Pay for performance (P4P), or the provision of financial rewards based on the achievement of pre-specified performance indicators, is a popular mechanism for trying to improve the availability, quality and utilisation of essential health services.

An ongoing project, Equi-PMAQ investigates how Brazil's national P4P scheme for improving primary care access and quality (PMAQ) has affected socioeconomic inequalities in the financing and delivery of primary care and the extent to which different incentive designs affect these outcomes. The Brazilian experience provides a unique opportunity to explore this question as:

• municipalities have autonomy in the design and delivery of incentives to providers in their area
• extensive secondary data are available on socioeconomic status, financing and quality of care
• the scheme is potentially the largest in the world, with substantial heterogeneity between areas

Equi-PMAQ aims to:

• examine socio-economic inequalities in the quality of primary care under PMAQ
• examine whether PMAQ has changed the level of primary funding, as well as socio-economic inequalities in the distribution of funding
• develop a typology of PMAQ incentive designs and investigate factors associated with the adoption of different designs by municipalities
• explore the mechanisms through which PMAQ affects the level of funding and quality of care and the distribution of these outcomes at the municipal level and below

Publications

• Kovacs R, Barreto, JOM. da Silva EN, Borghi J, Kristensen SR, Costa DRT, Gomes LB, Gurgel Junior GD, Sampaio J, Powell-Jackson T. (2021). Socioeconomic inequalities in the quality of primary care under Brazil’s national pay-for-performance programme: a longitudinal study of family health teams, Lancet Global Health
• Kovacs RJ, Powell-Jackson T, Kristensen SR, Singh N, Borghi J. (2020). How are pay-for-performance schemes in healthcare designed in low- and middle-income countries? Typology and systematic literature review, BMC Health Serv Res.
• de Medeiros OL, Barreto JOM, Harris M, Russo LX, da Silva EN. (2020). Delivering maternal and childcare at primary healthcare level: The role of PMAQ as a pay for performance strategy in Brazil. PLoS One

Team

From the London School of Hygiene & Tropical Medicine:

• Josephine Borghi
• Timothy Powell-Jackson
• Roxanne J. Kovacs
• Neha Singh
• Nasser Fardousi 
• Loveday Penn-Kekana

Other team members:

• Soeren Rud Kristensen
• Matt Sutton, Everton Silva
• Garibaldi Dantas Gurgel
• Luciano Bezerra Gomes
• Adriana Falangola
• Helena Shimiz
• Jorge Maia Barreto
• Juliana Sampaio

Publication

• Pay for performance in primary care: the contribution of the Programme for Improving Access and Quality of Primary Care (PMAQ) on avoidable hospitalisations in Brazil, 2009-2018. Russo LX, Powell-Jackson T, Maia Barreto JO, Borghi J, Kovacs R, Gurgel Junior GD, Gomes LB, Sampaio J, Shimizu HE, de Sousa ANA, Bezerra AFB, Stein AT, Silva EN. BMJ Glob Health. 2021 Jul;6(7):e005429. doi: 10.1136/bmjgh-2021-005429. PMID: 34244203; PMCID: PMC8273460.

Performance based financing (PBF) has been proposed as a strategy to strengthen health systems, to improve service delivery and population health. PBF consists of financial incentives to health care providers and their managers based on the achievement of pre-defined quantity and/or quality targets related to service delivery. Over 40 low- and middle-income countries (LMICs) are implementing PBF schemes with substantial financial support from international donors.

The PEMBA project assesses the effects of PBF on the health system in Zimbabwe and Mozambique. The research goes beyond examining average programme effects and focuses on identifying causal pathways and ‘active ingredients’ of the programme, and how these vary across settings.

The project aims to:

• map key differences in PBF scheme design and context in each of the two countries
• develop a theory of change for how PBF affects service delivery and health outcomes through changes to health system inputs
• evaluate the short and longer term impact of PBF on health system inputs in each country
• evaluate the short and longer term impact of PBF on service delivery and health outcomes in each country
• identify the specific causal pathway(s) through which PBF results in service delivery and health outcome effects
• evaluate whether PBF effects on health system inputs, service delivery and health outcomes differ according to: scheme design; health facilities readiness; contextual factors; population characteristics; and implementation of concurrent interventions
• develop a framework of conceptual links between PBF design, its effects on the health system and policy, and ultimately on health outcomes that can be adapted to other countries as well as inform regional and global policy

Publications

• Borghi J, Singh N, Brown G, Anselmi L, Kristensen S (2018). Understanding for whom, why and in what circumstances payment for performance works in low and middle income countries: protocol for a realist review. BMJ Global Health, 3(3), e000695.
• Kovacs RJ, Powell-Jackson T, Kristensen S, Singh N, Borghi J (2020) How are pay-for-performance schemes in healthcare designed in low- and middle-income countries? Typology and systematic literature review. BMC Health Services Research, 20:291.
• Anselmi L, Borghi J, Wallace Brown G, Fichera E, Hanson K, Kadungure A, Kovacs R, Kristensen S, Singh N, Sutton M (2020) Pay for Performance: A Reflection on How a Global Perspective Could Enhance Policy and Research, International Journal of Health Policy and Management.

