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Advancing the application of systems thinking in health: provider payment and service supply behaviour and incentives in the Ghana National Health Insurance Scheme – a systems approach

机译：促进系统思想在健康中的应用：加纳国家健康保险计划中的提供者支付和服务提供行为及激励措施–一种系统方法

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Background Assuring equitable universal access to essential health services without exposure to undue financial hardship requires adequate resource mobilization, efficient use of resources, and attention to quality and responsiveness of services. The way providers are paid is a critical part of this process because it can create incentives and patterns of behaviour related to supply. The objective of this work was to describe provider behaviour related to supply of health services to insured clients in Ghana and the influence of provider payment methods on incentives and behaviour. Methods A mixed methods study involving grey and published literature reviews, as well as health management information system and primary data collection and analysis was used. Primary data collection involved in-depth interviews, observations of time spent obtaining service, prescription analysis, and exit interviews with clients. Qualitative data was analysed manually to draw out themes, commonalities, and contrasts. Quantitative data was analysed in Excel and Stata. Causal loop and cause tree diagrams were used to develop a qualitative explanatory model of provider supply incentives and behaviour related to payment method in context. Results There are multiple provider payment methods in the Ghanaian health system. National Health Insurance provider payment methods are the most recent additions. At the time of the study, the methods used nationwide were the Ghana Diagnostic Related Groupings payment for services and an itemized and standardized fee schedule for medicines. The influence of provider payment method on supply behaviour was sometimes intuitive and sometimes counter intuitive. It appeared to be related to context and the interaction of the methods with context and each other rather than linearly to any given method. Conclusions As countries work towards Universal Health Coverage, there is a need to holistically design, implement, and manage provider payment methods reforms from systems rather than linear perspectives, since the latter fail to recognize the effects of context and the between-methods and context interactions in producing net effects.
机译：背景技术要确保能够公平地普遍获得基本卫生服务而又不会遭受不适当的财政困难，则需要充分调动资源，有效利用资源，并注意服务质量和响应能力。为提供者付款的方式是该过程的关键部分，因为它可以创建与供应有关的激励机制和行为模式。这项工作的目的是描述与向加纳的被保险客户提供医疗服务有关的提供者行为，以及提供者支付方式对激励和行为的影响。方法采用混合方法研究，涉及灰色和公开发表的文献综述，以及健康管理信息系统和主要数据收集与分析。主要数据收集包括深入访谈，观察获得服务所花费的时间，处方分析以及与客户的退出访谈。手动分析了定性数据，以得出主题，共性和对比。在Excel和Stata中分析定量数据。使用因果环图和原因树图来开发与上下文中的付款方式相关的提供商提供激励和行为的定性解释模型。结果加纳的卫生系统中有多种提供者付款方式。国民健康保险提供者的付款方式是最近添加的。在研究时，全国范围内使用的方法是加纳诊断相关分组服务付款和药品的逐项和标准化费用表。提供者付款方式对供应行为的影响有时是直观的，有时是相反的。它似乎与上下文以及方法与上下文以及彼此之间的交互有关，而不是与任何给定方法线性相关。结论随着各国努力实现全民健康覆盖，有必要从系统而不是线性的角度全面设计，实施和管理提供者支付方式的改革，因为后者未能认识到环境以及方法之间和环境之间的相互作用的影响。产生净效应。

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