Available online 19 November 2022

Abstract

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.

Section snippetsPolicy background

Pay for performance (P4P) links financial payments to the performance of health care providers. P4P has been widely applied in the United States, the United Kingdom, and other OECD countries to improve the quality of primary and secondary care [1], [2], [3], [4]. P4P is also increasingly being implemented in low- and middle-income countries to improve quality of care and service uptake [5] [6].

Brazil introduced a P4P scheme for primary care in 2011: the National Programme for Improving Primary

Key design features of PMAQ

The use of financial incentives to improve the quality of care can be analysed through the lens of agency theory [25, 26]. In this framework, an agent (in this case a primary care provider) carries out a task (here, health care provision) on behalf of a principal (the payer/ministry of health). In health care, there is a further complication in that the primary care provider has a second principal, namely the patient, whose interest the agent is also expected to serve [27]. Due to asymmetric

Comparison with England's QOF

In Table 2, we compare the design features of PMAQ and the QOF [5]. A first notable difference is the measurement of quality. While the majority of indicators in the QOF reflect processes of care, PMAQ focused on structural quality indicators, possibly because they were easier to measure. However, inputs to care are often poor predictors of evidence-based clinical care [44], and larger effects come from linking incentives to process measures [3]. PMAQ's greater use of structure rather than

Discussion

We assess the strengths and weaknesses of PMAQ's design and discuss the incentives potentially generated by the programme, before concluding with some reflections on the future of P4P in Brazil and lessons for other countries.

Conclusion

PMAQ represented an important new funding stream for primary health care in Brazil. Our review of its design suggests that theoretical incentives generated were unclear and could have been better structured to direct health providers towards improvements in quality of care. We conclude by distilling some key lessons that may be relevant for both the future of P4P in Brazil and other countries.

First, in any P4P programme, the choice of indicators that are linked to payment is a key decision. The

Declaration of Competing Interest

None declared.

Funding

UK Medical Research Council, Newton Fund (grant MR/R022828/1), and CONFAP (Conselho Nacional das Fundações Estaduais deAmparo à Pesquisa) by means of Fundação de Amparo à Pesquisa do Distrito Federal (FAP-DF), Fundação de Amparo à Ciência e Tecnologia do Estado de Pernambuco (FACEPE) and Fundação de Apoio à Pesquisa do Estado da Paraíba (FAPESQ).

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