]. Technical performance entails delivering scientifically proven services at the appropriate time. For instance, during routine antenatal visit, a woman should undergo weighing; testing of blood and urine samples for infection and signs of pre-eclampsia; palpation of abdomen; and measurement of claret pressure and intestinal girth. Not-technical performance relates to interpersonal human relationship, provider behavior, privacy, and confidentiality [13, 16–18]. Key consequences of the service delivery such as morbidity, mortality, out-of-pocket expenses, and client satisfaction plant the outcomes [12]. In this review, we prefer Donabedian'due south definition of quality in healthcare.

Methods

Protocol and registration

This report is registered with the PROSPERO international prospective register of systematic reviews (registration number CRD42014013077) [xix]. A peer-reviewed protocol guided the conduct of review. This review is reported every bit per PRISMA guidelines [xx].

Selection of studies

Studies from low- and middle-income countries as defined by the World Bank income criteria were included [21]. Two of the authors (AD and SG) independently searched the literature, screened abstracts and retrieved full papers. Final choice of studies against the inclusion criteria was washed independently by these authors and disagreements were resolved through a consultative process.

Inclusion criteria

  1. 1.

    Evaluation reporting results of whatsoever supply-side (i.due east. facility/provider) P4P on a quantitative measure of MCH care quality

  2. 2.

    Study conducted in depression- and middle-income countries

  3. 3.

    Published in English between January, 1990 and June, 2014. This selection is based on the fact that P4P programs started from the 1990s.

  4. 4.

    Presence of at least ane comparison group

  5. 5.

    Written report reporting statistical significance of the intervention than only descriptive analysis

  6. 6.

    Report meeting a minimum quality score of six, divers by ii reviewers

Exclusion criteria

  1. 1.

    Written report presenting the impact of P4P on only access to and usage of MCH care without any quality of intendance measures

  2. 2.

    Qualitative study or review

  3. 3.

    Study on P4P presenting not-MCH care

  4. 4.

    Study reporting but descriptive analysis

  5. 5.

    Study with a quality score of less than 6

Type of studies

Studies were selected if they met the criteria used past the Cochrane Effective Practice and Organization of Intendance group (EPOC) [22]. The EPOC study designs are: randomized controlled trials (RCTs), clustered randomized controlled trials (c-RCT), controlled clinical trials (CCT), controlled before-after studies (CBAs) and quasi-experimental studies including interrupted time serial. Given the dearth of literature on P4P and quality of MCH care, in addition studies having at least 1 intervention and i comparing group were included.

Types of participants

Study population comprised of women during pregnancy and post-partum catamenia; children younger than five years; and health workers nether assessment for a P4P programme.

Type of interventions

P4P interventions in public or private sector, providing conditional financial incentives to facilities and/or providers to accomplish sure performance measures on MCH services including quality were selected.

Operational definitions

Maternal health care included whatever routine or disease intendance received during the antenatal, delivery and postpartum period. Child wellness care included any care received from birth upwardly to v years of age for any routine or illness conditions. Health workers were divers as medically trained personnel (doctors, clinical officers, midwives, and nurses) working at a master or secondary care level in LMIC settings.

Outcomes of interest

Primary result of interest was quality of MCH disaggregated into structural quality, process quality and outcomes. Under structural quality, we considered availability of health facility infrastructure, skilled staff, equipment, commodities, and drugs. For process quality, we included adherence to standard protocols and guidelines for management of health conditions. Morbidity, mortality, out-of-pocket expenses for medical services in the healthcare facility, and client satisfaction constituted the outcomes.

Information sources and search

Records were searched in several electronic search engines and databases namely MEDLINE, EMBASE, Global Health, PsycINFO, Econlit and Web of Science. Additionally, Google Scholar was searched electronically. Websites of primal organizations involved in P4P programs (World Bank, DFID and NORAD) were purposively searched for published articles or working papers. A mitt search enabled to retrieve certain relevant papers from the selected records. Contacts were fabricated to authors and scholars in the field of P4P to identify additional studies.

The literature search was conducted during May-August 2014. Records published between January, 1990 and June, 2014 were selected. Each database had different search words equally a combination of MeSH (medical subject heading) and not-MeSH terms using Boolean operators "AND" and "OR". The search algorithm was developed based on a preliminary search in PubMed and Google Scholar. The thematic search words are given in Tabular array 1.

