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1.
Expert Rev Pharmacoecon Outcomes Res ; 19(6): 627-632, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31810392

RESUMO

Introduction: There is significant difference in utilization of patented medicines in the EU, as pharmaceuticals at Western European price levels are usually not cost-effective in Central and Eastern European (CEE) countries. The article reviews options to solve the 'financing gap' posed by the challenge of covering patented medicines from more restricted resources in countries with greater unmet medical need.Areas covered: Hidden volume restrictions to patented pharmaceuticals implemented by payers to facilitate financial sustainability may increase European inequity in patient access. Confidential price discounts and financial risk-sharing agreements improve cost-effectiveness of pharmaceuticals with limited impact on the European floor price. Narrowing the eligible group of patients on the positive drug list can help to target the medicines to patients with potentially greater health benefit whilst reducing the budget impact. Pay-for-performance schemes can improve cost-effectiveness of pharmaceuticals with significant uncertainty or heterogeneity in the magnitude of added therapeutic value. Increased utilization of off-patent pharmaceuticals can increase patient access through re-investing the savings from generic or biosimilar price erosion.Expert opinion: Transparent and sustainable pharmaceutical policies aiming to improve the allocative efficiency of scarce resources should be implemented in CEE to reduce financing gap and improve patient access to high-cost medicines.


Assuntos
Custos de Medicamentos/estatística & dados numéricos , Acesso aos Serviços de Saúde/economia , Preparações Farmacêuticas/provisão & distribução , Reembolso de Incentivo/economia , Análise Custo-Benefício , Controle de Medicamentos e Entorpecentes , Farmacoeconomia , União Europeia , Humanos , Patentes como Assunto , Preparações Farmacêuticas/economia , Participação no Risco Financeiro/economia
2.
Global Health ; 15(1): 59, 2019 10 16.
Artigo em Inglês | MEDLINE | ID: mdl-31619291

RESUMO

BACKGROUND: Tanzania is one of many low income countries committed to universal health coverage and Sustainable Development Goals. Despite these bold goals, there is growing concern that the country could be off-track in meeting these goals. This prompted the Government of Tanzania to look for ways to improve health outcomes in these goals and this led to the introduction of Payment for Performance (P4P) in the health sector. Since the inception of P4P in Tanzania a number of impact, cost-effective and process evaluations have been published with less attention being paid to the experiences of care in this context of P4P, which we argue is important for policy agenda setting. This study therefore explores these experiences from the perspectives of health workers, service users and community health governing committee members. METHODS: A qualitative study design was used to elicit experiences of health workers, health service users and health governing committee members in Rufiji district of the Pwani region in Tanzania. The Payment for Performance pilot was introduced in Pwani region in 2011 and data presented in this article is based on this pilot. A total of 31 in-depth interviews with health workers and 9 focus group discussions with health service users and health governing committee members were conducted. Collected data was analysed through qualitative content analysis. RESULTS: Study informants reported positive experiences with Payment for Performance and highlighted its potential in improving the availability, accessibility, acceptability and quality of care (AAAQ). However, the study found that persistent barriers for achieving AAAQ still exist in the health system of Tanzania and these contribute to negative experiences of care in the context of P4P. CONCLUSION: Our findings suggest that there are a number of positive aspects of care that can be improved by Payment for Performance. However its targeted nature on specific services means that these improvements cannot be generalized at health facility level. Additionally, health workers can go as far as they can in improving health services but some factors that act as barriers as demonstrated in this study are out of their control even in the context of Payment for Performance. In this regard there is need to exercise caution when implementing such initiatives, despite seemingly positive targeted outcomes.


Assuntos
Atitude do Pessoal de Saúde , Pessoal de Saúde/psicologia , Reembolso de Incentivo , Grupos Focais , Humanos , Pesquisa Qualitativa , Qualidade da Assistência à Saúde , Tanzânia
4.
Orv Hetil ; 160(39): 1542-1553, 2019 Sep.
Artigo em Húngaro | MEDLINE | ID: mdl-31544494

