Gestational diabetes mellitus (GDM) is among the most common pregnancy complications, with its incidence increasing rapidly worldwide. Although lifestyle interventions and insulin therapy remain standard treatments, they can be difficult to maintain and costly. Because of the role of gut microbiota in GDM, probiotics have been proposed as a potential therapeutic option. This study aimed to evaluate the cost‑effectiveness of probiotics for GDM management in China. A cost‑effectiveness analysis was performed using a decision‑tree model in TreeAge Pro to compare probiotics with placebo following GDM diagnosis. The analysis was conducted from the Chinese healthcare system perspective with a short‑term time horizon corresponding to the 8‑week treatment period. This analysis should be interpreted as an acute‑treatment economic evaluation, not a comprehensive lifetime cost‑effectiveness analysis, as it does not capture long‑term maternal or offspring outcomes. No discounting was applied owing to the short time frame. The model incorporated GDM complications, preterm birth, and neonatal death as key health states. Probabilities, utilities, and costs were obtained from meta‑analyses and national pharmacoeconomic data. Health outcomes were measured in quality‑adjusted life years (QALYs), and the incremental cost‑effectiveness ratio (ICER) was calculated and compared with the willingness‑to‑pay (WTP) threshold of ¥257,094 per QALY. One‑way and probabilistic sensitivity analyses were conducted to test robustness. The probiotic strategy resulted in an average total cost of ¥2,119.29 and 0.14997 QALYs, while the placebo cost ¥1,687.90 and provided 0.14996 QALYs. The extremely high ICER of ¥65,400,488 per QALY arises primarily from the very small QALY difference (0.00001 QALYs, equivalent to approximately 5.3 quality‑adjusted life minutes) between strategies, reflecting the short treatment duration and limited health utility gains captured in the model. This ICER far exceeds the WTP threshold, demonstrating that probiotics are not cost‑effective compared with placebo. Sensitivity analyses confirmed the stability of these results. Under current Chinese healthcare economic conditions, probiotics do not represent a cost‑effective treatment for GDM. However, this conclusion is subject to uncertainty stemming from the limited utility gain captured and the short‑term modeling assumptions. Future research should evaluate long‑term effects, species‑specific outcomes, and regional utility values to refine policy decisions.
The integration of artificial intelligence (AI) in radiology has become increasingly relevant due to its potential to improve diagnostic accuracy and optimize healthcare workflows. This study reviews health economic evaluations of AI in radiology, following Cochrane international standards in the field. A systematic search was conducted in PubMed, Embase, Web of Science, and Google Scholar for studies evaluating AI-based health technologies in radiology from a health economics perspective. A qualitative synthesis of the data was performed, and each study was assessed for quality using the Consolidated Health Economic Evaluation Reporting Standards 2022. The PROSPERO registration number is CRD42024616818. A total of 938 records were retrieved, with 14 included in the review. Most studies were published between 2021 and 2024. The United States and the United Kingdom had the highest number of studies, with most research focusing on high-income countries. Cost-effectiveness analysis was the most common type of economic evaluation used. X-ray imaging was the most frequently analyzed modality, particularly for cancer detection, with a focus on breast and lung cancer. The most commonly used software for modeling was TreeAge Pro, followed by R and Microsoft Excel. AI in radiology offers substantial clinical benefits, but comprehensive long-term economic evaluations are necessary to fully assess its value. High initial investments, infrastructure changes, and ongoing maintenance were identified as key obstacles, especially in low-resource settings. Future research should prioritize underrepresented regions and incorporate diverse patient demographics to enhance the generalizability of findings. Not applicable.
