Performance-based contracting for hospitals: a mixed methods analysis of impacts on patient outcomes, equity and efficiency in a middle income country The Ministry of Public Health (MoPH) is the largest insurer for hospitalizations in Lebanon, covering 52% of citizens and about 240,000 hospital admissions annually. Typical patients are those who are unable to afford health insurance, are unemployed or self-employed, are older than 64 years, or have a chronic disease (e.g. diabetes, hypertension, cancer). To provide these services, the MoPH contacts with 135 public and private hospitals.   Since 2001 the reimbursement rate paid to hospitals by the ministry was determined by the results of a hospital accreditation process. However, over the past several years evidence has accumulated that this was not an effective way to manage the relationship between the MoPH and hospitals. Importantly, the ministry has imperfect information on the performance of hospitals. In 2014 the MoPH began a transition away from the accreditation-only contracting system, and towards one based on performance, including patient outcomes.  The main purpose of this research is to develop a performance-based contracting (PBC) system between the MoPH and hospitals in Lebanon, and evaluate its impact on patients and the health system. Such contracting means that the ministry would reward hospitals that perform better by paying them a higher base rate per patient. We will investigate what factors may affect hospital performance and how hospitals responded to this intervention.  There has been much work on PBC in health services over the past two decades. However the evidence to support its benefit to patients and cost-effectiveness presents mixed results. One of the main reasons for this is the limited number of strongly designed studies.  Recent evidence from England and the United States has also found that positive effects such as reduced readmissions and mortality may be limited to the short-term, and underlined the importance of PBC measurement, context and design. In low/middle-income countries (LMIC) evidence is still more limited, though PBC holds much promise as it may have larger impact on health outcomes given the potential to improve. However this also means it may have larger unintended or negative consequences, and should be designed with great care and close monitoring of impact.  In designing PBC, it is important to determine how performance will be measured and how we would evaluate its impact. In our research, at the patient level we will look at changes in patient readmissions for specific conditions, which could indicate inadequate treatment, hospital-acquired infections, or other causes. We will also look at the proportion of patients admitted to each hospital in terms of their age and presence of chronic diseases, as some hospitals may 'cherry-pick' and avoid patients with more complex conditions. We will also develop a patient satisfaction questionnaire, and use it to measure the satisfaction of patients that would be representative of the hospital they were treated at. At the health system/hospital level we will look at the utilization and cost of different services, as well as how complex are the cases being admitted to each hospital (case-mix). We will compare the results for these performance indicators before and after implementation of PBC, and investigate any changes. We will also interview a sample of hospital managers to understand how hospitals responded to PBC and what changes they may have made to affect their performance, such as better application of clinical guidelines, increased training or incentives to the health workforce.  We will actively share our research findings with stakeholders and the public through various channels including developing knowledge translation materials and events such as seminars and policy roundtables. The knowledge gained will be used to inform future PBC development in Lebanon and similar initiatives in LMICs. The Global Challenges Research Fund (GCRF) supports cutting-edge research to address challenges faced by developing countries. The fund addresses the UN sustainable development goals. It aims to maximise the impact of research and innovation to improve lives and opportunity in the developing world.