Primary care providers' preferences for pay-for-performance programs: a discrete choice experiment study in Shandong China.

BACKGROUND: Pay-for-performance (P4P) schemes are commonly used to incentivize primary healthcare (PHC) providers to improve the quality of care they deliver. However, the effectiveness of P4P schemes can vary depending on their design. In this study, we aimed to investigate the preferences of PHC providers for participating in P4P programs in a city in Shandong province, China. METHOD: We conducted a discrete choice experiment (DCE) with 882 PHC providers, using six attributes: type of incentive, whom to incentivize, frequency of incentive, size of incentive, the domain of performance measurement, and release of performance results. Mixed logit models and latent class models were used for the statistical analyses. RESULTS: Our results showed that PHC providers had a strong negative preference for fines compared to bonuses (- 1.91; 95%CI - 2.13 to - 1.69) and for annual incentive payments compared to monthly (- 1.37; 95%CI - 1.59 to - 1.14). Providers also showed negative preferences for incentive size of 60% of monthly income, group incentives, and non-release of performance results. On the other hand, an incentive size of 20% of monthly income and including quality of care in performance measures were preferred. We identified four distinct classes of providers with different preferences for P4P schemes. Class 2 and Class 3 valued most of the attributes differently, while Class 1 and Class 4 had a relatively small influence from most attributes. CONCLUSION: P4P schemes that offer bonuses rather than fines, monthly rather than annual payments, incentive size of 20% of monthly income, paid to individuals, including quality of care in performance measures, and release of performance results are likely to be more effective in improving PHC performance. Our findings also highlight the importance of considering preference heterogeneity when designing P4P schemes.

Study on the determinants of health professionals' performance on diabetes management care in China.

BACKGROUND: As the direct providers of diabetes management care in primary health care facilities (PHFs) in China, health professionals' performance on management care of diabetes determines the quality of services and patients' outcomes. This study aims to analyze the key determinants of health professionals' performance on diabetes management care in PHFs in China. METHODS: We conducted a cross-sectional study in 72 PHFs in 6 cities that piloted the contracted family doctor service (CFDS). Self-developed questionnaire was used to measure three kinds of factors (capacity, motivation and opportunity) potentially influencing the performance of health professionals. The performance of diabetes management care in the study was measured as whether health professionals delivered 7 service items required by the National Basic Public Health Service Guideline with a total of 7 points and was divided into three grades of good, medium and bad. The questionnaire is self-administered by all the health professionals involved in the study with the number of 434. The Chi-square tests were used to compare differences of performance on diabetes management care among health professionals with different characteristics. The ordinal logistic regression was used to analyze the determinants on the performance of diabetes management care. RESULTS: Health professionals who got higher score on diabetes knowledge test had odds of better performance on diabetes management care (OR = 1.529, P < 0.001). health professionals with higher degree of self-reported satisfaction on training (OR = 1.224, P < 0.05) and perception of decreasing workload (OR = 3.336, P < 0.01) had odds of better performance on diabetes management care. While health professionals with negative feeling on information system support had odds of worse performance on diabetes management care (OR = 0.664, P < 0.01). CONCLUSIONS: Attention should be paid to the training of health professionals' knowledge on diabetes management capacity. Furthermore, measures to improve training for health professionals could satisfying their needs for self-growth and improve the motivation of health professionals. The information system supporting management care should be improved continuously to improve the health professionals' working opportunities and decrease the workload.

Continuity of health care: measurement and application in two rural counties of Guangxi Province, China.

BACKGROUND: Continuity of care (COC) is highly regarded in health promotion and health system strengthening. However, there is a lack of multidimensional quantitative assessment of continuity, making it challenging to evaluate and compare. Our objective was to create a novel measurement for COC and apply it in two rural counties in China to assess its validity and feasibility in evaluating health system reform. METHOD: This study conducted a scoping literature review on COC, examining existing frameworks and indicators. Following an online expert poll, a composite indicator was developed using the analytical hierarchy process (AHP). The measurement tool was then applied to assess the current state of COC in two rural counties in China. In addition to descriptive analysis, demographic and economic characteristics were analyzed for their association with COC scores using t-tests and multiple linear regression models. RESULTS: The final COC measurement encompasses three dimensions, six sub-dimensions, and ten individual indicators, which integrated and improved the current frameworks and indicators. Relational continuity, informational continuity, and management continuity were identified as the primary dimensions of COC measurement. The COC score is 0.49 in County A and 0.41 in County B, with information continuity being the highest-scoring dimension. Notably, the disparity in continuity scores is most pronounced among individuals with varying attitudes towards health, demonstrating a positive correlation. CONCLUSION: The construction of the composite indicator in this study offers a scientific and effective metric for comprehensively measuring continuity of care. The empirical data analysis conducted in Western China serves as an illustrative application of the indicator, demonstrating its efficiency. The results obtained from this analysis provide a solid foundation and valuable reference for strengthening the health system.

