Behavioral responses of healthcare providers to prospective payment systems: a systematic review using the WHO framework (2000–2024)

Prospective payment systems (PPS) have become increasingly prevalent in healthcare globally, yet their impact on provider behavior remains complex and context-dependent. This systematic review examines the behavioral responses of healthcare providers to PPS using the World Health Organization’s four-function framework. A comprehensive systematic review was conducted in accordance with PRISMA 2020 guidelines. Electronic searches were performed in PubMed/MEDLINE, Web of Science, Scopus, and Embase for studies published between January 2000 and December 2024. Studies assessing the impact of PPS on healthcare provider behavior were included. Methodological quality was evaluated using the Joanna Briggs Institute checklists. Data were synthesized through narrative synthesis and thematic analysis aligned with the WHO framework (governance, service delivery, financing, and resource generation). From 8,615 identified records, 168 studies met the inclusion criteria. Among these, Diagnosis-Related Group (DRG)-based systems (32.1%) and pay-for-performance models (26.2%) were the most frequently examined payment mechanisms. The included studies covered 25 countries, with the United States (33.9%), China (28.0%), and European countries (24.4%) accounting for the largest shares. Most studies (64.9%) were published between 2016 and 2024. Hospitals (51.8%) and physicians (28.0%) were the primary provider groups investigated. Analysis within the WHO framework revealed distinct behavioral patterns across all four system functions. In the governance domain, PPS was associated with improvements in quality indicators and cost efficiency, alongside concerns regarding risk selection and potential reductions in care quality. Service delivery responses included greater emphasis on preventive care and shifts from inpatient to outpatient services, but also evidence of induced demand and selective patient provision. Financing-related outcomes demonstrated cost containment effects, accompanied by cost-shifting behaviors. In the resource generation function, PPS encouraged clinical process optimization and more efficient resource utilization. PPS implementation generates complex and multidimensional behavioral responses among healthcare providers. Although these systems generally support cost containment, they may also prompt strategic behaviors that risk undermining care quality and equity. The overall effectiveness of PPS depends on payment design, regulatory context, and provider characteristics. Incorporating behavioral insights into future payment system design is essential to enhance intended effects and mitigate unintended consequences.