RESUMO

Introduction: The indicator-based performance monitoring and pay-for-performance system for Hungarian primary care was established in 2009, covering the whole country. It is based on a stable legal system and well operating information technology. Although, the health insurance system is able to facilitate the performance improvement only by the financing for general medical practices, the many times modified present system does not take into consideration (apart from the geographical location of practices) factors which determine the performance but cannot be influenced by general practitioners. Aim: The study aimed at renewing the indicator set and evaluation methodology in order to enable the monitoring to evaluate the performance of general medical practices independent of their structural characteristics. Method: Each adult care specific primary care performance indicator from June 2016 covering the whole country has been investigated. Indicators adjusted for structural practice characteristics (age and gender of patients; relative education of people provided; settlement type and county of the practice) have been computed. The difference between adjusted indicators and national reference values has been evaluated by statistical testing. Appropriateness of the present monitoring and financing system has been investigated by comparing the practice level presently applied and adjusted indicators to outline the opportunities to develop the present system. Results: The present monitoring allocates 34.46% of pay-for-performance resources for improving the performance of practices. The majority of resources supports the conservation of performance. Furthermore, the present system is not able to identify each practice with better than reference performance, withholding amount corresponding to 8.83% of pay-for-performance resources. If this financing were restricted to practices with significantly better than reference performance, the maximum of the financing a month in a practice would increase from 176 042 HUF (551 EURO) to 406 604 HUF (1274 EURO). Conclusion: Completing the performance monitoring system operated at present by the National Health Insurance Fund of Hungary with indicators adjusted for structural characteristics of the general medical practices, the resource allocation effectiveness could be improved. Orv Hetil. 2019; 160(39): 1542-1553.


Assuntos
Assistência à Saúde/organização & administração , Atenção Primária à Saúde/organização & administração , Indicadores de Qualidade em Assistência à Saúde , Reembolso de Incentivo , Desempenho Profissional , Adulto , Humanos , Hungria , Seguro Saúde , Médicos de Família , Alocação de Recursos
5.
AIDS Behav ; 23(9): 2467-2476, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31407212

RESUMO

This pilot randomized controlled trial examined the feasibility and acceptability of a Syndemics intervention targeting the intersection of stimulant use, trauma, and difficulties with HIV disease management in cocaine-using women. All participants received contingency management (CM) for 3 months with financial incentives for stimulant abstinence during thrice-weekly urine screening and refilling antiretroviral medications monthly. Sixteen participants were randomized to complete four expressive writing (n = 9) or four neutral writing (n = 7) sessions delivered during the CM intervention period. Completion rates for writing sessions were high (15 of 16 women completed all four sessions) and engagement in CM urine screening was moderate with women randomized to expressive writing providing a median of 11 non-reactive urine samples for stimulants. There were non-significant trends for those randomized to expressive writing to provide more CM urine samples that were non-reactive for stimulants, report greater decreases in severity of cocaine use, and display reductions in log10 HIV viral load at 6 months. Although the Syndemics intervention was feasible and acceptable to many women, qualitative interviews with eligible participants who were not randomized identified structural and psychological barriers to engagement. Further clinical research is needed to test the efficacy of Syndemics interventions with HIV-positive, cocaine-using women.


Assuntos
Antirretrovirais/uso terapêutico , Transtornos Relacionados ao Uso de Cocaína/complicações , Infecções por HIV/tratamento farmacológico , Motivação , Aceitação pelo Paciente de Cuidados de Saúde , Sindemia , Redação , Adulto , Terapia Comportamental , Estimulantes do Sistema Nervoso Central/administração & dosagem , Estimulantes do Sistema Nervoso Central/efeitos adversos , Estudos de Viabilidade , Feminino , Infecções por HIV/psicologia , Soropositividade para HIV , Humanos , Entrevistas como Assunto , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Pesquisa Qualitativa , Reembolso de Incentivo , Resultado do Tratamento , Carga Viral
6.
Med Care ; 57(10): 757-765, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31453891