To evaluate, from a Chinese healthcare system perspective, the cost-utility of three treatment strategies (Western medicine, Traditional Chinese Medicine [TCM], and combined therapy) for stable chronic obstructive pulmonary disease (COPD) using a discrete event simulation (DES) model parameterized with clinical trial data. A DES model was developed for stable COPD patients (aged 18–80 years) from a Chinese healthcare system perspective. The model incorporated 24 baseline variables, six intermediate outcomes (FEV1, 6MWD, dyspnea, cough, sputum, COPD-PRO), and acute exacerbation as the final outcome. Multilevel mixed-effects models and Weibull regression updated these longitudinal outcomes every three months over a 2-year time horizon. Health outcomes were measured as quality-adjusted life years (QALYs), the primary outcome of the economic evaluation. Costs were estimated in 2013 RMB and adjusted to 2022 values using the China Consumer Price Index (CPI). In the three-month base-case analysis, patients with COPD showed a mean 6.8 m increase in six-minute walk distance (6MWD), 0.25 fewer acute exacerbations, and improved symptom scores. The mean two-year total cost was 12,726.18 RMB. Cost-utility ratios (CURs) were 5,066.79, 4,477.09, and 4,540.93 RMB/QALY for the Western medicine, TCM, and combined therapy groups, respectively. Compared with the TCM group, the combined therapy group incurred an additional 448 RMB and gained 0.060 additional QALYs, yielding an incremental cost-utility ratio (ICUR) of 7,467 RMB/QALY; Western medicine alone was dominated. At a willingness-to-pay (WTP) threshold of 85,698 RMB/QALY (1x China’s per-capita GDP), the probability that combined therapy was cost-effective was 98.5
The PAOLA-1 trial randomized 806 patients with newly diagnosed advanced ovarian cancer to olaparib plus bevacizumab or placebo plus bevacizumab and demonstrated a progression-free survival (PFS) and overall survival (OS) benefit when maintenance olaparib was added to bevacizumab in patients with a positive tumor homologous recombination deficiency (HRD) test. We conducted an economic evaluation based on patient-level data from the PAOLA-1 trial. Costs were assessed from the French health care system perspective with a 60-month time horizon. Individual healthcare consumptions were collected from the case report forms. Survival analysis was conducted using restricted mean survival time (RMST). Health-related quality of life (HRQoL) was measured using the EQ-5D-5L questionnaire. Costs and HRQoL were discounted at 2.5
Abstract Background Type 2 Diabetes Mellitus (T2DM) imposes a severe economic burden on Indonesia’s Social Health Insurance Administration Body (BPJS Kesehatan), driven predominantly by expensive late-stage complications. While the Prolanis program offers community-based prevention, a lack of long-term economic forecasting hinders optimal resource allocation among its core interventions. To address this gap, this study aims to evaluate community-based intervention strategies to determine which approach is the most cost-effective for long-term T2DM management in Indonesia. Methods We developed a deterministic linear compartmental state-transition model to forecast the 25-year epidemiological and economic impacts of six intervention strategies derived from three Prolanis pillars: health education, physical activity, and lifestyle modification. The model integrated an economic resource allocation framework, Indonesian epidemiology data, and a 3.8-fold complication cost penalty multiplier for complication states. Cost-effectiveness was evaluated from a healthcare payer perspective using the Incremental Cost-Effectiveness Ratio (ICER) and Time-Horizon Sensitivity Analysis. Results Over 25 years, the Lifestyle Modification intervention emerged as the dominant strategy compared to baseline care. It generated the highest increase in the managed T2DM population while incurring the lowest total systemic cost. ICER analyses demonstrated that Lifestyle Modification strictly dominated individual and combined promotive activities, which were subject to severe budgetary restrictions due to their high delivery cost-weights. Furthermore, temporal analysis confirmed that Lifestyle Modification achieves systemic net savings rapidly by Year 5. By Year 25, it resulted in projected cumulative net savings of 19.22 trillion IDR under the 3% base-case discount rate, with sensitivity analyses confirming robust dominance across 0% (27.61 trillion IDR savings) and 5% (15.48 trillion IDR savings) discount rates. Conclusion Lifestyle Modification is the most economically dominant community-based intervention for managing T2DM in Indonesia. To avert the financial penalties of downstream complications, policymakers should strategically rebalance the Prolanis capitation budget to prioritize proactive, monitoring-driven lifestyle interventions.