The Association Between Financial Incentives and Job Performance Among Primary Care Providers in Six Provinces of China.

Objective: This study aims to explore the association between financial incentives and job performance of primary care providers (PCPs) from a nationally representative survey in China. Methods: This is a cross-sectional study conducted in six provinces of China in 2019. A sample of 1388 PCPs participated in the survey was selected using a stratified cluster sampling method. A self-administered questionnaire composed of socio-demographic, work-related characteristics, financial incentives received by PCPs and their job performance was used. The association between financial incentives and job performance are analyzed using logistic regression model. The significance level for statistics is set at P < 0.05. Results: The PCPs with higher real income level have lower contextual performance (OR = 0.67, p < 0.01) and learning performance (OR = 0.63, p < 0.01) than those with lower real income level. The PCPs with the expectation of income rising above 50% have lower contextual performance (OR = 0.66, p < 0.05) than those with the expectation of income rising above 20%. The PCPs with preference for monetary income have lower task performance (OR = 0.62, p < 0.01), contextual performance (OR = 0.55, p < 0.01) and learning performance (OR = 0.57, p < 0.01) than those without lower preference for monetary income. The percent of performance-based income has no significant effect on all the three dimensions of job performance. Conclusion: Financial incentive was regarded as the most important motivating factor of PCPs in China, but existing financial incentives received by PCPs could not improve their job performance. The findings can be attributed to the unsatisfying total income level, "intrinsic motivation crowding out" effect, and the poorly designed performance-based salary system for PCPs. Policy attention is called for to continuing efforts and system reform to increase the total income level for PCPs in China, and improve the performance-based salary system to better motivate PCPs and improve their job performance.

A guideline for economic evaluations of vaccines and immunization programs in China.

This study aimed to develop a consensus framework for economic evaluations of vaccines as a national guideline in China. Some unique and important aspects were particularly emphasized. Nineteen Chinese experts in the field of health economics and immunization decision-making were nominated to select and discuss relevant aspects of vaccine economic evaluations in China. A workshop attended by external experts was held to summarize unique and important aspects and formulate consensus recommendations. There were ten unique and/or important aspects identified for economic evaluations of vaccines in China, including study perspectives, comparator strategies, analysis types, model choices, costing approaches, utility measures, discounting, uncertainty, equity, and evaluation purposes. Background information and expert recommendations were provided for each aspect. Economic evaluations of vaccines should play an important role in China's immunization policy-making. This guideline can help improve the quality of economic evaluations as a good practice consensus.

Satisfaction of Township Hospitals Health Workers on How They Are Paid in China.

BACKGROUND: Township Hospitals (THs) are crucial providers in China's primary health delivery system. Low job satisfaction of THs health workers has been one of biggest challenges to strengthening the health system in China. Even huge amounts of studies confirmed low remuneration level as a key demotivating factor though few studies have explored the feelings of health workers on how they were paid. OBJECTIVE: To analyze how the key design of Performance-based Salary System (PBS) influences the satisfaction of health workers on the payment system in China's THs. METHOD: A cross-sectional study was conducted in 47 THs in Shandong China, and a total of 1136 participants were recruited. Expectancy theory was applied to design the measurements on designs of PBS. The associations between PBS design and satisfaction of health workers were analyzed by logistic regression. RESULTS: Three key components of PBS design were all related to the satisfaction of health workers. Those health workers who were aware of assessment methods were more likely to be satisfied with how they were paid (OR = 2.44, p < 0.001) compared with those being not aware of the methods. The knowledge on personal performance was also associated with being satisfied (OR = 3.34, p < 0.001). The percentage of floating income in total income was negatively associated with the satisfaction, and one percentage point increase in floating income proportion could result in the possibility of being satisfied decreasing by 2.82% (95%CI -4.9 to -0.7, p = 0.01). Subgroup analysis found that only in those with lower value on monetary income, the negative influence of more floating income was significant. CONCLUSIONS: When policymakers or managers apply performance-related payment to incentivize certain work behavior, they should pay attention to the design details, including keeping transparency in the performance assessment criteria, clear performance feedback, and setting the proportion of the performance-related part based on the preference of health workers in certain cultural settings.