Tabular array i Search strategy

Total size table

Data items and extraction

Country and yr of report, study settings and design, sample size, type of incentive (recipient, conditionality and frequency), comparison groups, effect measures, and quality chemical element of the outcome measures were extracted using a data extraction form. The primary writer extracted the information and a second author validated the process.

Summary measures and information synthesis

Where possible we presented either odds ratio or coefficient along with the confidence interval. Net effects of the interventions were calculated every bit the difference between intervention and control groups at baseline and follow upwardly, and presented as percent points, coefficients or absolute numbers in natural units. Nosotros considered an issue statistically significant at 5 % level (p < 0.05). The reported outcomes were presented by the elements of quality, i.e. structure, procedure and outcomes. Due to heterogeneity of studies and presentation of results, no meta-analysis could be performed.

Appraising methodological and reporting quality of included studies

Nosotros adult a customized quality assessment tool for appraising methodological quality of studies, adapted from Downs and Black [23]. The quality tool took into account methodological quality (randomization, baseline balance of cardinal variables), external validity (representativeness of study sample, contagion of interventions), and reporting quality (clear description of objectives, interventions, outcomes, power calculations, findings). Our adaptation was reflected in scoring various types of studies with the highest score assigned to RCTs, replacing representativeness of patients with facilities, and removal of items related to blinding of randomization and patient adverse events. There were xviii quality indicators for RCTs and 17 for CBAs and each indicator had an indicative score. Wherever the description did non include a detail item mentioned in the quality assessment tool or it was unclear, we scored that item naught. Because of the variation in scoring between studies (i.e. RCT and CBA), nosotros standardized the absolute scores to pct to ensure comparability. Based on the aggregate quality score, studies were ranked as depression (<34 %), moderate (34-66 %) and loftier (>66 %). Ii of the authors (Advertizement and SG) independently assessed the quality of studies, with whatsoever disagreements resolved through discussions.

Results

Study option

Search from the databases identified 4535 records, and an additional 113 records were retrieved from other sources and personal communications with researchers. Screened records were 188 afterward removing duplicates and excluding records that did non mention P4P and quality. From 13 articles eligible for full-text assessment, only eight were included in the review. Details of the report selection are given in the Fig. one.

Fig. 1
figure 1

Menstruum diagram for option of articles

Full size image

Study characteristics and settings

In that location were four CBAs, three cluster RCT and 1 instance control with post-intervention comparing [24–31] of P4P programs on MCH care in Republic of burundi, Democratic Republic of Congo (DRC), Egypt, the Philippines, and Rwanda (Table 2). V studies took place in principal care health centers [24–27, 31], two reported results from commune level hospitals [28, 29] and one was conducted in both chief and secondary level facilities [xxx].

Table 2 Study characteristics and Quality score

Full size tabular array

Ii cluster randomized trials of performance based salary bonus to wellness care providers were reported from the Philippines [28, 29]. In these 2 RCTs, 30 district hospitals from districts matched by socio-economic, demographic and health contour were randomized to one of the ii intervention arms or to the control arm. In the cluster randomized trial in DRC, 96 health facilities in one commune were randomly assigned to intervention and command artillery [30]; the intervention arm received performance-based incentives, while control arms simply input-based financing.

The CBA in Rwanda randomly assigned 80 health facilities from 12 districts to receive a P4P intervention and 86 health facilities from 7 districts to receive an equivalent input-based financing [27]. The CBA of a P4P programme in DRC [24] allocated ii districts to receive performance-based incentives and compared the outcomes with some other two districts having similar socio-economic characteristics. From Egypt, a post-test only comparison study that assessed a P4P program in chief health centers receiving incentives for more than than ii years [31] was reported. Comparing groups received equivalent additional incentives as salary top-off without any operation conditionality. Two studies of P4P plan were reported from Burundi. 1 study used a CBA for the pilot phase [26] and the second study compared population level outcomes on quality of antenatal care between P4P and non-P4P provinces in the nation-broad roll-out phase [25].