Metabolic dysfunction-associated steatotic liver disease (MASLD) is among the most common chronic liver diseases worldwide [1], and its targeted therapy and new drug development have drawn extensive global attention. Prior relevant studies mainly focus on the clinical efficacy and economic returns of MASLD drugs, rarely covering social and environmental impacts across the drug R D lifecycle. This study aims to fill this research gap by evaluating MASLD drug development risks from a sustainable accounting perspective with triple bottom line indicators. Based on the sustainable accounting framework covering economic, social and environmental dimensions, this paper analyzes the global MASLD drug R D landscape. It adopts annual report data and core product information of four typical listed pharmaceutical companies: Madrigal, Huadong Pharmaceutical, Novo Nordisk and Inventiva. This study systematically compares five representative MASLD therapeutic agents and candidates, including resmetirom, semaglutide, DR10624, lanifibranor and HTD1801, in terms of pharmacological mechanisms, clinical performance, R D costs and commercial prospects, including thyroid hormone receptor agonists, GLP-1 receptor agonists, multi-target agonists, pan-PPAR agonist and entero-hepatic system modulators. Based on the Delphi consensus, In the main text, the name chosen to replace MASH, MAFLD, NASH and NAFLD is metabolic dysfunction-associated steatotic liver disease (MASLD). Three key sustainable risks exist in current MASLD drug development. Economically, high R D costs lead to expensive marketed drugs and uncertain cost-effectiveness. At the economic level, resmetirom has a reported ICER of US140,134/QALY, while semaglutide shows lower ICERs of US42,200/QALY and US44,138/QALY, respectively. Socially, uneven drug accessibility across regions and income groups, low grassroots diagnosis rates and unpopular interdisciplinary treatments cause missed early intervention opportunities for patients. Environmentally, green R D technologies are poorly promoted, small and medium-sized drug enterprises face resource constraints, and quantitative life-cycle assessment data remain limited for the MASLD drugs reviewed, making it difficult to clarify long-term ecological risks of drug residues. The three bottom lines of economy, society, and environment are interconnected and are the core criteria for measuring sustainable research and development of MASLD drugs. The industry still needs to address issues such as economic returns, medical fairness, and ecological protection. By optimizing R D layout, improving medical insurance policies, and perfecting the drug lifecycle environmental evaluation system, the industry can ultimately achieve sustainable development of MASLD pharmaceuticals.
During the early phases of the COVID-19 pandemic, health systems faced urgent decisions about allocating resources to repurposed community treatments in the absence of definitive evidence. While large platform trials reported clinical outcomes, their implications for cost-effective resource allocation under uncertainty remain unclear. Using the Platform Randomised trIal of treatmeNts in the Community for epIdemic and Pandemic iLlnEsses (PRINCIPLE) trial as a case study, we evaluated the cost-effectiveness of six repurposed drugs compared with usual care. Trial-based economic analyses assessed National Health Service (NHS) costs and clinical outcomes over 28 days post-randomisation using multiply imputed data. Incremental cost-effectiveness ratios (ICERs) were estimated as incremental cost per day saved until recovery and per hospitalisation or death avoided. Sensitivity analyses explored decision uncertainty. A total of 8825 participants randomised between April 3, 2020 and July 1, 2022 were included. Inhaled budesonide showed a favourable balance across outcomes, with ICERs of £6,386 per hospitalisation or death avoided and -£77 per day saved until recovery, indicating lower costs and faster recovery than usual care. Colchicine had a low ICER for hospitalisation or death avoided (£2,858), but limited recovery benefit. Azithromycin and doxycycline were cost-saving for recovery but had high ICERs for hospitalisation or death avoided (£27,490 and £21,278, respectively). Favipiravir was associated with lower costs and faster recovery but higher cost for a modest reduction in hospitalisation or death avoided than usual care. Ivermectin was associated with higher costs for both outcomes and had a low probability of cost-effectiveness. Sensitivity analyses largely supported these findings. Trial-based economic evidence from large platform trials can inform efficient resource allocation during public health emergencies, including identifying interventions that offer limited or no economic value. These findings highlight the importance of integrating economic evaluation into rapid trial platforms to support timely funding and disinvestment decisions under uncertainty. ISRCTN registry, ISRCTN86534580, registered 23 March 2020.