Team

From the London School of Hygiene & Tropical Medicine:

• Josephine Borghi
• Neha S Singh
• Roxanne Kovacs

Other team members:

• Laura Anselmi
• Eleonora Fichera
• Søren Rud Kristensen
• Matt Sutton
• Garrett Brown
• Artwell Kadungure
• Susan Mutambu
• Sergio Chicumbe
• Rene Loewenson

This study uses system dynamic modelling (SDM) and agent based modelling (ABM) to:

• understand how low-income country health systems respond to payment for performance (P4P) schemes
• identify potential adverse events
• examine how variations in the design of P4P schemes affect health system response and patient outcomes
• identify which designs would optimise programme impact
• examine how these methods can be adapted for use by international donors and decision makers in these settings to inform their investments in health systems

The project aims to:

• develop a SDM and an ABM of the Tanzanian health system and its response to a P4P programme
• validate the SDM and ABM in the Tanzanian setting
• compare the SDM and ABM developed
• examine the generalisability of SDM and ABM developed (in Objective 1) to the Zambian setting
• generate policy-relevant recommendations and translate them to decision makers to optimise the design of P4P for maximum, sustained impact on maternal and child health in Tanzania and Zambia
• build capacity among decision makers and researchers on SDM and ABM to strengthen health systems and improve maternal and child health outcomes in low- and middle-income countries (LMIC)

Publications

• Cassidy R, Singh N, Schiratti PR, Semwanga A, Binyaruka P, Sachingongu N, Chama-Chiliba CM, Chalabi Z, Borghi J, Blanchet K (2019) Mathematical Modelling for Health Systems Research: A Systematic Review of System Dynamics and Agent-Based Models, BMC Health Services Research, Nov 19;19(1):845.

Team

From the London School of Hygiene & Tropical Medicine:

• Josephine Borghi
• Neha S Singh
• Rachel Cassidy
• Anna Foss

Other team members:

• Agnes Semwanga
• Peter Binyaruka
• Nkenda Sachingongu
• Chitalu Miriam Chama-Chiliba
• Karl Blanchert
• Zaid Chalabi
• Nicholaus Mziray
• John Mtei

This project builds on over 10 years of research tracking aid to RMNCH and domestic financing in selected countries for Countdown 2030. This grant includes ongoing monitoring of global aid flows for RMNCH, while focusing on country-level tracking and analysis of financing for health and RMNCH, and related capacity development activities.

The project aims to:

• generate annual updates of aid flows to RMNCH globally, by country and by donor, using Muskoka2 for the period 2018–20
• review and propose methods for tracking domestic and external funding at country level
• conduct and support analytical work on health financing at country level
• build capacity to track funding and analyse financing at country level
• build a data depository of relevant health financing data

Publications

• Grollman C, Cavallaro FL, Duclos D, Bakare V, Martínez Álvarez M, Borghi J (2018) Donor funding for family planning: levels and trends between 2003 and 2013. Health Policy and Planning. 33(4):574-582.
• Countdown to 2030: tracking progress towards universal coverage for reproductive, maternal, newborn, and child health, The Lancet, 2018 Apr 14;391(10129):1538-1548.
• Martinez-Alvarez M, Federspiel F, Singh NS, Schäferhoff M, Lewis Sabin M, Onoka C, Mounier-Jack S, Borghi J, Pitt C (2020) Equity of resource flows for reproductive, maternal, newborn, and child health: are those most in need being left behind?, BMJ. Feb 3;368:m305.
• Dingle A, Schäferhoff M, Borghi J, Lewis Sabin M, Arregoces L, Martinez-Alvarez M, Pitt C (2020) Estimates of aid for reproductive, maternal, newborn, and child health: findings from application of the Muskoka2 method, 2002-17,Lancet Global Health. Mar;8(3):e374-e386.
• Martinez-Alvarez M, Acharya A, Arregoces L, Brearley L, Pitt C, Grollman C, Borghi J (2017) Trends In The Alignment And Harmonization Of Reproductive, Maternal, Newborn, And Child Health Funding, 2008-13, Health Affairs(Millwood);36(11):1876-1886.
• Borghi J, Munthali S, Million LB, Martinez-Alvarez M (2018) Health financing at district level in Malawi: an analysis of the distribution of funds at two points in time, Health Policy and Planning;33(1):59-69.