Payment methods for healthcare providers working in outpatient healthcare settings.

BACKGROUND: Changes to the method of payment for healthcare providers, including pay-for-performance schemes, are increasingly being used by governments, health insurers, and employers to help align financial incentives with health system goals. In this review we focused on changes to the method and level of payment for all types of healthcare providers in outpatient healthcare settings. Outpatient healthcare settings, broadly defined as 'out of hospital' care including primary care, are important for health systems in reducing the use of more expensive hospital services. OBJECTIVES: To assess the impact of different payment methods for healthcare providers working in outpatient healthcare settings on the quantity and quality of health service provision, patient outcomes, healthcare provider outcomes, cost of service provision, and adverse effects. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase (searched 5 March 2019), and several other databases. In addition, we searched clinical trials platforms, grey literature, screened reference lists of included studies, did a cited reference search for included studies, and contacted study authors to identify additional studies. We screened records from an updated search in August 2020, with any potentially relevant studies categorised as awaiting classification. SELECTION CRITERIA: Randomised trials, non-randomised trials, controlled before-after studies, interrupted time series, and repeated measures studies that compared different payment methods for healthcare providers working in outpatient care settings. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We conducted a structured synthesis. We first categorised the payment methods comparisons and outcomes, and then described the effects of different types of payment methods on different outcome categories. Where feasible, we used meta-analysis to synthesise the effects of payment interventions under the same category. Where it was not possible to perform meta-analysis, we have reported means/medians and full ranges of the available point estimates. We have reported the risk ratio (RR) for dichotomous outcomes and the relative difference (as per cent change or mean difference (MD)) for continuous outcomes. MAIN RESULTS: We included 27 studies in the review: 12 randomised trials, 13 controlled before-and-after studies, one interrupted time series, and one repeated measure study. Most healthcare providers were primary care physicians. Most of the payment methods were implemented by health insurance schemes in high-income countries, with only one study from a low- or middle-income country. The included studies were categorised into four groups based on comparisons of different payment methods. (1) Pay for performance (P4P) plus existing payment methods compared with existing payment methods for healthcare providers working in outpatient healthcare settings P4P incentives probably improve child immunisation status (RR 1.27, 95% confidence interval (CI) 1.19 to 1.36; 3760 patients; moderate-certainty evidence) and may slightly increase the number of patients who are asked more detailed questions on their disease by their pharmacist (MD 1.24, 95% CI 0.93 to 1.54; 454 patients; low-certainty evidence). P4P may slightly improve primary care physicians' prescribing of guideline-recommended antihypertensive medicines compared with an existing payment method (RR 1.07, 95% CI 1.02 to 1.12; 362 patients; low-certainty evidence). We are uncertain about the effects of extra P4P incentives on mean blood pressure reduction for patients and costs for providing services compared with an existing payment method (very low-certainty evidence). Outcomes related to workload or other health professional outcomes were not reported in the included studies. One randomised trial found that compared to the control group, the performance of incentivised professionals was not sustained after the P4P intervention had ended. (2) Fee for service (FFS) compared with existing payment methods for healthcare providers working in outpatient healthcare settings We are uncertain about the effect of FFS on the quantity of health services delivered (outpatient visits and hospitalisations), patient health outcomes, and total drugs cost compared to an existing payment method due to very low-certainty evidence. The quality of service provision and health professional outcomes were not reported in the included studies. One randomised trial reported that physicians paid via FFS may see more well patients than salaried physicians (low-certainty evidence), possibly implying that more unnecessary services were delivered through FFS. (3) FFS mixed with existing payment methods compared with existing payment methods for healthcare providers working in outpatient healthcare settings FFS mixed payment method may increase the quantity of health services provided compared with an existing payment method (RR 1.37, 95% CI 1.07 to 1.76; low-certainty evidence). We are uncertain about the effect of FFS mixed payment on quality of services provided, patient health outcomes, and health professional outcomes compared with an existing payment method due to very low-certainty evidence. Cost outcomes and adverse effects were not reported in the included studies. (4) Enhanced FFS compared with FFS for healthcare providers working in outpatient healthcare settings Enhanced FFS (higher FFS payment) probably increases child immunisation rates (RR 1.25, 95% CI 1.06 to 1.48; moderate-certainty evidence). We are uncertain whether higher FFS payment results in more primary care visits and about the effect of enhanced FFS on the net expenditure per year on covered children with regular FFS (very low-certainty evidence). Quality of service provision, patient outcomes, health professional outcomes, and adverse effects were not reported in the included studies. AUTHORS' CONCLUSIONS: For healthcare providers working in outpatient healthcare settings, P4P or an increase in FFS payment level probably increases the quantity of health service provision (moderate-certainty evidence), and P4P may slightly improve the quality of service provision for targeted conditions (low-certainty evidence). The effects of changes in payment methods on health outcomes is uncertain due to very low-certainty evidence. Information to explore the influence of specific payment method design features, such as the size of incentives and type of performance measures, was insufficient. Furthermore, due to limited and very low-certainty evidence, it is uncertain if changing payment models without including additional funding for professionals would have similar effects. There is a need for further well-conducted research on payment methods for healthcare providers working in outpatient healthcare settings in low- and middle-income countries; more studies comparing the impacts of different designs of the same payment method; and studies that consider the unintended consequences of payment interventions.