Medical scribes are increasingly used in outpatient clinics in the United States to reduce physician documentation burden, but their economic and operational impact remains inconsistently characterized. This scoping review synthesized evidence on the impact of medical scribes in outpatient care in the United States, focusing on physician productivity, documentation efficiency, and financial outcomes. Nine databases were searched from January 2010 to September 2024 for English-language studies reporting economic or productivity outcomes of medical scribe use in outpatient settings. Two reviewers independently screened 1,945 unique records; data were charted using a piloted template and synthesized thematically. Twenty United States-based studies met the inclusion criteria: nine pre-post evaluations, five controlled cohort studies, two randomized controlled trials (RCTs), two microsimulation models, and two systematic reviews. Scribes consistently improved physician productivity: 19 of 20 studies (95
Reflex testing (RT) - pathologist-initiated molecular testing performed at non–small cell lung cancer (NSCLC) diagnosis - enables rapid identification of actionable genomic alterations for targeted therapy (TT) selection. Despite national and international guideline recommendations, approximately 15
Preterm birth significantly affects neonatal and child health through various severe complications, contributing to high neonatal and under-5 mortality rates globally. While the overall medical costs associated with preterm birth have been explored, comprehensive studies specifically focused on the medication costs related to health conditions arising from preterm birth remain limited. Systematic searches were conducted across MEDLINE, Embase, Web of Science, International HTA database and Pediatric Economic Database Evaluation Project using broad search terms for literature published before May 31, 2024. Included studies, published in English, reported the medication costs of preterm birth individuals from birth to age 17 using primary evidence, which were then categorised according to corresponding life stages. Collected medication costs were converted to U.S dollars for the financial year in which the costs were reported based on purchasing power parities and inflated to 2025 U.S. dollar values. The literature search yielded 5,269 articles. Of these, 42 articles satisfied criteria and were incorporated into this systematic review. Among these articles, 38 papers reported medication costs in infancy (under age 1), 3 papers reported costs in childhood (age 1 to age 12) and 1 paper reported costs across infancy and childhood. The review found that medication costs for common complications varied widely, with higher costs associated with severe conditions and specific treatments. The highest medication cost in this study was observed in patients with chronic lung disease treated with nitric oxide for approximately 24 days, totalling 20,705 per patient (2025 USD). Additionally, costs during childhood showed variability influenced by gestational age at birth and respiratory disease history. In infancy, medication costs typically accounted for less than 15
Primary Health Centre (PHC) coverage in Himalayan India is constrained by terrain, dispersed settlement and a population-based norm (one PHC per 20,000 in hilly areas) that treats elevation as exogenous. Existing accessibility analyses describe these gaps but rarely evaluate the resource-allocation trade-offs of closing them. Using village-level Census 2011 data and PHC locations from the Department of Medical Health and Family Welfare, Uttarakhand, we mapped catchment areas in Chamoli and Rudraprayag using Voronoi polygons and 5/10/15-km buffers, and recomputed coverage with attention to the limitations of Euclidean distance in mountainous terrain. We then built a resource-allocation model comparing four scenarios: status quo (S0); strict NHM compliance at one PHC per 20,000 population (S1); a coverage-optimised scenario that adds the minimum number of PHCs needed to bring the share of population beyond 15 km below 5
Bacterial vaginosis (BV) is associated with reduced fecundability in women. To address the limited accessibility and diagnostic sensitivity of current preconception BV screening in China, this study evaluated the cost-effectiveness of BV Blue, an accessible, self-administered rapid test. A decision tree model was constructed from a societal perspective to compare five screening strategies: No screening, Amsel criteria, BV Blue testing alone, sequential BV Blue–Nugent testing, and Nugent scoring alone. Effectiveness was defined as the number of pregnancies per 100,000 women over one year. Cost-effectiveness was evaluated using incremental cost-effectiveness ratios (ICERs), referenced against a willingness-to-pay (WTP) threshold based on China’s per capita GDP. Sensitivity analyses were conducted to assess model robustness. In a simulated cohort of 100,000 women, BV Blue testing yielded 842 additional pregnancies compared with no screening (ICER: CNY 2,827 per pregnancy), well below the WTP threshold of CNY 99,665. The sequential and Amsel strategies were absolutely dominated by BV Blue testing. Compared with BV Blue testing, Nugent strategy yielded 171 additional pregnancies (ICER: CNY 198,051 per pregnancy), remaining below the three-fold per capita GDP threshold (CNY 298,995). However, sensitivity analyses indicated that the cost-effectiveness of Nugent strategy was not robust, being highly sensitive to BV Blue testing’s diagnostic sensitivity and pregnancy rates. On the cost-effectiveness acceptability curve, BV Blue testing consistently demonstrated the highest probability of being the optimal strategy. In the preconception period, all screening strategies yielded more pregnancies than no screening. Both BV Blue testing and Nugent scoring were cost-effective, whereas the Amsel and sequential strategies were not. BV Blue testing is a promising screening tool for preconception BV management. These findings may inform the selection of diagnostic pathways in China’s national preconception screening program.
