DRG-based payments systems in low- and middle-income countries:
Implementation experiences and challenges
Inke Mathauer1, Friedrich Wittenbecher2
1 Department of Health Systems Financing, World Health Organization, Switzerland
2 University of Berlin, Germany
HSF Discussion Paper 01-2012, Department of Health Systems Financing, World Health Organization
Available online PDF [55p.] at: http://bit.ly/SSqM70
This discussion paper provides an in-depth overview of DRG-based payment systems in low- and middle-income countries.
This fills a research gaps as it is the first in its kind. Evidence is presented of how DRG-based payment systems have been implemented in low- and middle-income countries, and what challenges they face to operate in their institutional environment.
Of equal interest is their institutional design, e.g. the number of groups, type of costing, purchasing arrangements and related thereto the scope of fragmentation, expenditure ceilings and monitoring/review features.
Findings and conclusions:
This overview reveals that DRG-based payment is increasingly applied across the world, with 13 low- and middle-income countries with national DRG-systems in place in Eastern Europe, across Asia and one in the Central American region. 12 other low- and middle-income countries across all regions are in the process of developing and piloting DRGs. Another 9 countries are in the explorative stage.
Patterns emerge with regards to the role of government financing and presence of a public purchaser, the number and scope of DRGs, the choice of DRG variant, the approaches to adapt a DRG variant to a country context, and DRG piloting processes. Challenges relate to the technical complexity of a DRG-based payment system, and more so to wider health financing institutional design issues that are crucial for desirable DRG incentives to become effective.
Several success factors for DRG payment system implementation are identified:
1) mandatory application to the widest range of providers;
2) purchaser capacity
3) regulation relating to balance-billing,
4) inclusion of the private sector in the DRG-based remuneration;
5) piloting and incremental introduction, particularly in larger countries;
6) definition of expenditure ceilings; an
7) instruments to promote provider cooperation and patient acceptance…..”
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