Table 1 Financial, regulatory and legislative interventions eligible for inclusion

Capitation

Prospective*, fixed payment to healthcare providers in order to care for a defined population for a defined period of time such as a year. Payment made to physicians per patient registered with them or in their care. Reimbursement for providers is not linked to inputs (such as diagnostic tests) or to the volume of service provided to patients.

Physician knows in advance the amount of payment they will receive before any care is provided. This prospective payment plan may encourage healthcare providers to contain costs.

*The term prospective refers to when the payment rate for a predefined package of healthcare services for a fixed period of time is determined before the treatment takes place.

Equalizing reimbursement fees for vaginal and caesarean deliveries

Equalising fees intended to reduce incentives / motivations for healthcare providers to perform CS.

Higher reimbursement fees for vaginal than caesarean deliveries

Higher fees for vaginal deliveries intended to motivate health care providers to switch from caesarean to vaginal deliveries in the absence of medical justification.

Global budget payment (GBP) systems

Aggregate cash sum, fixed in advance by payers/government agency, intended to cover (reimburse) the total cost of a service provided, and is usually set for 1 year ahead.

The hospital, health facility or clinic is used as a unit of payment based on previous historical spending, the volume of service and hospital bed size, which are brought together in a resource allocation formula.

GBP system is intended to create incentives for hospitals to reduce the volume of services provided (including reducing unnecessary services) and encourage efficient resource utilisation.

Case-based reimbursement systems

A prospective reimbursement mechanism in which hospitals are paid for each discharged inpatient case, based on a previously defined rate for each group of cases with similar clinical conditions and resource requirement. The International Classification of Diseases (ICD) developed by WHO is widely used to define these groups for the purpose of setting payment rates.

Hospitals are paid a fixed payment rate for each treated case that falls into one of a set of defined categories of cases, such as diagnosis-related groups (DRGs).

Case-based payment mechanism provides significant incentives for providers to contain cost per case by minimising the use of resources utilised per case, for example, reducing the unnecessary utilisation of diagnostic and surgical services.

Diagnosis related group (DRG) reimbursement schemes

Diagnosis-related-groups (DRGs) are clinically meaningful groups of patients with similar clinical characteristics and resource consumption patterns who incur comparable costs. DRGs provide a flat per-discharge payment that varies based on diagnosis, severity, and the procedures performed.

All patients treated by a hospital are classified into a limited number of DRGs, which are supposed to be clinically meaningful and relatively homogenous in their resource consumption patterns. Each DRG is associated with a specific cost weight or tariff, which is usually calculated from information about average treatment costs of patients falling within a specific DRG in at least a sample of other hospitals in the past. Depending on the country, hospitals under DRG-based hospital payment systems either receive a DRG-based case payment or a DRG-based budget allocation.

Co-payment

Direct patient payments for part of the cost of health services. Copayment when CS is not medically indicated is intended to disincentivize women from choosing medically unnecessary CS, by increasing the cost of CS to patients).

Liability of health care organisations

Interventions that limit liability of health care organisations, for example malpractice lawsuits (legal cover may reduce CS conducted for fear of medical lawsuits).

Insurance

Regulation of the provision of insurance, for example insurance coverage of maternal health services (may influence women’s requests for non-medically indicated CS, particularly if they do not bear the full cost through insurance).

Quality of practice

Interventions for assuring quality of care, for example legislatively imposed clinical guidelines may reduce unnecessary CS by reducing the discretion of individual clinicians to perform CS that are convenient for them, or that involve requests from patients in the absence of any maternal or fetal indications.

Professional competence

Interventions for assuring professional competence (for example, accreditation requirements intended to improve compliance with evidence-based obstetric practice may reduce non-medically indicated CS).

Professional liability

Regulation of liability for health professionals (for example, provision of legal cover may reduce CS conducted for fear of medical lawsuits).