Health system reforms in China a half century apart: Continuity but adaptation.

Well-functioning governance arrangements are an essential, but often overlooked or poorly understood contributor to high quality health systems. Yet governance systems are embedded in institutional structures and shaped by cultural norms that can be difficult to change. We look at a country that has implemented two major health system reforms separated by half a century during which it has undergone remarkable political, economic, and social change. These are the Chinese Patriotic Health Campaign (PHC), beginning in the 1950s, and the New Cooperative Medical Scheme (NCMS), in the 2000s. We use these as case studies to explore how governance arrangements supported the design and implementation of policies implemented on a large scale in these quite different contexts. Drawing on review of archival documents, published literature, and semi-structured interviews with key policy makers, we conclude that few aspects of governance underwent fundamental changes. In both periods, the policy design stage included encouragement of sub-national tiers of government to pilot policy options, accumulate evidence, and disseminate it to others facing similar challenges, all facilitated by clear lines of accountability and a willingness by those at the top of the hierarchy to learn lessons from lower levels. At the implementation stage, rapid scaling up benefitted from leadership by national institutions that could enact regulations and set policy goals and targets for lower tiers of government, evaluating the performance of local government officers in terms of their ability to implement policy, while encouraging local government to pilot innovative measures. These findings highlight the importance of a detailed understanding of governance and how it is shaped by context, demonstrating continuity over long periods even at times of major social, political, and economic change. This understanding can inform future policy development in China and measures to strengthen governance aspects of reforms elsewhere.

Motivating factors on performance of primary care workers in China: a systematic review and meta-analysis.

OBJECTIVE: Although China has made remarkable progress in strengthening its primary healthcare system, lack of well-performed primary health workforce is still the bottleneck of deepening the reform. The objective of this review is to understand the current profile of Chinese primary care workers (PCWs) and their motivating factors of performance and propose targeted policy suggestions on improving their work performance. DESIGN: Systematic review. METHODS: A systematic search of PubMed and MEDLINE was conducted to identify articles published from January 1, 2000, to June 2, 2018. Quality assessment and data extraction for the studies closely relevant to performance of PCWs in China were conducted by two reviewers independently. A preliminary framework containing different levels of factors influencing PCWs' motivation based on existence, growth and relatedness (ERG) theory guided the synthesis analysis. In addition, we used a random-effects model to pool individual studies on job satisfaction and estimate the overall job satisfaction of PCWs. RESULTS: A total of 36 articles were included; 16 (23 882 participants) in the meta-analysis. Regarding the individual level of motivation, 3 overarching themes and 12 subthemes were developed. The subthemes of financial incentives, career advancement and work itself were frequently mentioned and have more influences on PCWs' performance. Moreover, the healthcare system reform policies have inevitable and complex impacts on different levels of human needs, and then influences on the motivation and performance of PCWs. Meta-analysis showed that the overall job satisfaction score among PCWs was 3.30, just reaching a satisfied rating and varied in different regions. CONCLUSIONS: This study suggests low work satisfaction among PCWs in China, with financial incentives and career advancement being two most important motivating factors. Efforts to improve the work performance in PCWs should give priority to these motivating factors and systematically take into account the health policy's impacts on performance of PCWs.