RESUMO

BACKGROUND: Medicare's Hospital Readmission Reduction Program (HRRP) penalizes hospitals with elevated 30-day readmission rates for acute myocardial infarction (AMI), heart failure (HF), or pneumonia. To reduce readmissions, hospitals may have increased referrals to skilled nursing facilities (SNFs) and home health care. RESEARCH DESIGN: Outcomes included 30-day postdischarge utilization of SNF and home health care, including any use as well as days of use. Subjects included Medicare fee-for-service beneficiaries aged 65 years and older who were admitted with AMI, HF, or pneumonia to hospitals subject to the HRRP. Using an interrupted time-series analysis, we compared utilization rates observed after the announcement of the HRRP (April 2010 through September 2012) and after the imposition of penalties (October 2012 through September 2014) with projected utilization rates that accounted for pre-HRRP trends (January 2008 through March 2010). Models included patient characteristics and hospital fixed effects. RESULTS: For AMI and HF, utilization of SNF and home health care remained stable overall. For pneumonia, observed utilization of any SNF care increased modestly (1.0%, P<0.001 during anticipation; 2.4%, P<0.001 after penalties) and observed utilization of any home health care services declined modestly (-0.5%, P=0.008 after announcement; -0.7%, P=0.045 after penalties) relative to projections. Beneficiaries with AMI and pneumonia treated at penalized hospitals had higher rates of being in the community 30 days postdischarge. CONCLUSIONS: Hospitals might be shifting to more intensive postacute care to avoid readmissions among seniors with pneumonia. At the same time, penalized hospitals' efforts to prevent readmissions may be keeping higher proportions of their patients in the community.


Assuntos
Utilização de Instalações e Serviços/tendências , Serviços de Assistência Domiciliar/estatística & dados numéricos , Readmissão do Paciente/legislação & jurisprudência , Reembolso de Incentivo/legislação & jurisprudência , Instituições de Cuidados Especializados de Enfermagem/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Análise de Séries Temporais Interrompida , Masculino , Medicare/legislação & jurisprudência , Estados Unidos
7.
Bone Joint J ; 101-B(8): 1015-1023, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31362544

RESUMO

AIMS: Hip fractures are associated with high morbidity, mortality, and costs. One strategy for improving outcomes is to incentivize hospitals to provide better quality of care. We aimed to determine whether a pay-for-performance initiative affected hip fracture outcomes in England by using Scotland, which did not participate in the scheme, as a control. MATERIALS AND METHODS: We undertook an interrupted time series study with data from all patients aged more than 60 years with a hip fracture in England (2000 to 2018) using the Hospital Episode Statistics Admitted Patient Care (HES APC) data set linked to national death registrations. Difference-in-differences (DID) analysis incorporating equivalent data from the Scottish Morbidity Record was used to control for secular trends. The outcomes were 30-day and 365-day mortality, 30-day re-admission, time to operation, and acute length of stay. RESULTS: There were 1 037 860 patients with a hip fracture in England and 116 594 in Scotland. Both 30-day (DID -1.7%; 95% confidence interval (CI) -2.0 to -1.2) and 365-day (-1.9%; 95% CI -2.5 to -1.3) mortality fell in England post-intervention when compared with outcomes in Scotland. There were 7600 fewer deaths between 2010 and 2016 that could be attributed to interventions driven by pay-for-performance. A pre-existing annual trend towards increased 30-day re-admissions in England was halted post-intervention. Significant reductions were observed in the time to operation and length of stay. CONCLUSION: This study provides evidence that a pay-for-performance programme improved the outcomes after a hip fracture in England. Cite this article: Bone Joint J 2019;101-B:1015-1023.


Assuntos
Fixação de Fratura/economia , Fraturas do Quadril/economia , Melhoria de Qualidade/economia , Reembolso de Incentivo , Idoso , Idoso de 80 Anos ou mais , Inglaterra , Feminino , Seguimentos , Fixação de Fratura/estatística & dados numéricos , Fraturas do Quadril/mortalidade , Fraturas do Quadril/cirurgia , Humanos , Análise de Séries Temporais Interrompida , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/economia , Readmissão do Paciente/estatística & dados numéricos , Melhoria de Qualidade/estatística & dados numéricos , Escócia , Tempo para o Tratamento/economia , Resultado do Tratamento
9.
Med Care ; 57(9): 695-701, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31335756

RESUMO

BACKGROUND: The Hospital Readmissions Reduction Program (HRRP) penalizes hospitals for higher-than-expected readmission rates. Almost 20% of Medicare fee-for-service (FFS) patients receive postacute care in skilled nursing facilities (SNFs) after hospitalization. SNF patients have high readmission rates. OBJECTIVE: The objective of this study was to investigate the association between changes in hospital referral patterns to SNFs and HRRP penalty pressure. DESIGN: We examined changes in the relationship between penalty pressure and outcomes before versus after HRRP announcement among 2698 hospitals serving 6,936,393 Medicare FFS patients admitted for target conditions: acute myocardial infarction, heart failure, or pneumonia. Hospital-level penalty pressure was the expected penalty rate in the first year of the HRRP multiplied by Medicare discharge share. OUTCOMES: Informal integration measured by the percentage of referrals to hospitals' most referred SNF; formal integration measured by SNF acquisition; readmission-based quality index of the SNFs to which a hospital referred discharged patients; referral rate to any SNF. RESULTS: Hospitals facing the median level of penalty pressure had modest differential increases of 0.3 percentage points in the proportion of referrals to the most referred SNF and a 0.006 SD increase in the average quality index of SNFs referred to. There were no statistically significant differential increases in formal acquisition of SNFs or referral rate to SNF. CONCLUSIONS: HRRP did not prompt substantial changes in hospital referral patterns to SNFs, although readmissions for patients referred to SNF differentially decreased more than for other patients, warranting investigation of other mechanisms underlying readmissions reduction.