The pharmaceutical industry plays a pivotal role in the healthcare economy, with drug quality and pricing being critical to consumer welfare. China’s government has implemented National centralized volume-based drug procurement(NVBP) policy, aiming to reduce medication costs through bulk purchasing. While existing research confirms its price-reduction effects, unintended consequences regarding pharmaceutical quality incentives remain overlooked. This study investigates how the NVBP policy reshapes firms’ quality-pricing strategies, addressing a critical gap in policy evaluation. Game-theoretical model is constructed to simulate interactions between two pharmaceutical firms with distinct technological capabilities before and after China’s National volume-based procurement (NVBP) policy. Prior to the policy, the Hotelling model’s spatial competition is reinterpreted as a quality-preference spectrum After the policy, drugs are standardized through consistency evaluation, and competition reduces to pure price competition as in the Bertrand model. Then a double-envelope bidding game is introduced where the government sets a minimum quality standard and firms bid on price. After winning the bid, firms need to decide the production strategy. Before NVBP policy implementation, equal-quality price differences depend solely on technical parameters. Under endogenous quality, a firm’s quality rises with its own technology; the technologically superior firm charges a higher price, but a weaker firm facing a superior rival lowers its price. After NVBP policy implementation, during the bidding time, if both firms pass consistency evaluation, the winning bid price falls, but quality may drop below pre-NVBP levels. If the low-tech firm fails, the high-tech firm gains monopoly pricing power and raises prices. During the production time, some unintended consequences may occur, such as quality risk and supply disruption risk. The implementation of NVBP policy could lower drug prices and improve access, but it may also generate unintended consequences. Low standards induce price competition and reduce quality investment, while high standards may create sole-supplier monopoly. Excessively low bids pose quality or supply risks. Policy should calibrate standards, use tiered incentives, and strengthen surveillance, but empirical validation remains needed.
This study aimed to assess the cost-utility of luseogliflozin compared with Standard of Care (SoC) for patients with T2DM in Vietnam, under two reimbursement scenarios by Vietnam Social Health Insurance (VSHI). A Markov model with five health states was developed to simulate lifetime disease progression. The analysis adopted the VSHI perspective, including only direct medical costs. Health outcomes were expressed as quality-adjusted life-years (QALYs), and cost-effectiveness was evaluated against a willingness-to-pay (WTP) threshold of 1 GDP per capita in Vietnam (USD 4,700 per QALY). Both costs and outcomes were discounted at 3
The present study evaluates the cost-effectiveness of India’s 2019 childhood pneumonia management guidelines compared with no treatment, assuming 100
Innovation in the pharmaceutical industry relies on sustained R D investment, but the high-input, long-cycle, and high-risk characteristics of R D activities often create financing constraints for enterprises. How to effectively incentivize enterprises to increase R D investment through fiscal and tax policies is a focus of attention for both the government and academia. Based on the panel data of 57 pharmaceutical companies from 2016 to 2024, this study employs a benchmark regression model to investigate the impact of government tax refunds on pharmaceutical companies’ R D investment, and conducts empirical analysis using semi-parametric estimation. When LTr < 15, the partial derivative graph of tax refunds on R D investment generally exhibits a horizontal trend. When 15 ≤ LTr, it shows a linear growth trend. For companies with innovative drugs, there is a “W”-shaped fluctuation trend between tax refunds and R D investment, while for companies without innovative drugs, the impact of tax refunds on pharmaceutical companies’ R D investment exhibits a “U”-shaped fluctuation trend. There is a certain optimal range for the promotional effect of tax refunds on pharmaceutical companies’ R D investment. Compared with companies without innovative drugs, companies with innovative drugs are more sensitive to tax refunds on R D investment.
Background: Diffuse large B-cell lymphoma (DLBCL) accounts for 58% of non-Hodgkin lymphoma cases in Thailand. Positron Emission Tomography-Computed Tomography (PET-CT) offers superior accuracy for staging and assessing end-of-treatment (EOT) response than Computed Tomography (CT) and is recommended in Thai and international clinical practice guidelines. Due to its high cost, an economic evaluation and budget impact analysis were conducted to inform policy decisions. Methods: A cost-utility analysis using a decision tree and Markov model was conducted from a societal perspective, alongside a budget impact analysis from the payer's perspective. Parameters were derived from literature and primary data. Three policy options were compared with current practice (CT for staging and EOT): (1) PET-CT for both staging and EOT, (2) PET-CT for staging only, and (3) PET-CT for EOT only. Sensitivity and scenario analyses were also conducted. Results: At Thailand’s cost-effectiveness threshold of 160,000 THB per quality-adjusted life year (QALY), PET-CT for EOT only was the most cost-effective option, with an incremental cost-effectiveness ratio (ICER) of 23,282 THB/QALY. PET-CT for both staging and EOT was the second most cost-effective (ICER 123,586 THB/QALY), while PET-CT for staging only was not cost-effective. Results were consistent across analyses. Budget impact over 5 years was lowest for PET-CT for EOT only (67 million THB) and highest for PET-CT for both staging and EOT (150 million THB). Conclusion: Using PET-CT solely for EOT is not only the most cost-effective option but also results in the lowest budget impact. Inclusion of this option in the benefit package is recommended.