Characteristics of performance measures and payments on quality of intendance

Studies described various performance measurement and payment mechanisms for quality of intendance. Performance mechanisms included achieving a sure level of volume and quality of MCH services. 3 programs incentivized quality of care with limited gear up of indices [26–29, 32]. Three others utilized a composite index including availability of human and fabric resource, compliance to national standards, proper record keeping, and customer satisfaction [24, 30, 31].

Payment systems included payment for individual health workers [28, 29, 31] or for facilities [24–27]. Incentives accounted for v % of doc's salary in the Philippines [29] and 275 % times the base bacon of a primary wellness facility staff in Egypt [31]. In DRC, the monthly payments to facilities ranged from $200 to $4000 [24].

In DRC, autonomously from incentivizing utilization of MCH services, the program offered a bonus of upwardly to 15 % of the subsidies to facilities on quality of intendance [24]. Performance indicators in Arab republic of egypt consisted of preventive, curative and quality of care measures (abyss of medical records, patient satisfaction and waiting time) on MCH [31]. The Rwandan program incentivized facilities on a combination of service volume and quality for MCH [27]. The P4P facilities in the Philippines received incentives linked with the boilerplate clinical competence scores of physicians, facility caseload, and average utilization of services (quantity) and adherence to national standards and protocols (quality) [28]. This adherence to treatment guidelines was assessed for vaccinations, family planning, tuberculosis, HIV and antenatal care.

Reporting of quality of care in studies

Studies adopted different methods to report quality of care outcomes. Mostly, quality was reported either objectively (direct ascertainment of availability and receipt of services as per national standards of care) or reported by patients (eastward.g. receipt of services, perceptions on staff attitude, waiting fourth dimension, quality of services). Means of verification of quality were through get out and household interviews (patient perception and experiences), review of records, direct observation (infrastructure, drugs and equipment) and vignettes. Vi studies utilized household interviews to mensurate quality [24–27, 29, 30], while two studies each employed get out interviews [thirty, 31], review of records [24, 26], and direct observations [24, 26]. Merely i study applied vignettes as a means of verification [28].

Take a chance of bias across studies

The mean quality of studies score was 63.8 % with a range of 41 to 88 %. Ii RCTs were of loftier quality with a score of 78 % [29, 30] and one RCT had a score of 72 % [28] (Table two). Among the v CBA studies, merely 1 [27] was of loftier quality, scoring 88 %. Two studies were of medium quality with a score of 53 and 59 % [25, 26]. Two CBA studies were of depression quality with a score of 41 % [24, 31].

V studies did not report baseline participant characteristics, representativeness of the participants or facilities, estimates of random variability and actual probability values [24–26, 30, 31]. 3 CBAs did not mention the matching criteria for control and intervention sites [24, 27, 32]. Studies with selection bias did non consider the use of instrumental variable techniques to identifying treatment effects. Seasonality might take confounded the outcomes in the DRC study every bit the surveys were conducted at 2 different seasons [24].

Effects of interventions

Structural quality

Studies gathered results on structural quality from direct observation and review of records. Four studies described the upshot of P4P on elements of structural quality (Table three). The availability of qualified staff increased by 15 % points and patient perceived availability of drugs improved past 37 % points in DRC [24] compared to pre-intervention period. In the Philippines, P4P improved physicians' noesis to manage under-v diarrhea and pneumonia (coefficient one.half dozen; p < 0.001) [29]. However, some other study showed some negative furnishings of P4P on structural quality in DRC [30]. These negative effects were observed on overall structural quality index and availability of drugs and vaccines in the facility [30]. Patient perceived availability of drugs decreased (coefficient -308.33; p < 0.001). There was a decline in structural quality index based on interviewers' observation (coefficient -0.525; p = 0.014), equipment index (coefficient -0.639; p = 0.026) and vaccine availability (coefficient -0.744; p = 0.034). In this study, P4P did not prove any effect on patient perceived equipment quality, infrastructure index and the number of types of drug currently available. Patient perceived availability of drugs in Burundi (coefficient 0.04; p = 0.492) and equipment quality in DRC (coefficient 0; p = 0.997) did not change under the P4P plan [26, 30].