The interaction effect of health insurance reimbursement and health workforce on health care-seeking behaviour in China.

OBJECTIVE: In China, patients generally seek health care at high-level hospitals, which is leading to escalating medical costs and overloaded hospitals. Some studies have suggested that the health system is an important factor influencing individuals' health care-seeking behaviour; however, this association has not been studied in much depth. We therefore examined the impact of the health system (in terms of the interaction between health insurance reimbursement and health workforce) on health care-seeking behaviour. METHODS: Drawing on national survey data from 2008 and 2013, we linked individual-level data on choice of health care providers (our index of health care-seeking behaviour) with county-level data on the health workforce and health insurance. We then constructed a multilevel multinomial logistic model to examine the impacts of health insurance reimbursement (indexed as average reimbursement rate [ARR]) and the health workforce (number of registered physicians per 1000 population) at county hospitals and primary health care institutions (PHCs) on choice of inpatient care providers. RESULTS: Increases in ARR at county hospitals were associated with a greater probability of visiting such hospitals (relative risk ratio [RRR] = 1.23), and this positive impact was even greater in county hospitals with higher physician densities (RRR = 2.76). Greater ARR in PHCs was associated with a 73% lower probability of visiting municipal- and higher-level hospitals; increasing ARR was associated with an even lower probability when physician density in PHCs was considered (RRR = 0.09). CONCLUSION: Increases in the health insurance reimbursement and health workforce are necessary to improve health care access and thereby health care-seeking behaviour. Thus, comprehensive health system reform is necessary.

Increased Inequalities in Health Resource and Access to Health Care in Rural China.

Both health resources and access to these resources increased after China's health care reform launched in 2009. However, it is not clear if the inequalities were reduced within rural China, which was one of the main targets in the reform. This study aims to examine the changes in inequalities in health resources and access following the reform. Data came from the routine report of rural counties in every other year from 2008 to 2014. Health professionals and hospital beds per 1000 population were used for measuring health resources, and the hospitalization rate was used for access. Descriptive analysis and the fixed effect model were used in this study. Health resources and access increased by about 50% between 2008 and 2014 in rural China. The counties in richer quintiles got more health resources and hospitalizations. As for health professionals, the absolute differences between the richer and the poorest quintile were significantly enlarging in 2014 when compared to 2008. Regarding the hospitalization rate, the differences between the richest and the poorest quintile showed no significant change after 2012. In sum, absolute inequalities of health resources were increased, while that of health utilization kept constant following China's health care reform. The reform needs to continually recruit qualified health workers and appropriately allocate health infrastructures to strengthen the capacity of the health care system in the impoverished areas.

Precision targeting for more equitable distribution of health professionals in rural China.

A strong health workforce is widely recognized as a prerequisite for health care and a crucial determinant of health system performance. The number of health professionals in China increased following the 2009 health system reform, which, in part, aimed to address the shortage and unequal distribution of health professionals. We examined whether the distribution of health professionals was more equitable following the reform and whether the reform had targeted impacts in terms of the quantity of health professionals. We interacted economic (poor and non-poor counties) and geographic (eastern, central and western regions) dimensions to more precisely target vulnerable areas, focussing on the quantity and distribution of health professionals in rural China. We used a county-level longitudinal dataset from the National Health and Family Planning Commission consisting of 1978 counties in all 31 provinces in rural China, with measurements taken every other year from 2008 to 2014. The distribution of health professionals was summarized using descriptive and interaction analyses. We found a constant improvement in the number of health professionals per 1000 population co-existing with a worsening of the distribution across rural China following the health system reform. Most of the non-poor counties improved faster compared with poor counties across all geographic regions, especially in the western and eastern regions. The growth of the number of health professionals per 1000 population was greatest and fastest in western-non-poor counties and least and slowest in eastern-poor counties. As an example of the 'Central Region Downfall' phenomenon, the central counties (both poor and non-poor) performed poorly in terms of the quantity and distribution of health professionals. Based on an analysis of multiple dimensions, targeted and differential measures should be taken to reduce inequalities, and the central region should not be ignored in efforts to improve the distribution of health professionals in rural China.

