From Volume to Value: A Systematic Review of Payment and Financial Incentive Models for Preventive Care Delivery in Primary Health Care.

Payment and financial incentive models in primary healthcare have undergone substantial transformation over the past two decades, shifting from volume-based reimbursement towards value-oriented approaches designed to improve healthcare quality and strengthen preventive care delivery. Despite their widespread implementation, evidence regarding their effectiveness remains inconsistent. This systematic review aimed to evaluate the effects of payment and financial incentive models on healthcare provider behavior, preventive care delivery, and related quality-of-care outcomes in primary healthcare settings. A systematic search of electronic databases and grey literature was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines to identify randomised controlled trials (RCTs) and cluster-RCTs evaluating payment and financial incentive interventions. Study selection, data extraction, methodological quality assessment using the Cochrane Risk of Bias 2 (RoB 2) tool, and certainty of evidence assessment using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework were performed using predefined criteria. Ten studies met the eligibility criteria and evaluated a range of payment and financial incentive models, including pay-for-performance, performance-based financing, direct facility financing, physician financial incentives, and patient-directed financial incentives. Overall, the available evidence suggests that selected payment and financial incentive interventions may improve provider adherence to evidence-based clinical practice and strengthen preventive and process-of-care measures, including preventive screening, chronic disease management, vaccination uptake, and other quality-of-care indicators. However, improvements in patient-centered clinical outcomes were less consistent across studies. The methodological quality of the included trials was variable, with all studies demonstrating either some concerns or a high risk of bias, while the certainty of evidence ranged from very low to moderate. Payment and financial incentive interventions may strengthen selected aspects of preventive care delivery and quality of care in primary healthcare, although their effectiveness appears to depend on the design, target, and implementation of the intervention. The heterogeneity of intervention types, settings, and outcomes, together with methodological limitations among the included studies, limits the certainty and generalisability of the findings. Further high-quality multicenter RCTs with longer follow-up and standardized outcome measures are needed to determine the long-term effectiveness, cost-effectiveness, and generalisability of different payment and financial incentive models across diverse healthcare systems.