Team

From the London School of Hygiene & Tropical Medicine:

• Josephine Borghi
• Catherine Pitt
• Melisa Martinez-Alvarez

Other team members:

• Peter Binyaruka

Within Work Package 3: financing health, we are:

• examining access and affordability of care for refugees and vulnerable host populations in Northern Uganda
• investigating the effect of the Ebola outbreak on access to maternal and child health services and the affordability of health care in Sierra Leone
• working with International Red Cross (IRC) to examine how costs of cash transfer programmes vary across contexts and according to programme design variations.
• building capacity in health systems and economics methods

Publications

• Makhani LA, Moran V, Sadique Z, NS, Revill P, Roberts B (2020) Examining the Use of Economic Evaluations in Health-Related Humanitarian Programmes in Low- And Middle-Income Countries: A Systematic Review Health Policy and Planning, Mar 1;35(2):210-218.

• Neha S. Singh, Antonia Dingle, Alia H. Sabra, Jocelyn DeJong, Catherine Pitt, Ghina R. Mumtaz, Abla M. Sibai, Sandra Mounier-Jack (2020) Health care financing arrangements and service provision for Syrian refugees in Lebanon, In: Bozorgmehr K, Roberts B, Razum O, Biddle L (eds) Health Policy and Systems Responses to Forced Migration, Springer.

Team

From the London School of Hygiene & Tropical Medicine:

• Sandra Mounier-Jack
• Neha Singh
• Jess King
• Giulia Greco
• Zia Sadique
• Josephine Borghi

Other team members:

• Pallavi Prabhakar (Uganda)
• Munshi Sullaiman (Uganda)
• Michael Amara (Sierra Leone)
• Caitlin Tulloch (IRC)

This project, a Lancet Global Health Commission supported by the Bill and Melinda Gates Foundation, reflects on the key challenges in financing primary health care to develop an evidence-led agenda for action. Through a multidisciplinary and international collaboration, it examines the successes and lessons from previous country experiences, while acknowledging the constraints under which many countries operate. The report of the Commission – planned for October 2021 – will focus on country-relevant policy solutions that aim for transformational change.

Primary Health Care (PHC) is recognised as a necessary pathway to achieving Universal Health Coverage (UHC) in low- and middle-income countries (LMICs) (WHO, 2019). Yet PHC receives insufficient investment, jeopardising most LMICs’ hope of achieving this ambition (Stenberg, Hanssen, Brindley, & et al, 2019).  How primary healthcare is financed is vital if LMICs are to make progress in ensuring their citizens can benefit from good quality, efficient and equitable primary health care available to all without causing financial hardship.

The project aims to:

• generate actionable recommendations for national governments and global institutions on how financing for PHC can be increased and used effectively to achieve PHC targets, thereby contributing to UHC
• generate new evidence on levels and patterns of expenditure on PHC, and the gaps in PHC investment in relation to costs and needs
• review country experience and best practices of expanding fiscal space for PHC through different approaches to increasing spending, changing incentives and innovations to optimize the organisation of PHC delivery
• produce recommendations on options for improving governance, accountability, public financial management and information systems to enable increased financial flows and ensuring these are spent efficiently and equitably
• generate recommendations for measuring and monitoring progress towards greater health system investment in PHC which will underpin technical work and political advocacy in support of PHC

Team

• Kara Hanson
• Tim Powell-Jackson
• Dina Balabanova
• Nouria Brikci
• Darius Erlangga

To assess progress towards universal health coverage (UCH), countries such as Cambodia require evidence on equity in the financing and distribution of healthcare benefits. This evidence must be based on a system-wide perspective that recognises the complex roles played by the public and private sectors in many contemporary healthcare systems.

Funded by the Australian Research Council and due to complete in June 2020, CHEF aims to produce previously unavailable information on who pays for, and who benefits from, health services across the entire health system of Cambodia. The study:

• uses financing and benefit incidence analysis to calculate the financing burden and distribution of healthcare benefits across socioeconomic groups
• designs a cross-sectional household survey involving a random sample of 5,000 households
• derives data on healthcare usage, living standards and self-assessed health status derived from the survey
• supplements survey findings with secondary data from the Cambodian National Health Accounts and the Cambodian Socioeconomic Survey (CSES)
• collects qualitative data through focus group discussions and in-depth interviews to inform the interpretation of the quantitative analyses 

This evidence comes at a critical juncture in healthcare reform in South-East Asia with so many countries seeking guidance on the equity impact of their current financing arrangements that include a complex mix of public and private providers. 

The primary objective of this study is to evaluate equity in healthcare payment and service use in Cambodia to support progress towards UHC. Specific study questions include:

• How is the burden of healthcare payments distributed across socioeconomic groups in Cambodia?
• How are the benefits from the health financing system (measured in terms of healthcare use) distributed across socioeconomic groups and according to level of need?
• What are the complex range of determinants of healthcare usage and household spending on health services in Cambodia?