Tabular array iii Effect on structural quality

Full size table

Procedure quality

Studies reported process quality results from direct observation and review of records. 4 studies presented P4P's bear on on diverse elements of process quality (Table 4). One study reported P4P'southward consequence on history taking and examination of significant women during ANC [31]. Two studies reported the effect on prescription and handling of pregnant women and nether-five children [30, 31]. Three studies mentioned almost patient reported process quality on MCH services [29, 32, 33]. The report in Arab republic of egypt showed the P4P increased the chances of a provider asking about parity (coefficient eleven.4; p < 0.05) and past illness (coefficient 16.4; p < 0.01) during ANC visits [31]. But, the P4P did not significantly influence the chance of a provider enquiring almost a meaning women'southward name, age and concluding menstrual bike. In this study, P4P increased likelihood of measuring claret pressure (coefficient 8.four; p < 0.01), testing blood (coefficient 12; p < 0.01) and urine (coefficient twenty; p < 0.01) during ANC visits. Even so, P4P plan did not influence the chances of beingness weighed or fetal middle rate checked. The P4P increased provider'due south adherence to explaining medicine intake for children under v years (coefficient xi.1; p < 0.05), follow-upward treatment (coefficient 24.ii; p < 0.05) and medicines (coefficient 10.5; p < 0.05). However, the programme could non improve provider practices on treatment, prescribing iron, injections, vitamins, and tetanus toxoid for ANC visits. In Rwanda, P4P increased the ANC quality alphabetize in primary health centers (coefficient 0.157; p = 0.02) [27]. In DRC, P4P improved patient's perceived quality of care index (coefficient 15; p < 0.05) and professional quality score of facilities on MCH services (coefficient 26; P < 0.001) [24]. Patient perceived overall quality of intendance alphabetize is the aggregate score given by the patient for diverse dimensions of provider behavior and competence (e.g. how provider explores the example scenario, how provider explains the health condition, how much respect a provider gives for the patient etc.) Professional quality score of the facility is a blended score consisting of structural and process elements as shown past both studies in DRC and Burundi. All the same, P4P program did not influence provider'southward adherence to standardized medical process for any MCH service (coefficient -0.015; p = 0.695) [30].

Tabular array iv Effect on procedure quality

Full size table

Quality outcomes

Studies obtained results on quality outcomes from review of records, exit interviews, household interviews and vignettes. V studies demonstrated the consequence of P4P on patient knowledge on managing wellness conditions, morbidity, bloodshed, out-of-pocket expense and client satisfaction (Table 5) [24, 29–32].

Table 5 Effect on quality outcomes

Full size table

Patient knowledge

Number of pregnant women knowing the usage of pre-natal drugs increased in Egypt (coefficient 12; p < 0.05), while patient'southward knowledge on drug intake decreased in DRC (coefficient -0.072; p = 0.039) [30, 31].

Health outcomes

In the Philippines, in that location was a minor improvement in patient reported health mensurate for nether-five (coefficient 7.37; p = 0.001) [29]. However, P4P had no issue on the prognosis of astute infections or on the incidence of anemia among sick children after 6 to 10 weeks of discharge from hospital. Nether-5 children did not experience whatsoever improvements in their weight-for-height z-score (coefficient -0.347; p = 0.306), longevity (coefficient -0.012; p = 0.55) or infants' survival (coefficient -0.01; p = 0.093) in the DRC plan [30].

Out-of-pocket expenses

In DRC [30], P4P reduced patient out-off-pocket expenses on purchase of drugs at facilities (coefficient -1106.xvi, p = 0.005). On the contrary, there was no meaning result on fee paid for immunization, delivery and ANC and PNC visits.

Client satisfaction

3 studies reported how P4P could influence patient satisfaction on consultation time, provider behavior, waiting time, user fee, welcome quality, overall quality of intendance and cure. In the DRC plan, no improvement on provider attitude towards patients (coefficient 12; p <0.10) [24] was observed. Patients' hazard of feeling cured was higher nether P4P program in Burundi (coefficient 0.09; p = 0.012) [26]. The DRC P4P program did not affect level of client satisfaction on capability of consultation time, overall quality of care, user fee and welcome quality [thirty].