Assuntos
Readmissão do Paciente/estatística & dados numéricos , Encaminhamento e Consulta/estatística & dados numéricos , Reembolso de Incentivo/estatística & dados numéricos , Instituições de Cuidados Especializados de Enfermagem/estatística & dados numéricos , Cuidados Semi-Intensivos/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Medicare/legislação & jurisprudência , Readmissão do Paciente/legislação & jurisprudência , Avaliação de Programas e Projetos de Saúde , Encaminhamento e Consulta/legislação & jurisprudência , Estados Unidos
11.
N Engl J Med ; 381(3): 252-263, 2019 07 18.
Artigo em Inglês | MEDLINE | ID: mdl-31314969

RESUMO

BACKGROUND: Population-based global payment gives health care providers a spending target for the care of a defined group of patients. We examined changes in spending, utilization, and quality through 8 years of the Alternative Quality Contract (AQC) of Blue Cross Blue Shield (BCBS) of Massachusetts, a population-based payment model that includes financial rewards and penalties (two-sided risk). METHODS: Using a difference-in-differences method to analyze data from 2006 through 2016, we compared spending among enrollees whose physician organizations entered the AQC starting in 2009 with spending among privately insured enrollees in control states. We examined quantities of sentinel services using an analogous approach. We then compared process and outcome quality measures with averages in New England and the United States. RESULTS: During the 8-year post-intervention period from 2009 to 2016, the increase in the average annual medical spending on claims for the enrollees in organizations that entered the AQC in 2009 was $461 lower per enrollee than spending in the control states (P<0.001), an 11.7% relative savings on claims. Savings on claims were driven in the early years by lower prices and in the later years by lower utilization of services, including use of laboratory testing, certain imaging tests, and emergency department visits. Most quality measures of processes and outcomes improved more in the AQC cohorts than they did in New England and the nation in unadjusted analyses. Savings were generally larger among subpopulations that were enrolled longer. Enrollees of organizations that entered the AQC in 2010, 2011, and 2012 had medical claims savings of 11.9%, 6.9%, and 2.3%, respectively, by 2016. The savings for the 2012 cohort were statistically less precise than those for the other cohorts. In the later years of the initial AQC cohorts and across the years of the later-entry cohorts, the savings on claims exceeded incentive payments, which included quality bonuses and providers' share of the savings below spending targets. CONCLUSIONS: During the first 8 years after its introduction, the BCBS population-based payment model was associated with slower growth in medical spending on claims, resulting in savings that over time began to exceed incentive payments. Unadjusted measures of quality under this model were higher than or similar to average regional and national quality measures. (Funded by the National Institutes of Health.).


Assuntos
Planos de Seguro Blue Cross Blue Shield , Gastos em Saúde/tendências , Qualidade da Assistência à Saúde , Reembolso de Incentivo/economia , Planos de Seguro Blue Cross Blue Shield/organização & administração , Massachusetts , Qualidade da Assistência à Saúde/economia , Qualidade da Assistência à Saúde/tendências , Encaminhamento e Consulta/tendências , Mecanismo de Reembolso , Estados Unidos
13.
Cochrane Database Syst Rev ; 7: CD011156, 2019 Jul 05.
Artigo em Inglês | MEDLINE | ID: mdl-31276606

