Novel methods for optimising health systems payment for performance interventions to improve maternal and child health in low-resource settings

向医疗保健提供者支付费用有不同的方式。他们可以根据他们使用的资源(例如，工作人员、药品)和他们的人口规模来支付工资。他们也可以根据他们取得的成果来支付薪酬，这被称为绩效薪酬(P4P)。P4P计划旨在影响卫生工作者及其管理人员的行为，以提供更高质量的卫生保健。目前，许多低收入和中等收入国家正在实施P4P计划，以改善孕产妇、新生儿和儿童健康。许多研究侧重于评估这些P4P方案对绩效目标的影响。最近，研究考虑了P4P对提供卫生保健服务所需的投入和基础设施(即卫生系统)的影响。然而，这些研究主要侧重于对卫生系统内单一因素的影响，例如药品或工作人员，而不是以相互关联、全面的方式审视所有这些因素。数学模型能够分析卫生系统等相互关联的系统如何运作并对变化作出反应。虽然已经建立了模型并将其用于研究卫生规划，但迄今为止，这些模型用于研究低收入和中等收入国家的卫生系统及其对P4P等方案的反应的情况非常有限。模型的优点之一是，它们还可以用来在实际进行方案变化之前预测这些变化可能产生的影响。这对那些设计程序的人很有帮助，可以帮助他们找出哪种设计最有效。这项研究将使用两种类型的模型来理解P4P的影响：一种是卫生机构如何根据整个卫生机构中病人、药品和供应品的总体流动来运作的模型(即系统动力学模型)；另一种是卫生保健人员、他们的经理和患者在卫生机构内如何互动和行为的模型(即基于代理人的模型)。这些模式将在两个不同的环境中开发：坦桑尼亚和赞比亚。坦桑尼亚和赞比亚之所以被选中，是因为它们在孕产妇、新生儿和儿童健康结果方面取得了喜忧参半的进展，它们都决定引入P4P，试图改善孕产妇和儿童健康。这两个模型将使我们了解卫生系统在这些环境中如何运作和应对P4P方案，以及如何最好地设计P4P以最大限度地影响母亲、新生儿和儿童的健康。为了构建坦桑尼亚卫生保健系统的模型，我们将使用先前关于坦桑尼亚P4P影响的研究信息，并与方案实施者进行访谈。这些模型将在赞比亚使用，看看它们是否能准确预测P4P对赞比亚卫生系统的影响，或者是否需要改变模型结构。这些模型将被用来了解每个国家P4P的影响(有意和无意)，并探讨坦桑尼亚和赞比亚P4P方案设计的变化如何影响卫生和卫生系统的成果。结果将用于改进每个环境中的P4P方案设计。我们还将开发一个工具包，说明如何开发和使用系统动力学和基于代理的模型，以分析卫生系统对其他国家使用的P4P等干预措施的反应，以及支持其普及的培训活动。该项目将支持联合王国、坦桑尼亚、赞比亚和乌干达合作伙伴之间的知识共享和学习。

There are different ways to pay health care providers. They can be paid based on the resources they use (e.g. staff, drugs) and the size of their population. They can also be paid based on what outcomes they achieve, which is termed payment for performance (P4P). P4P schemes are aimed at influencing the behaviour of health workers and their managers to deliver better quality health care. P4P schemes are currently being implemented in many low- and middle-income countries to improve maternal, newborn and child health. Many studies have focused on assessing these P4P programmes' impact on the performance targets. More recently, studies have considered the effect of P4P on the inputs and infrastructure required to deliver health care services (i.e. the health system). However, these studies have mainly focused on effects on a single element within the health system, e.g. drugs or staff, rather than looking at all these factors in an interconnected, comprehensive manner. Mathematical models enable the analysis of how interconnected systems such as the health system function and respond to change. While models have been built and used to look at health programmes, to date there has been very limited use of these models to study health systems in low- and middle-income countries and their response to programmes such as P4P. One of the advantages of models is that they can also be used to anticipate the likely effects of programme changes before these changes are actually made. This can be helpful to those designing programmes to help them work out which design would work best. This study will use two types of models to understand the effects of P4P: a model of how a health facility functions in terms of the overall flows of patients and drugs and supplies across the facility (i.e. a system dynamic model) and a model of the way health care workers, their managers and patients interact and behave within the health facility (i.e. an agent-based model). The models will be developed in two different settings: Tanzania and Zambia. Tanzania and Zambia were chosen as they have made mixed progress in terms of maternal, newborn and child health outcomes and they both made the decision to introduce P4P to try to improve maternal and child health. These two models will provide us with an understanding of how health systems work and respond to the P4P programme in these settings, and how P4P can be best designed for maximum impact on the health of mothers, newborns and children. To construct models of the Tanzanian health care system, we will use information from a previous study of the impact of P4P in Tanzania together with interviews with programme implementers. The models will be used in Zambia to see if they can accurately predict the effects of P4P on the Zambian health system or if changes in the model structure are needed. The models will be used to understand the effects (both intended and unintended) of P4P in each country and explore how changes in the design of the Tanzanian and Zambian P4P programmes may affect health and health systems outcomes. Results will be used to improve P4P programme design in each setting. We will also develop a toolkit for how to develop and use system dynamics and agent-based models to analyse health system response to interventions such as P4P for use in other countries, and training activities to support their uptake. This project will support knowledge sharing and learning across partners in the United Kingdom, Tanzania, Zambia and Uganda.