Overall quality of intendance

Two studies demonstrated the effect of P4P on overall quality of intendance of MCH services considering structure, process and outcome measures (Table v). The P4P plan in DRC could enhance the total professional quality score of health centers (coefficient 26; p < 0.001) and patient perceived overall quality index (coefficient 25; p < 0.05) [24]. However, the facility quality score in Burundi though improved, it was not statistically significant (coefficient 17.24; p =0.062) [26].

Discussion

Summary of evidence

This systematic review makes a unique attempt to examine the effect of P4P on multiple quality of care elements by using a defined framework. This review establish that the current evidence indicating P4P'southward result on quality of MCH in LMICs is skewed towards procedure quality and antenatal care. Feeble evidence showing P4P's bear upon on quality of MCH intendance was mainly due to three reasons; 1) program evaluations did not fairly explore quality of intendance; two) evaluations were mostly non powered enough to examine quality elements; and 3) P4P could not touch on quality of care to a large extent.

The positive effect of P4P was observed merely on limited aspects of MCH quality elements. Studies focused predominantly on antenatal care than delivery, EmONC, post natal care and nether-five child intendance. Force of evidence on maternal and neonatal wellness outcomes and out-of-pocket expenses was as well limited. P4P program fetched a few negative outcomes on structural quality such as a reduction in the level of availability of drugs and equipment.

Despite targeting to improve structural quality of facilities, P4P programs could only improve availability of skilled staff, drugs and provider's clinical cognition. On the contrary, P4P negatively afflicted availability of equipment and vaccines [xxx]. The evidence was considerably positive on provider adherence to treatment protocols on ANC and child intendance. Patient out-of-pocket expenses on MCH did not reduce considerably under P4P programs, though out-of-pocket costs on drugs were reduced. However, client satisfaction did non substantially meliorate nether P4P.

Implications for policy and research

As P4P programs intend to reduce maternal and child deaths in LMICs, it is essential to demonstrate their potential to improve quality of MCH intendance comprehensively than process quality alone. Improving provider adherence to treatment guidelines on ANC lone cannot guarantee an improved maternal and child health. Clinical show suggests that quality of skilled birth attendance, EmONC and post natal care are necessary to reduce maternal and neonatal deaths [eleven]. In that location could exist a possibility of insufficient provider skills affecting the procedure quality on delivery, EmONC and postal service natal intendance [11]. Thus, adequate attention should be given to evaluate the evidence on other aspects of MCH care.

Ensuring structural quality such as facility infrastructure, equipment, drugs and supplies is equally pertinent to offer quality care on MCH [11]. Absence of these minimum standards tin can affect patient satisfaction and in turn reduce demand for services in the long term [11]. Inadequate structural quality could exist a reason for the poor client satisfaction in the studies [11]. Several P4P programs provided autonomy and funds to facilities to raise structural quality. P4P programs in Egypt, Burundi, Rwanda and DRC also had routinely monitored structural quality. However, the prevailing positive testify on structural quality is minimal. The DRC program faced negative effects on structural quality index, equally facilities could non spend on infrastructure and equipment due to their reduced revenue nether P4P. The adequacy of funds for infrastructural innovations under P4P programs needs to be investigated. Evaluations of P4P programs in loftier-income settings reflect that proportion of facility revenue is significant to ameliorate quality of care [6].

At that place could be besides a possibility of express motivation and capacity among wellness workers and managers restricting innovations on strengthening structural quality, as evident in many LMICs [30]. Currently, information technology is unknown if the prevailing complex procurement system and managerial bottlenecks in the service delivery organization to ameliorate structural quality are better under P4P programs. Otherwise, these inefficiencies could retard structural quality improvement under P4P [xxx]. In improver, if there was no incentive for structural quality comeback, information technology could have been neglected with a preference for other incentivized indicators (known equally cherry picking) [thirty].

Studies reflect that providers are motivated to improve process quality of care by adhering to treatment guidelines. There could be numerous reasons for their elevated motivation such as fiscal incentives, regular supervision, patient feedback and improved facility performance [33]. Several demand-side financing programs proved that increased patient load negatively affects provider efficiency to handle high book of patients and this could potentially reduce process quality of intendance in due form of time [33]. Thus, specific attention to retain process quality under P4P programs through optimum provider-patient ratio is needed.