RESUMO

BACKGROUND: Pay-for-Performance (P4P) is a payment model that rewards health care providers for meeting pre-defined targets for quality indicators or efficacy parameters to increase the quality or efficacy of care. OBJECTIVES: Our objective was to assess the impact of P4P for in-hospital delivered health care on the quality of care, resource use and equity. Our objective was not only to answer the question whether P4P works in general (simple perspective) but to provide a comprehensive and detailed overview of P4P with a focus on analyzing the intervention components, the context factors and their interrelation (more complex perspective). SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, three other databases and two trial registers on 27 June 2018. In addition, we searched conference proceedings, gray literature and web pages of relevant health care institutions, contacted experts in the field, conducted cited reference searches and performed cross-checks of included references and systematic reviews on the same topic. SELECTION CRITERIA: We included randomized trials, cluster randomized trials, non-randomized clustered trials, controlled before-after studies, interrupted time series and repeated measures studies that analyzed hospitals, hospital units or groups of hospitals and that compared any kind of P4P to a basic payment scheme (e.g. capitation) without P4P. Studies had to analyze at least one of the following outcomes to be eligible: patient outcomes; quality of care; utilization, coverage or access; resource use, costs and cost shifting; healthcare provider outcomes; equity; adverse effects or harms. DATA COLLECTION AND ANALYSIS: Two review authors independently screened all citations for inclusion, extracted study data and assessed risk of bias for each included study. Study characteristics were extracted by one reviewer and verified by a second.We did not perform meta-analysis because the included studies were too heterogenous regarding hospital characteristics, the design of the P4P programs and study design. Instead we present a structured narrative synthesis considering the complexity as well as the context/setting of the intervention. We assessed the certainty of evidence using the GRADE approach and present the results narratively in 'Summary of findings' tables. MAIN RESULTS: We included 27 studies (20 CBA, 7 ITS) on six different P4P programs. Studies analyzed between 10 and 4267 centers. All P4P programs targeted acute or emergency physical conditions and compared a capitation-based payment scheme without P4P to the same capitation-based payment scheme combined with a P4P add-on. Two P4P program used rewards or penalties; one used first rewards and than penalties; two used penalties only and one used rewards only. Four P4P programs were established and evaluated in the USA, one in England and one in France.Most studies showed no difference or a very small effect in favor of the P4P program. The impact of each P4P program was as follows.Premier Hospital Quality Incentive Demonstration Program: It is uncertain whether this program, which used rewards for some hospitals and penalties for others, has an impact on mortality, adverse clinical events, quality of care, equity or resource use as the certainty of the evidence was very low.Value-Based Purchasing Program: It is uncertain whether this program, which used rewards for some hospitals and penalties for others, has an impact on mortality, adverse clinical events or quality of care as the certainty of the evidence was very low. Equity and resource use outcomes were not reported in the studies, which evaluated this program.Non-payment for Hospital-Acquired Conditions Program: It is uncertain whether this penalty-based program has an impact on adverse clinical events as the certainty of the evidence was very low. Mortality, quality of care, equity and resource use outcomes were not reported in the studies, which evaluated this program.Hospital Readmissions Reduction Program: None of the studies that examined this penalty-based program reported mortality, adverse clinical events, quality of care (process quality score), equity or resource use outcomes.Advancing Quality Program: It is uncertain whether this reward-/penalty-based program has an impact on mortality as the certainty of the evidence was very low. Adverse clinical events, quality of care, equity and resource use outcomes were not reported in any study.Financial Incentive to Quality Improvement Program: It is uncertain whether this reward-based program has an impact on quality of care, as the certainty of the evidence was very low. Mortality, adverse clinical events, equity and resource use outcomes were not reported in any study.Subgroup analysis (analysis of modifying design and context factors)Analysis of P4P design factors provides some hints that non-payments compared to additional payments and payments for quality attainment (e.g. falling below specified mortality threshold) compared to quality improvement (e.g. reduction of mortality by specified percent points within one year) may have a stronger impact on performance. AUTHORS' CONCLUSIONS: It is uncertain whether P4P, compared to capitation-based payments without P4P for hospitals, has an impact on patient outcomes, quality of care, equity or resource use as the certainty of the evidence was very low (or we found no studies on the outcome) for all P4P programs. The effects on patient outcomes of P4P in hospitals were at most small, regardless of design factors and context/setting. It seems that with additional payments only small short-term but non-sustainable effects can be achieved. Non-payments seem to be slightly more effective than bonuses and payments for quality attainment seem to be slightly more effective than payments for quality improvement.


