Strengthening health system delivery and quality: Mechanisms and Effects of Performance Based Financing in the Sub-Saharan context

医疗服务提供者可以通过多种方式获得报酬。可以向他们提供同意提供服务的年度预算，或根据所覆盖人口的规模支付报酬。根据具体标准的实现情况或病人的治疗结果付款已在卫生部门得到广泛应用。这种方案被称为基于绩效的融资。这些计划旨在将卫生工作者及其管理者的重点放在具体成果上，并改变他们的行为方式，以改善卫生保健服务的质量和人口健康。40多个低收入和中等收入国家目前正在卫生部门实施基于绩效的筹资计划。然而，迄今为止，研究人员和从业人员的重点主要是评估基于业绩的融资计划对业绩目标的短期影响。我们对基于绩效的融资如何影响卫生工作者及其工作的组织以及如何将其转化为服务提供和健康结果的改进知之甚少。我们也不知道这种影响是否会持续一段时间。基于绩效的融资方案的设计也因地而异，我们对影响这种差异的因素以及这些因素如何影响基于绩效的融资的实施方式及其后续结果的理解有限。大多数评估都专门为每个项目收集数据，这限制了所考虑的健康结果的范围，并且难以在研究之间进行比较。这一研究项目将使参与在莫桑比克和津巴布韦这两个国家实施基于绩效的融资计划并对其进行评估的利益攸关方参与进来。我们将共同努力，澄清基于绩效的融资是如何在每种情况下概念化和实施的。我们还将确定基于绩效的融资预计将如何影响卫生工作者及其工作环境，以实现更好的护理，以及基于绩效的融资的哪些要素最为关键。我们将使用国家层面的卫生系统投入数据，考察长期以来基于绩效的融资对卫生系统的影响。我们将使用家庭人口和健康调查的数据，审查对健康结果和对基于业绩的筹资所没有针对的服务提供的影响。最后，我们将通过确定卫生系统投入的变化如何以及哪些变化与保健服务的改善有关，试图了解基于绩效的融资如何给服务提供带来变化。我们还将研究基于业绩的融资的影响如何根据人口和卫生设施的特点而变化。基于绩效的融资有时伴随着增加获得保健机会的单独努力，我们将审查这是否重要。最后，我们将在这两个国家考察基于绩效的融资计划的设计方式是否会影响结果。该项目将支持英国、莫桑比克、津巴布韦和更广泛的撒哈拉以南非洲地区各机构之间的知识共享和学习。

Health care providers can be paid in a variety of ways. They can be given an annual budget for agreeing to provide a service or be paid on the basis of the size of the population covered. Payment according to achievement of specific standards or patient outcomes has been widely applied in the health sector. Such schemes are called Performance Based Financing. These schemes aim to focus health workers and their managers on specific outcomes and to change the way they behave to improve the quality of health care services and population health. Over 40 low and middle-income countries are currently implementing performance based financing schemes in the health sector. However, to date the focus of researchers and practitioners has been mainly on assessing the short term impact of performance based financing schemes on the performance targets. We understand little about how performance based financing affects health workers and the organisations they work in and how this translates into improvements in service delivery and health outcomes. We also do not know if the effects are sustained over time. The design of performance based financing schemes also varies from place to place and we have limited understanding of the factors that influence this variation nor how this affects the way performance based financing is implemented and its subsequent results. Most evaluations collect data specifically for each project, which limits the range of health outcomes that are considered and makes it difficult to compare across studies. This research project will engage stakeholders involved in running performance based financing schemes and evaluating them in two countries: Mozambique and Zimbabwe. We will work together to clarify how performance based financing has been conceptualised and implemented in each setting. We will also identify how performance based financing is expected to affect health workers and their work environment to bring about better care, and what elements of performance based financing are most critical. We will use national level data on health system inputs to examine the effects of performance based financing on the health system over time. We will use data from household Demographic and Health Surveys to examine the effects on health outcomes and on the delivery of services that were not targeted by performance based financing. Finally we will seek to understand how performance based financing brings about changes to service delivery by identifying how and which changes in health system inputs are related to improvements in care delivery. We will also examine how the effects of performance based financing vary according to population and health facility characteristics. Performance based financing is sometimes accompanied by separate efforts to increase access to care and we will examine if this matters. Finally, we will look across the two countries to examine if the way in which the performance based financing scheme is designed affects the results. The project will support knowledge sharing and learning across institutions in the United Kingdom, Mozambique, Zimbabwe and the wider Sub-Saharan African region.