Some P4P programs did not intend to charge user fee, only patient out-of-pocket expense was not reported to exist lesser under P4P. Additional research is needed to explore specific cost drivers for out-of-pocket expenses under P4P. In DRC, facilities could non start the revenue loss from reduced user fee as there was not sufficient demand generation, negatively affecting quality of care [30]. Design of P4P programs need to approach the issue of utilization and quality of services comprehensively by addressing both need- and supply-side challenges.

Fractional positive effect of P4P on quality of MCH care asks for a deeper investigation into function of design, implementation and evaluation of P4P programs. According to a review of P4P in loftier income countries, quality of care is the final event of the changes brought in past incentives at provider level, provider group level and health organisation level [half-dozen]. Nevertheless, P4P programs in LMICs do not provide any like prove. Further, there could also be a possibility of preferential attention to P4P services at the cost of non-incentivized services or positive spillover from incentivized to non-incentivized services [eight, 34]. None of the studies reported effects on not-P4P services.

Morbidity and mortality are difficult to aspect to the quality of care delivered because various factors such every bit severity and pre-existing illnesses, delayed care seeking, and non-adherence to treatment would impact these outcomes [15]. Since most of the P4P programs were less than two years, their evaluations did non potentially take acceptable statistical power to explore the impact on mortality. Also, results demand to exist interpreted because contextual factors e.g. elapsing and design of interventions, size of incentives, frequency of payment, timing of evaluation, representativeness of intervention areas and presence of private providers. Written report sites were small and in some, were not representative of the country. Effectiveness can exist different if intervention is exclusively on quality than many operation targets as shown in the studies.

A few studies with CBAs utilized matching of authoritative areas such as provinces or districts [24, thirty]. Yet, within these administrative areas there were gross heterogeneity amongst facilities in terms of infrastructure, staffing, catchment population and service volume. These differences tin can exist minimized during the analysis if further matching of facilities could exist performed. Matching technique such as propensity score matching which allows for comparison of effects between similar units can exist tried to strengthen the rigor of evidence [35]. Studies in Rwanda, Egypt and DRC have tried to balance the financial resource issue beyond intervention artillery by providing equivalent financing [27, thirty, 31]. However, none had attempted to balance the effects of additional supportive interventions such equally supportive supervision, continuous quality measurement, consistent use of checklists and operational plans that might have led to overestimation of P4P's effects.

Limitations

About studies focused on other performance indicators such as service usage forth with quality of care, restricting an in-depth exploration on the latter. This review may endure from publication bias, equally the existing literature may predominantly include studies reporting positive results. Despite these limitations, this review has attempted to include various quality of intendance elements comprehensively and explored in-depth.

Conclusions

This systematic review showed that P4P is effective to improve process quality of ante natal intendance but not so effective on improving structural quality, customer satisfaction, out-of-pocket expenses and maternal and kid health condition. Several studies neither explored the upshot of P4P on quality of MCH in-depth, nor were powered enough statistically. Farther research is needed to understand P4P's touch on EmONC, delivery and post natal care and their causal pathways in LMICs.

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Acknowledgments

The authors are grateful to LSHTM for paying to make the paper Open Access. The views expressed in this newspaper are those of the authors and do not represent the official views of their organizations.

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Affiliations

  1. London Schoolhouse of Hygiene and Tropical Medicine, London, United kingdom

    Ashis Das, Saji Due south. Gopalan & Daniel Chandramohan

  2. Health, Nutrition and Population Global Do, The World Bank Grouping, Washington, DC, USA

    Ashis Das

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Correspondence to Ashis Das.

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Competing interests

The authors declare that they take no competing interests.

Authors' contributions

All authors drafted the systematic review protocol. AD and SG conducted the search, option of records and quality appraisement. All authors have read and canonical the final manuscript.

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Das, A., Gopalan, S.Due south. & Chandramohan, D. Upshot of pay for performance to improve quality of maternal and child intendance in low- and middle-income countries: a systematic review. BMC Public Health xvi, 321 (2016). https://doi.org/10.1186/s12889-016-2982-4

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Keywords

  • Pay for performance
  • Quality of healthcare
  • Maternal and child health
  • Low- and middle income countries

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