Dementia is one of the most serious health issues in an aging society, placing a significant burden on patients and their families, while also posing considerable socioeconomic challenges at the national level. In response, the Korean government introduced the National Responsibility for Dementia Care policy in 2017 to improve healthcare accessibility for patients with dementia and reduce their financial burden. This study utilized the cohort data of patients with dementia collected from Ajou University Hospital between 2012 and 2022. To quantitatively assess the changes in healthcare utilization, we applied panel multivariate negative binomial regression and panel multivariate gamma regression analyses. The analysis identified key factors influencing healthcare utilization, including place of residence, presence of comorbidities, age, and duration of dementia. After the policy was implemented, there was a general decline in outpatient visits and medical expenditure, suggesting a positive effect of the policy on alleviating the economic burden on patients with dementia. Significant changes in healthcare utilization were observed among patients in the early stages of dementia, highlighting the importance of early diagnosis and home-based care services. The findings indicate a need for personalized treatment and the expansion of community-based healthcare services for patients with dementia.
Extended Cost-Effectiveness Analysis (ECEA) extends conventional cost-effectiveness analysis by incorporating financial risk protection (FRP) and examining the distribution of health and economic outcomes across socioeconomic groups. This scoping review aimed to map the application of ECEA in health-sector studies, identify methodological patterns, and explore geographic and thematic research gaps. A scoping review was conducted in accordance with PRISMA 2020 guidelines. Searches were performed on 29 October 2025 in PubMed, Scopus, Web of Science, ProQuest, and Google Scholar. Studies published between 2000 and 2025 that applied ECEA to evaluate health interventions were eligible for inclusion. Data were extracted on intervention characteristics, analytical approaches, equity measures, and FRP outcomes and were synthesized narratively. A total of 1,955 records were identified, of which 19 studies met the inclusion criteria. Most studies were conducted in low- and middle-income countries, particularly in Asia and Africa. The included studies primarily evaluated vaccination programs, taxation policies on harmful products, publicly financed health services, and maternal and child health interventions. Financial Risk Protection (FRP) outcomes were most commonly reported as reductions in out-of-pocket expenditures, catastrophic health expenditures averted, and poverty cases averted. Across studies, ECEA was predominantly used to assess the distribution of health and financial outcomes across socioeconomic groups, with outcomes commonly reported by income quintiles. ECEA applications remain limited and are predominantly concentrated in low- and middle-income countries, particularly within preventive and fiscal health interventions. The reviewed evidence suggests that ECEA provides a useful framework for assessing both health outcomes and financial risk protection across socioeconomic groups. Future research should expand ECEA applications to underrepresented settings and promote greater methodological standardization of equity and FRP measures.
Provider payment mechanisms are critical policy tools for shaping healthcare delivery, yet their effectiveness is mediated by contextual and organizational factors. This study examines the implementation of capitation prepayment under China’s Integrated County Healthcare Consortium (ICHC) system, aiming to elucidate the complex interplay of factors influencing provider behavioral responses and the resulting system dynamics. We conducted a mixed-methods study in Datong prefecture, China. Qualitative data from 63 semi-structured interviews with county hospital physicians and administrators were analyzed using Latent Dirichlet Allocation (LDA) to identify key influencing factors. Social Network Analysis (SNA) and Interpretative Structural Modeling (ISM) were employed to examine the interrelationships and hierarchical structure of these factors. A System Dynamics Model (SDM) was developed using longitudinal data (2015–2019) from 15 county hospitals to simulate the incentive mechanisms of capitation prepayment. The analysis revealed four primary domains influencing provider behavior under capitation prepayment: (1) external environmental factors (population characteristics, economic conditions, market competition), (2) institutional resources (bed capacity, workforce, medical equipment), (3) management strategies (particularly cost-control measures), and (4) service delivery outcomes. Management strategies emerged as the most direct determinant of provider behavior, while environmental factors and institutional resources moderated the effects of payment incentives. The SDM simulations indicated potential unintended consequences, including cost-shifting from inpatient to outpatient services. The study demonstrates that provider responses to capitation prepayment are predominantly driven by institutional cost-control measures, mediated by contextual and resource factors. Policy implementation should address potential unintended consequences through strengthened referral mechanisms between county and tertiary hospitals and enhanced monitoring of service shifting. These findings contribute to the global understanding of payment reform implementation in resource-constrained settings and highlight the importance of contextual adaptation in payment system design.