Impact of health workforce availability on health care seeking behavior of patients with diabetes mellitus in China.

BACKGROUND: China has a high burden of diabetes mellitus (DM), and a large proportion of DM patients remain untreated for various reasons, including low availability of primary health care providers. DM patient management is one of the priorities in China's national essential public health programs. Shortage of health workforce has been a major barrier to improving access to health care for DM patients. This study examines the impact of the health workforce on outpatient utilization of DM patients. METHODS: Data were collected from China National Health Service Surveys in 2008 and 2013, covering 94 rural counties and 156 urban districts, respectively, with a total of 15,984 DM patients. Household data and facility-based data at county/district level were merged. The health workforce was measured by number of physicians per 1,000 population in county hospitals and primary health centers (PHCs), respectively. Health care seeking behavior was measured by health care utilization and distribution of health providers of the DM patients. Multilevel zero-inflated negative binomial regression was used to analyze the impact of the health workforce on outpatient visits by DM patients, and a multilevel, multinomial logit model was used to examine the impact of the health workforce on choice of health providers by DM patients. RESULTS: An increase in the number of physicians at both county hospitals and PHCs was associated with increased outpatient visits by DM patients, particularly more physicians at PHCs. With increased numbers of physicians at PHCs, outpatient visits among residents with DM in rural and western areas of China increased more than those in urban and eastern areas. More physicians at PHCs had a positive impact on improving the likelihood of outpatient visits at PHCs. The positive influence of increasing the number of physicians available to DM patients in rural and western areas was greater than that for urban and eastern DM patients. CONCLUSIONS: The health workforce is a key component of any healthcare system and is critical in improving health care accessibility. Strategies to increase coverage of health workforce at PHCs are crucial to achieving adequate levels of health services for DM patients. Allocation of health workforce should focus on PHCs in rural and low-income areas.

Efficiency performance of China's health care delivery system.

Improving efficiency performance of the health care delivery system has been on the agenda for the health system reform that China initiated in 2009. This study examines the changes in efficiency performance and determinants of efficiency after the reform to provide evidence to assess the progress of the reform from the perspective of efficiency. Descriptive analysis, Data Envelopment Analysis, the Malmquist Index, and multilevel regressions are used with data from multiple sources, including the World Bank, the China Health Statistical Yearbook, and routine reports. The results indicate that over the last decade, health outcomes compared with health investment were relatively higher in China than in most other countries worldwide, and the trend was stable. The overall efficiency and total factor productivity increased after the reform, indicating that the reform was likely to have had a positive impact on the efficiency performance of the health care delivery system. However, the health care delivery structure showed low system efficiency, mainly attributed to the weakened primary health care system. Strengthening the primary health care system is central to enhancing the future performance of China's health care delivery system.

The role of health system governance in strengthening the rural health insurance system in China.

BACKGROUND: Systems of governance play a key role in the operation and performance of health systems. In the past six decades, China has made great advances in strengthening its health system, most notably in establishing a health insurance system that enables residents of rural areas to achieve access to essential services. Although there have been several studies of rural health insurance schemes, these have focused on coverage and service utilization, while much less attention has been given to the role of governance in designing and implementing these schemes. METHODS: Information from publications and policy documents relevant to the development of two rural health insurance policies in China was obtained, analysed, and synthesise. 92 documents on CMS (Cooperative Medical Scheme) or NCMS (New Rural Cooperative Medical Scheme) from four databases searched were included. Data extraction and synthesis of the information were guided by a framework that drew on that developed by the WHO to describe health system governance and leadership. RESULTS: We identified a series of governance practices that were supportive of progress, including the prioritisation by the central government of health system development and certain health policies within overall national development; strong government commitment combined with a hierarchal administrative system; clear policy goals coupled with the ability for local government to adopt policy measures that take account of local conditions; and the accumulation and use of the evidence generated from local practices. However these good practices were not seen in all governance domains. For example, poor collaboration between different government departments was shown to be a considerable challenge that undermined the operation of the insurance schemes. CONCLUSIONS: China's success in achieving scale up of CMS and NCMS has attracted considerable interest in many low and middle income countries (LMICs), especially with regard to the schemes' designs, coverage, and funding mechanisms. However, this study demonstrates that health systems governance may be critical to enable the development and operation of such schemes. Given that many LMICs are expanding health financing system to cover populations in rural areas or the informal sectors, we argue that strengthening specific practices in each governance domain could inform the adaptation of these schemes to other settings.

