Pay-for-performance in resource-constrained settings: Lessons learned from Thailand’s Quality and Outcomes Framework

Abstract

Introduction.  Many countries have introduced pay-for-performance (P4P) models to encourage health providers and institutions to provide good quality of care. In 2013, the National Health Security Office of Thailand introduced P4P, based on the UK Quality and Outcomes Framework (QOF), as a mandatory programme for primary care providers. This study aims to review the first year of the Thai QOF policy, focusing on the key features of its formulation and implementation stages.  Methods. This study used a mix of data collection approaches, such as literature review, in-depth interviews with QOF managers, and focus-group discussions with health officers and practitioners. Data were collected between June and August 2015 and transcribed and analysed using qualitative content analysis (interpretation of the content of text data through the systematic classification process of identifying themes or patterns). Two consultation meetings were organised to verify the preliminary findings.  Results.  Based on the UK model, the Thai QOF was formulated without formal consultation with key stakeholders. Additionally, programme managers adopted a ‘learning by doing’ approach, since Thai authorities were already aware of health system limitations, such as insufficient human and financial resources and unreliable databases. There were also problems with QOF implementation, as follows: 1) deducting the budget from the annual payment for ambulatory care made the policy unjustified because providers did not receive full subsidisation of their service delivery; 2) lack of key stakeholder engagement resulted in miscommunication, and subsequently misunderstanding and inadequate coordination, for the translation of QOF policy into action; and 3) the unreliability of the IT system led to inaccurately-reported data on service delivery, thereby adversely affecting performance.  Conclusion. There is still room for improvement in formulating and implementing the Thai QOF programme. Policy makers and programme implementers at both the national and international levels can benefit from this study for ensuring effective policy transfer and implementation of future QOF programmes.