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

有不同的方式支付医疗保健提供者。他们可以根据他们使用的资源（例如工作人员，药物）和他们的人口规模获得报酬。他们也可以根据他们取得的成果获得报酬，这被称为绩效报酬（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，许多中低收入国家正在实施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采购换进展方案对业绩目标的影响。最近，研究考虑了采购换采购对提供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，例如药物或工作人员，而不是以相互关联的综合方式看待所有这些因素。数学模型使人们能够分析相互关联的系统（如卫生系统）如何运作和应对变化。虽然已经建立了模型并用于研究卫生方案，但迄今为止，这些模型在研究中低收入国家的卫生系统及其对采购促进步等方案的反应方面的使用非常有限。模型的优点之一是，它们还可以用来在实际作出方案变动之前预测这些变动可能产生的影响。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好。本研究将使用两种类型的模型来了解P4P的影响：一个模型的卫生设施的功能，在整个设施的病人和药物和用品的整体流动（即系统动态模型）和一个模型的方式，卫生保健工作者，他们的管理人员和病人的互动和行为的卫生设施（即代理模型）。这些模型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、新生儿和儿童健康成果方面取得的进展参差不齐，它们都决定引入P4P，以努力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如何在这些环境中运作和应对P4P计划，以及如何最好地设计P4P计划，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，我们将使用以前的P4P在坦桑尼亚的影响研究的信息，以及与方案实施者的访谈。这些模型将在赞比亚使用，以确定它们是否能够准确预测采购换采购对赞比亚卫生系统的影响，或者是否需要改变模型结构。这些模型将用于了解采购促进步在每个国家的影响（预期和非预期），并探讨坦桑尼亚和赞比亚采购促进步方案设计的变化如何影响卫生和卫生系统的成果。研究结果将用于改进每种情况下的采购换进展方案设计。我们还将开发一个工具包，介绍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P4P等干预措施的反应，供其他国家使用，并开展培训活动，以支持这些措施的采用。该项目将支持联合王国、坦桑尼亚、赞比亚和乌干达的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.