Extending access to essential services against constraints: the three-tier health service delivery system in rural China (1949-1980).

BACKGROUND: China has made remarkable progress in scaling up essential services during the last six decades, making health care increasingly available in rural areas. This was partly achieved through the building of a three-tier health system in the 1950s, established as a linked network with health service facilities at county, township and village level, to extend services to the whole population. METHODS: We developed a Theory of Change to chart the policy context, contents and mechanisms that may have facilitated the establishment of the three-tier health service delivery system in rural China. We systematically synthesized the best available evidence on how China achieved universal access to essential services in resource-scarce rural settings, with a particular emphasis on the experiences learned before the 1980s, when the country suffered a particularly acute lack of resources. RESULTS: The search identified only three peered-reviewed articles that fit our criteria for scientific rigor. We therefore drew extensively on government policy documents, and triangulated them with other publications and key informant interviews. We found that China's three-tier health service delivery system was established in response to acute health challenges, including high fertility and mortality rates. Health system resources were extremely low in view of the needs and insufficient to extend access to even basic care. With strong political commitment to rural health and a "health-for-all" policy vision underlying implementation, a three-tier health service delivery model connecting villages, townships and counties was quickly established. We identified several factors that contributed to the success of the three-tier system in China: a realistic health human resource development strategy, use of mass campaigns as a vehicle to increase demand, an innovative financing mechanisms, public-private partnership models in the early stages of scale up, and an integrated approach to service delivery. An implementation process involving gradual adaptation and incorporation of the lessons learnt was also essential. CONCLUSIONS: China's 60 year experience in establishing a de-professionalized, community-based, health service delivery model that is economically feasible, institutionally and culturally appropriate mechanism can be useful to other low- and middle-income countries (LMICs) seeking to extend essential services. Lessons can be drawn from both reform content and from its implementation pathway, identifying the political, institutional and contextual factors shaping the three-tier delivery model over time.

Payment methods for outpatient care facilities.

