RESUMO
The design of complex health systems interventions, such as pay for performance (P4P), can be critical to determining such programmes' success. In P4P programmes, the design of financial incentives is crucial in shaping how these programmes work. However, the design of such schemes is usually homogenous across providers within a given scheme. Consequently, there is a limited understanding of the strengths and weaknesses of P4P design elements from the implementers' perspective. This study takes advantage of the unique context of Brazil, where municipalities adapted the federal incentive design, resulting in variations in incentive design across municipalities. The study aims to understand why municipalities in Brazil chose certain P4P design features, the associated challenges, and the local adaptations made to address problems in scheme design. This study was a multiple-case study design relying on qualitative data from twenty municipalities from two states in northeastern Brazil. We conducted two key informant interviews with municipal-level stakeholders and focus group discussions with primary care providers. We also reviewed municipal PMAQ laws in each municipality. We found substantial variation in the design choices made by municipalities regarding 'who was incentivised', the 'payment size' and 'frequency'. Design choices affected relationships within municipalities and within teams. Challenges were chiefly associated with fairness relating to 'who received the incentive', 'what is incentivised', and the 'incentive size'. Adaptations were made to improve fairness, mostly in response to pressure from the healthcare workers. The significant variation in design choices across municipalities and providers' response to them highlights the importance of considering local context in the design and implementation of P4P schemes and ensuring flexibility to accommodate local preferences and emerging needs. Attention is needed to ensure the choice of 'who is incentivised' and the 'size of incentives' are inclusive and fair, and the allocation and 'use of funds' are transparent.
RESUMO
Pay-for-performance (P4P) has been widely applied in OECD countries to improve the quality of both primary and secondary care, and is increasingly being implemented in low- and middle-income countries. In 2011, Brazil introduced one of the largest P4P schemes in the world, the National Programme for Improving Primary Care Access and Quality (PMAQ). We critically assess the design of PMAQ, drawing on a comparison with England's quality and outcome framework which, like PMAQ, was implemented at scale relatively rapidly within a nationalised health system. A key feature of PMAQ was that payment was based on the performance of primary care teams but rewards were given to municipalities, who had autonomy in how the funds could be used. This meant the incentives felt by family health teams were contingent on municipality decisions on whether to pass the funds on as bonuses and the basis upon which they allocated the funds between and within teams. Compared with England's P4P scheme, performance measurement under PMAQ focused more on structural rather than process quality of care, relied on many more indicators, and was less regular. While PMAQ represented an important new funding stream for primary health care, our review suggests that theoretical incentives generated were unclear and could have been better structured to direct health providers towards improvements in quality of care.