Publications (selected)

• Wiseman V, Asante A, Ir P, Limwattananon S, Jacobs B, Liverani M, Hayen A, Jan S (2017) System-wide analysis of health financing equity in Cambodia: a study protocol. BMJ Global  Health. 2017;2(1):e000153.

• Asante A, Ir P, Jacobs B, Limwattananon S, Liverani M, Hayen A, Jan S, Wiseman V (2019) Who benefits from healthcare spending in Cambodia? Evidence for a universal health coverage policy, Health Policy and Planning, Volume 34, Issue Supplement_1, Pages i4–i13.

• Ir P, Jacobs B, Asante A, Liverani M, Jan S, Chhim S, Wiseman V (2019) Exploring the determinants of distress health financing in Cambodia, Health Policy and Planning, Volume 34, Issue Supplement_1, Pages i26–i37.

• Asante A, Jacobs B, Wiseman V (2019) Transforming health systems financing in Lower Mekong: making sure the poor are not left behind, Health Policy and Planning, Volume 34, Issue Supplement_1, Pages i1–i3.

• Nagpal S, Masaki N, Pambudi E, Jacobs B (2019) Financial protection and equity of access to health services with the free maternal and child health initiative in Lao PDR, Health Policy and Planning, Volume 34, Issue Supplement_1, Pages i14–i25.

• Asante A, Price J, Hayen A, Jan S, Wiseman V (2016) Equity in Health Care Financing in Low- and Middle-Income Countries: A Systematic Review of Evidence from Studies Using Benefit and Financing Incidence Analyses, PLoS ONE ,11(4): e0152866.

Team

• Virginia Wiseman (LSHTM & Kirby Institute at the University of New South Wales)
• Por Ir (Cambodian Institute of Public Health)
• Marco Liverani (LSHTM)
• Augustine Asante (University of New South Wales)
• Andrew Hayen (University of Technology Sydney)
• Stephen Jan (George Institute for Global Health, University of New South Wales)

Many low and middle income countries are implementing reforms to support Universal Health Coverage (UHC). Perhaps one of the most ambitious examples of this is Indonesia’s national health scheme known as the JKN which is designed to make health care available to its entire population of 255 million by end of 2019. If successful, the JKN will be the biggest single payer system in the world. While Indonesia has made steady progress, around a third of its population remains without cover and out of pocket payments for health are widespread even among JKN members. To help close these gaps, especially among the poor, the Indonesian government is currently implementing a set of UHC policy reforms that include the integration of remaining government insurance schemes into the  JKN, expansion of provider networks, restructuring of provider payments systems, accreditation of all contracted health facilities and a range of demand side initiatives to increase insurance uptake, especially in the informal sector. Using a before and after design, we will evaluate the combined effects of the national UHC reforms at baseline (early 2018) and target of JKN full implementation (end 2019) on: progressivity of the health care financing system; pro-poorness of the health care delivery system; levels of catastrophic and impoverishing health expenditure; and self-reported health outcomes. In-depth interviews with stakeholders to document the context and the process of implementing these reforms, will also be undertaken.

Primary aims of this study are to:

• (i) measure and compare key equity outcomes - including health care utilisation, subsidies received through the use of health services, payments people make for health care, and self-assessed health – in early 2018 (study baseline) and end of 2019 (target of JKN full implementation);
• (ii) develop and apply ‘quality-weightings’ to the benefits of health spending, to account for variation in the quality of health services utilised; and
• (iii)document the changing context and processes for implementing UHC-reforms in Indonesia.

Publications

• Wiseman, V., Thabrany, H., Asante, A. et al. An evaluation of health systems equity in Indonesia: study protocol. Int J Equity Health 17, 138 (2018).
• John E Ataguba, Augustine D Asante, Supon Limwattananon, Virginia Wiseman, How to do (or not to do) … a health financing incidence analysis, Health Policy and Planning, Volume 33, Issue 3, April 2018, Pages 436–444

People involved (staff as well as students):  

• Virginia Wiseman (LSHTM & Kirby Institute at the University of New South Wales),
• Hasbullah Thabrany (University of Indonesia),
• Soewarta Kosen (Indonesian Ministry of Health), 
• Augustine Asante (University of New Suth Wales),
• Andrew Hayen (University of Technology Sydney),
• Anne Mills (LSHTM),
• Lucy Gilson (University of Cape Town, LSHTM),
• Stephen Jan (George Institute for Global Health, University of New South Wales),
• Manon Haemmerli (PhD student, LSHTM),
• Viroj Tangcharoensathien (Ministry of Public Health, Thailand),
• Walaiporn Patcharanarumol (Ministry of Public Health, Thailand)