BACKGROUND: Outpatient care facilities provide a variety of basic healthcare services to individuals who do not require hospitalisation or institutionalisation, and are usually the patient's first contact. The provision of outpatient care contributes to immediate and large gains in health status, and a large portion of total health expenditure goes to outpatient healthcare services. Payment method is one of the most important incentive methods applied by purchasers to guide the performance of outpatient care providers. OBJECTIVES: To assess the impact of different payment methods on the performance of outpatient care facilities and to analyse the differences in impact of payment methods in different settings. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), 2016, Issue 3, part of the Cochrane Library (searched 8 March 2016); MEDLINE, OvidSP (searched 8 March 2016); Embase, OvidSP (searched 24 April 2014); PubMed (NCBI) (searched 8 March 2016); Dissertations and Theses Database, ProQuest (searched 8 March 2016); Conference Proceedings Citation Index (ISI Web of Science) (searched 8 March 2016); IDEAS (searched 8 March 2016); EconLit, ProQuest (searched 8 March 2016); POPLINE, K4Health (searched 8 March 2016); China National Knowledge Infrastructure (searched 8 March 2016); Chinese Medicine Premier (searched 8 March 2016); OpenGrey (searched 8 March 2016); ClinicalTrials.gov, US National Institutes of Health (NIH) (searched 8 March 2016); World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (searched 8 March 2016); and the website of the World Bank (searched 8 March 2016).In addition, we searched the reference lists of included studies and carried out a citation search for the included studies via ISI Web of Science to find other potentially relevant studies. We also contacted authors of the main included studies regarding any further published or unpublished work. SELECTION CRITERIA: Randomised trials, non-randomised trials, controlled before-after studies, interrupted time series, and repeated measures studies that compared different payment methods for outpatient health facilities. We defined outpatient care facilities in this review as facilities that provide health services to individuals who do not require hospitalisation or institutionalisation. We only included methods used to transfer funds from the purchaser of healthcare services to health facilities (including groups of individual professionals). These include global budgets, line-item budgets, capitation, fee-for-service (fixed and unconstrained), pay for performance, and mixed payment. The primary outcomes were service provision outcomes, patient outcomes, healthcare provider outcomes, costs for providers, and any adverse effects. DATA COLLECTION AND ANALYSIS: At least two review authors independently extracted data and assessed the risk of bias. We conducted a structured synthesis. We first categorised the comparisons and outcomes and then described the effects of different types of payment methods on different categories of outcomes. We used a fixed-effect model for meta-analysis within a study if a study included more than one indicator in the same category of outcomes. We used a random-effects model for meta-analysis across studies. If the data for meta-analysis were not available in some studies, we calculated the median and interquartile range. We reported the risk ratio (RR) for dichotomous outcomes and the relative change for continuous outcomes. MAIN RESULTS: We included 21 studies from Afghanistan, Burundi, China, Democratic Republic of Congo, Rwanda, Tanzania, the United Kingdom, and the United States of health facilities providing primary health care and mental health care. There were three kinds of payment comparisons. 1) Pay for performance (P4P) combined with some existing payment method (capitation or different kinds of input-based payment) compared to the existing payment methodWe included 18 studies in this comparison, however we did not include five studies in the effects analysis due to high risk of bias. From the 13 studies, we found that the extra P4P incentives probably slightly improved the health professionals' use of some tests and treatments (adjusted RR median = 1.095, range 1.01 to 1.17; moderate-certainty evidence), and probably led to little or no difference in adherence to quality assurance criteria (adjusted percentage change median = -1.345%, range -8.49% to 5.8%; moderate-certainty evidence). We also found that P4P incentives may have led to little or no difference in patients' utilisation of health services (adjusted RR median = 1.01, range 0.96 to 1.15; low-certainty evidence) and may have led to little or no difference in the control of blood pressure or cholesterol (adjusted RR = 1.01, range 0.98 to 1.04; low-certainty evidence). 2) Capitation combined with P4P compared to fee-for-service (FFS)One study found that compared with FFS, a capitated budget combined with payment based on providers' performance on antibiotic prescriptions and patient satisfaction probably slightly reduced antibiotic prescriptions in primary health facilities (adjusted RR 0.84, 95% confidence interval 0.74 to 0.96; moderate-certainty evidence). 3) Capitation compared to FFSTwo studies compared capitation to FFS in mental health centres in the United States. Based on these studies, the effects of capitation compared to FFS on the utilisation and costs of services were uncertain (very low-certainty evidence). AUTHORS' CONCLUSIONS: Our review found that if policymakers intend to apply P4P incentives to pay health facilities providing outpatient services, this intervention will probably lead to a slight improvement in health professionals' use of tests or treatments, particularly for chronic diseases. However, it may lead to little or no improvement in patients' utilisation of health services or health outcomes. When considering using P4P to improve the performance of health facilities, policymakers should carefully consider each component of their P4P design, including the choice of performance measures, the performance target, payment frequency, if there will be additional funding, whether the payment level is sufficient to change the behaviours of health providers, and whether the payment to facilities will be allocated to individual professionals. Unfortunately, the studies included in this review did not help to inform those considerations.Well-designed comparisons of different payment methods for outpatient health facilities in low- and middle-income countries and studies directly comparing different designs (e.g. different payment levels) of the same payment method (e.g. P4P or FFS) are needed.

Consolidating the social health insurance schemes in China: towards an equitable and efficient health system.

Fragmentation in social health insurance schemes is an important factor for inequitable access to health care and financial protection for people covered by different health insurance schemes in China. To fulfil its commitment of universal health coverage by 2020, the Chinese Government needs to prioritise addressing this issue. After analysing the situation of fragmentation, this Review summarises efforts to consolidate health insurance schemes both in China and internationally. Rural migrants, elderly people, and those with non-communicable diseases in China will greatly benefit from consolidation of the existing health insurance schemes with extended funding pools, thereby narrowing the disparities among health insurance schemes in fund level and benefit package. Political commitments, institutional innovations, and a feasible implementation plan are the major elements needed for success in consolidation. Achievement of universal health coverage in China needs systemic strategies including consolidation of the social health insurance schemes.