绩效付费干预措施提高阿富汗母婴健康服务的效果：一项整群随机试验。

Effectiveness of a pay-for-performance intervention to improve maternal and child health services in Afghanistan: a cluster-randomized trial.

机构信息

Towson University, Department of Interprofessional Health Studies, Towson, MD, USA Johns Hopkins University, Department of International Health, Baltimore, MD, USA

World Health Organization, Health Systems Governance and Financing, Geneva, Switzerland.

出版信息

Int J Epidemiol. 2016 Apr;45(2):451-9. doi: 10.1093/ije/dyv362. Epub 2016 Feb 13.

DOI:10.1093/ije/dyv362

PMID:26874927

Abstract

BACKGROUND

A cluster randomized trial of a pay-for-performance (P4P) scheme was implemented in Afghanistan to test whether P4P could improve maternal and child (MCH) services.

METHODS

All 442 primary care facilities in 11 provinces were matched by type of facility and outpatient volume, and randomly assigned to the P4P or comparison arm. P4P facilities were given bonus payments based on the MCH services provided. An endline household sample survey was conducted in 72 randomly selected matched pair catchment areas (3421 P4P households; 3427 comparison).The quality of services was assessed in 81 randomly sampled matched pairs of facilities. Data collectors and households were blinded to the intervention assignment. MCH outcomes were assessed at the cluster level.

RESULTS

There were no substantial differences in any of the five MCH coverage indicators (P4P vs comparison): modern contraception(10.7% vs 11.2% (P = 0.90); antenatal care: 56.2% vs 55.6% (P = 0.94); skilled birth attendance (33.9% vs 28.5%, P = 0.17); postnatal care (31.2% vs 30.3%, P = 0.98); and childhood pentavalent3 vaccination (49.6 vs 52.3%, P = 0.41), or in the equity measures. There were substantial increases in the quality of history and physical examinations index (P = 0.01); client counselling index (P = 0.01); and time spent with patients (P = 0.05). Health workers reported limited understanding about the bonuses.

CONCLUSIONS

The intervention had minimal effect, possibly due to difficulties communicating with health workers and inattention to demand-side factors. P4P interventions need to consider management and community demand issues.

摘要

背景

在阿富汗实施了一项针对绩效付费（P4P）计划的整群随机试验，以检验 P4P 是否能够改善母婴保健（MCH）服务。

方法

将所有 442 家初级保健机构按照机构类型和门诊量进行匹配，并随机分配到 P4P 或对照组。P4P 机构根据提供的 MCH 服务获得奖金。在 72 个随机选择的匹配对子集落地区（3421 个 P4P 家庭；3427 个对照组）进行了终线家庭抽样调查。在 81 个随机抽样的匹配对子机构中评估了服务质量。数据收集员和家庭对干预分配不知情。MCH 结果在群体水平上进行评估。

结果

在任何五个 MCH 覆盖指标中，两组之间都没有实质性差异（P4P 与对照组）：现代避孕方法（10.7% vs 11.2%（P = 0.90）；产前护理：56.2% vs 55.6%（P = 0.94）；熟练接生（33.9% vs 28.5%（P = 0.17）；产后护理（31.2% vs 30.3%（P = 0.98）；和儿童五联疫苗接种（49.6 vs 52.3%（P = 0.41）），或在公平措施方面。历史和体检指数（P = 0.01）；客户咨询指数（P = 0.01）；以及与患者在一起的时间（P = 0.05）都有了实质性的提高。卫生工作者报告说，他们对奖金的理解有限。