Contractual health services performance agreements for responsive health systems: from conception to implementation in the case of Qatar

Objective: Despite their use worldwide, strategy-based performance management is limited in the Eastern Mediterranean Region. This article explores Qatar's experience, the first from the Region, in implementing contractual agreements between healthcare providers and the regulator-Ministry of Public Health-to align strategy, performance and accountabilities. Design: mixed-methods including tools development and pilot-testing, guided by performance management cycle with a focus on knowledge translation and key principles: feasibility; mandatory participation; participatory approach through Steering Committee. Setting: All public, private and semi-governmental hospitals and primary healthcare centers. Intervention(s): (i) semi-structured interviews; (ii) review of 4982 indicators; (iii) Delphi technique for selecting indicators with > 80% agreement on importance and > 60% agreement on feasibility; (iv) capacity-building of providers and Ministry staff and 2-month pilot assessed by questionnaire with indicators scoring > 3 considered valid, reliable and feasible; and (v) 1-year grace period assessed by questionnaire. Main Outcome Measure(s): Approach strengths and challenges; Data collection and healthcare quality improvements. Results: Contracts mandate reporting 25 hospital and 15 primary healthcare indicators to the regulator, which delivers confidential benchmarking reports to providers. Scorecards were discussed with the regulator for evidence-informed policymaking. The approach uncovered system-related challenges and learning for public and private sectors: providers commended the participatory approach (82%) and indicated that contracts enabled collecting valid and timely data (64%) and improved healthcare quality (55%). Conclusion: This experience provides insights for countries implementing performance management, responsive regulation and public-private partnerships. It suggests that contractual agreements can be useful, despite their mandatory nature, if clear principles are applied early on.