Assuntos
Economia Hospitalar , Qualidade da Assistência à Saúde , Reembolso de Incentivo , Custos e Análise de Custo , Europa (Continente) , Planos de Pagamento por Serviço Prestado , Hospitais , Humanos , Melhoria de Qualidade/economia , Estados Unidos
14.
BMC Health Serv Res ; 19(1): 529, 2019 Jul 29.
Artigo em Inglês | MEDLINE | ID: mdl-31357999

RESUMO

BACKGROUND: There is international interest in whether improved primary care, in particular for patients with chronic or complex conditions, can lead to decreased use of health resources and whether financial incentives help achieve this goal. This trial (EQuIP-GP) will investigate whether a funding model based upon targeted, continuous quality incentive payments for Australian general practices increases relational continuity of care, and lessens health-service utilisation, for high-risk patients and children. METHODS: We will use a mixed methods approach incorporating a two-arm pragmatic cluster randomised control trial with nested qualitative case studies. We aim to recruit 36 general practices from Practice-Based Research Networks (PBRN) covering urban and regional areas of Australia, randomised into intervention and control groups. Control practices will provide usual care while intervention practices will be supported to implement a new service model incorporating incentives for relational continuity and timely access to appointments. Patients will comprise three groups: older (over 65 years); 18-65 years with chronic and/or complex conditions; and those aged less than 16 years with increased risk of hospitalisation. The funding model includes financial incentives to general practitioners (GPs) for providing longer consultations, same day access and timely follow-up after hospitalisation to enrolled patients. The payments are proportional to expected health system savings associated with improved quality of GP care. An outreach facilitator will work with practices to help incorporate the incentive model into usual work. The main outcome measure is relational continuity of care (Primary Care Assessment Tool short-form survey), with secondary outcomes including health-related quality of life and health service use (hospitalisations, emergency presentations, GP and specialist services in the community, medicine prescriptions and targeted pathology and imaging ordering). Outcomes will be initially evaluated over a period of 12 months, with ongoing data collection for 5 years. DISCUSSION: The trial will provide robust evidence on a novel approach to providing continuous incentives for improving quality of general practice care, which can be compared to block payment incentives awarded at target quality levels of pay-for-performance, both within Australia and also internationally. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12618000105246. Registered on 23 January 2018.


Assuntos
Medicina Geral/economia , Atenção Primária à Saúde/economia , Melhoria de Qualidade , Reembolso de Incentivo , Adolescente , Adulto , Idoso , Austrália , Criança , Análise Custo-Benefício , Medicina Geral/normas , Pesquisas sobre Serviços de Saúde , Acesso aos Serviços de Saúde , Hospitalização/estatística & dados numéricos , Humanos , Pessoa de Meia-Idade , Seleção de Pacientes , Atenção Primária à Saúde/normas , Qualidade de Vida , Reembolso de Incentivo/economia , Adulto Jovem
16.
Int J Health Policy Manag ; 8(5): 272-279, 2019 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-31204443

RESUMO

BACKGROUND: Performance-based financing (PBF) is currently tested in many low- and middle-income countries as a health system strengthening strategy. One of the main mechanisms through which PBF is assumed to effect change is by motivating health workers to improve their service delivery performance. This article aims at a better understanding of such motivational effects of PBF. In particular, the study focused on organizational context factors and health workers' perceptions thereof as moderators of the motivational effects of PBF, which to date has been little explored. METHODS: We conducted a multiple case study in 2 district hospitals and 16 primary health facilities across three districts. Health facilities were purposely sampled according to pre-PBF performance levels. Within sampled facilities, 82 clinical skilled healthcare workers were in-depth interviewed one year after the start of the PBF intervention. Data were analyzed using a blended deductive and inductive process, using self-determination theory (SDT) as an analytical framework. RESULTS: Results show that the extent to which PBF contributed to positive, sustainable forms of motivation depended on the "ground upon which PBF fell," beyond health workers' individual personalities and disposition. In particular, health workers described three aspects of the organizational context in which PBF was implemented: the extent to which existing hierarchies fostered as opposed to hindered participation and transparency; managers' handling of the increased performance feedback inherent in PBF; and facility's pre-PBF levels in regards to infrastructure, equipment, and human resources. CONCLUSION: Our results underline the importance of leadership styles and pre-implementation performance levels in shaping health workers' motivational reactions to PBF. Ancillary interventions aimed at fostering participatory as opposed to directional leadership or start-up support to low-performing health facilities will likely boost PBF effects in regards to the development of valuable motivational capacities.


