BACKGROUND: The funding of primary care is subject to intense debate internationally. Three main funding models predominate: capitation, pay-for-performance, and fee-for-service. A number of systematic reviews regarding the effect of primary care funding structures have been published, but not synthesized through an equity lens. Given the urgent need for evaluating funding models and addressing inequalities, a reliable, synthesized evidence base concerning the effects of funding on inequalities is imperative.
AIMS: This umbrella review aims to systematically evaluate all systematic reviews available on the effect of different primary care funding models in high-income countries on inequalities in funding, access, outcomes, or experience from inception until 2024.
METHODS: Three databases (MEDLINE, EMBASE, Cochrane) and a machine learning living evidence map were searched. Abstracts and titles were double screened, before two authors independently screened full texts, extracted data, and performed quality assessments utilizing the AMSTAR2 tool.
FINDINGS: The search identified 2480 unique articles, of which 14 were included in the final review. Only one review compared reimbursement systems; capitation systems were more equitable between ethnic groups compared to pay-for-performance in terms of primary care access, continuity, and quality. Twelve reviews reviewed the impact of the introduction of pay-for-performance models, predominantly focusing on the Quality and Outcomes Framework (QOF) in the UK. Synthesized findings suggest that QOF's introduction coincided with reduced socioeconomic health inequalities in the UK overall, but not in Scotland. Overall, inequalities in age narrowed, but inequalities measured by sex widened. One review found evidence that targeting funding for minority groups, with poorer health, was effective. A further review found that introducing privately provided general practices in Sweden and allowing patients to choose these over public-owned options generally benefitted those with higher income and lower health needs. We identify a range of gaps in the literature, which should inform future research.
Pay-for-performance (P4P) has been widely used around the world seeking to improve health outcomes, and in Brazil it is the basis of the National Program for Improving Access and Quality (PMAQ). The literature published between 1998 and January 2013 that evaluated the effectiveness of P4P to produce results or patterns of access and quality in health was scrutinized. A total of 138 studies, with the inclusion of a further 41 studies (14 systematic reviews, 07 clinical trials and 20 observational studies) were retrieved and analyzed Among the more rigorous studies, favorable conclusions for P4P were less frequent, whereas observational studies were more favorable to positive effects of P4P on the quality of, and access to, health services. Methodological limitations of observational studies may have contributed to these results, but the range of results is more linked to the conceptual and contextual aspects of the use of the P4P schemes reviewed, the heterogeneity of P4P models and results. P4P can be helpful in promoting the achievement of objectives in health care systems, especially in the short term and for specific actions requiring less effort of health care providers, but should be used with caution and with a rigorous planning model, also considering undesirable or adverse effects.
The funding of primary care is subject to intense debate internationally. Three main funding models predominate: capitation, pay-for-performance, and fee-for-service. A number of systematic reviews regarding the effect of primary care funding structures have been published, but not synthesized through an equity lens. Given the urgent need for evaluating funding models and addressing inequalities, a reliable, synthesized evidence base concerning the effects of funding on inequalities is imperative.
AIMS:
This umbrella review aims to systematically evaluate all systematic reviews available on the effect of different primary care funding models in high-income countries on inequalities in funding, access, outcomes, or experience from inception until 2024.
METHODS:
Three databases (MEDLINE, EMBASE, Cochrane) and a machine learning living evidence map were searched. Abstracts and titles were double screened, before two authors independently screened full texts, extracted data, and performed quality assessments utilizing the AMSTAR2 tool.
FINDINGS:
The search identified 2480 unique articles, of which 14 were included in the final review. Only one review compared reimbursement systems; capitation systems were more equitable between ethnic groups compared to pay-for-performance in terms of primary care access, continuity, and quality. Twelve reviews reviewed the impact of the introduction of pay-for-performance models, predominantly focusing on the Quality and Outcomes Framework (QOF) in the UK. Synthesized findings suggest that QOF's introduction coincided with reduced socioeconomic health inequalities in the UK overall, but not in Scotland. Overall, inequalities in age narrowed, but inequalities measured by sex widened. One review found evidence that targeting funding for minority groups, with poorer health, was effective. A further review found that introducing privately provided general practices in Sweden and allowing patients to choose these over public-owned options generally benefitted those with higher income and lower health needs. We identify a range of gaps in the literature, which should inform future research.