Assuntos
Pessoal de Saúde/organização & administração , Financiamento da Assistência à Saúde , Motivação , Reembolso de Incentivo , Burkina Faso , Feminino , Pessoal de Saúde/psicologia , Humanos , Entrevistas como Assunto , Liderança , Masculino , Estudos de Casos Organizacionais , Reembolso de Incentivo/organização & administração
19.
AIDS Behav ; 23(9): 2443-2452, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31098747

RESUMO

We examine the effect of the Undetectables Intervention (UI) on viral loads among socially vulnerable HIV-positive clients. The UI utilized a toolkit that included financial incentives, graphic novels, and community-based case management services. A pre-post repeated measures analysis (n = 502) through 4 years examined longitudinal effects of the intervention. Logistic models regressed social determinants on viral loads. Finally, in-depth qualitative interviews (n = 30) examined how UI shaped adherence. The proportion of virally suppressed time-points increased 15% (from 67 to 82% pre to post-enrollment, p < 0.0001). The proportion of the sample virally suppressed at all time-points increased by 23% (from 39 to 62% pre to post-enrollment, p < 0.0001). African Americans and the homeless were the most likely to be unsuppressed at baseline, but, along with substance users, benefitted the most from UI. The intervention shaped adherence through two pathways, by: (1) establishing worth around adherence, and (2) increasing motivation to become suppressed, and maintain adherence.


Assuntos
Infecções por HIV/tratamento farmacológico , Infecções por HIV/virologia , Pessoas em Situação de Rua/estatística & dados numéricos , Adesão à Medicação , Aceitação pelo Paciente de Cuidados de Saúde , Reembolso de Incentivo/organização & administração , Determinantes Sociais da Saúde , Carga Viral/efeitos dos fármacos , Populações Vulneráveis , Adulto , Afro-Americanos , Administração de Caso , Grupos de Populações Continentais , Feminino , Infecções por HIV/psicologia , Humanos , Entrevistas como Assunto , Pessoa de Meia-Idade , Motivação , Pesquisa Qualitativa
20.
BMC Pregnancy Childbirth ; 19(1): 150, 2019 May 20.
Artigo em Inglês | MEDLINE | ID: mdl-31104629

RESUMO

BACKGROUND: Gaps in postnatal care use represent missed opportunities to prevent maternal and neonatal death in sub-Saharan Africa. As one in every three non-facility deliveries in Nigeria is assisted by a traditional birth attendant (TBA), and the TBA's advice is often adhered to by their clients, engaging TBAs in advocacy among their clients may increase maternal and neonatal postnatal care use. This study estimates the impact of monetary incentives for maternal referrals by TBAs on early maternal and neonatal postnatal care use (within 48 h of delivery) in Nigeria. METHODS: We conducted a non-blinded, individually-randomized, controlled study of 207 TBAs in Ebonyi State, Nigeria between August and December 2016. TBAs were randomly assigned with a 50-50 probability to receive $2.00 for every maternal client that attended postnatal care within 48 h of delivery (treatment group) or to receive no monetary incentive (control group). We compared the probabilities of maternal and neonatal postnatal care use within 48 h of delivery in treatment and control groups in an intention-to-treat analysis. We also ascertained if the care received by mothers and newborns during these visits followed World Health Organization guidelines. RESULTS: Overall, 207 TBAs participated in this study: 103 in the treatment group and 104 in the control group. The intervention increased the proportion of maternal clients of TBAs that reported attending postnatal care within 48 h of delivery by 15.4 percentage points [95% confidence interval (CI): 7.9-22.9]. The proportion of neonatal clients of TBAs that reportedly attended postnatal care within 48 h of delivery also increased by 12.6 percentage points [95% CI: 5.9-19.3]. However, providers often did not address the issues that may have led to maternal and newborn postnatal complications during these visits. CONCLUSIONS: We show that motivating TBAs using monetary incentives for maternal postnatal care use can increase skilled care use after delivery among their maternal and neonatal clients, who have a higher risk of mortality because of their exposure to unskilled birth attendance. However, improving the quality of care is key to ensuring maternal and neonatal health gains from postnatal care attendance. TRIAL REGISTRATION: The trial was retrospectively registered in clinicaltrials.gov ( NCT02936869 ) on October 18, 2016.


Assuntos
Tocologia/economia , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Cuidado Pós-Natal/economia , Encaminhamento e Consulta/economia , Reembolso de Incentivo , Feminino , Humanos , Tocologia/métodos , Nigéria , Gravidez
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