Unpacking the effect of the national pay for performance scheme (PMAQ) on inequalities in the financing and delivery of primary care in Brazil.

Lead Research Organisation: London Sch of Hygiene and Trop Medicine
Department Name: Public Health and Policy

Abstract

Health care providers can be paid in a variety of ways. They can be given an annual budget for agreeing to provide a service or they can be paid on the basis of the size of the population they serve. Alternatively, providers can be paid according to achievement of specific standards or patient outcomes. Such schemes are called Pay for Performance (P4P) schemes and have been used in a variety of setting. These schemes try to change the way health workers behave. By providing financial rewards, they aim to make health workers and their managers focus on specific outcomes that are important for improving the quality of health care services as well as population health. These schemes have been implemented in the United Kingdom and the United States and a growing number of low and middle income countries.
Although P4P schemes are usually referred to as a single programme, the design of P4P schemes varies a lot from place to place. For example, some schemes reward the performance of individual providers, whilst others reward the performance of the team. Some schemes base rewards on achieving a fixed target, others set targets relative to current performance. Some schemes involve penalties for poor performance, others do not. From previous research, we know that the design of P4P schemes is important. Yet we understand little about how variations in the design of P4P schemes affect the impact of such programmes. In particular, we don't know how changes in design affect who benefits from these schemes in terms of levels of funding and in terms of the improved delivery of services that is intended to be triggered by P4P. It is possible that some scheme designs primarily benefit rich communities (thereby increasing socio-economic inequalities), whilst others benefit the poorest. Unfortunately, we do not know which P4P designs have that effect.

This project will explore how a P4P scheme in Brazil (PMAQ), which was gradually introduced across the country, affected the distribution of health sector funding to health care providers and the delivery of health care services to local communities. We will also explore whether and how the design of P4P incentives affects levels of funding and service delivery. The Brazilian experience is a valuable opportunity to explore this question as: 1) municipalities can choose how to distribute financial rewards linked to P4P, 2) there is a lot of data available on the wealth of communities being served by particular providers and on health sector funding received by providers and quality of care delivered by providers, and 3) the scheme is the largest in the world, with substantial variation in geographical context.
The research will begin by reviewing the P4P designs adopted by municipalities nationally and developing a classification of designs. The project will then investigate whether PMAQ has affected the way health sector funding is distributed across health care providers and how this relates to the wealth of the communities they serve; and whether this differs according to the P4P design adopted by municipalities. We will also examine whether providers receiving PMAQ funding receive more or less funding for health care from other sources. The project will consider how the quality of care delivered by health care providers in terms of the way services are delivered to patients and patients satisfaction with services, as well as the capacity of the providers to deliver services, differs according to community wealth and the P4P design adopted by municipalities. Finally, we will carry out an in-depth study of 20 municipalities in 2 Brazilian states that have adopted different P4P designs, to see how they affect health care financing and quality of care and the way different communities benefit or lose out. The study will strengthen relationships between researchers in the UK and in Brazil.

Technical Summary

Pay for performance (P4P) schemes, i.e. financial rewards based on the achievement of pre-specified performance indicators, are employed to improve the availability, quality and utilisation of essential health services globally. Although the design of P4P schemes may be key to understanding the variations in programme effectiveness, we know very little about how incentive designs affect performance and inequalities in outcomes. This project will investigate how Brazil's national P4P scheme for improving primary care access and quality (PMAQ) has affected socioeconomic inequalities in the financing and delivery of primary care and the extent to which different incentive designs affect these outcomes. The Brazilian experience provides a unique opportunity to explore this question as: 1) municipalities have autonomy in the design and delivery of incentives to providers in their area, 2) there is extensive secondary data available on socio-economic status, financing and quality of care, and 3) the scheme is the largest in the world, with substantial heterogeneity between areas. We will review the incentive designs adopted by municipalities nationally and develop a typology of designs. We will then investigate whether PMAQ affects inequalities in the distribution of funding across teams and if this differs by incentive design using routine data. We will also examine whether PMAQ funding is a substitute or complement to other health sector funding. We will examine the relationship between socio-economic inequalities and structure and process quality of care using data from the PMAQ External Evaluation. Finally, we will conduct 20 in-depth municipality level case studies in 2 states, varying in context and incentive design, to evaluate the mechanisms through which PMAQ affects inequalities in funding and quality of primary care. The study will promote knowledge exchange between researches in the United Kingdom and in Brazil.

Planned Impact

Here we outline who we expect to benefit from this research and how we expect them to benefit. The Pathways to Impact and the Academic beneficiaries sections explain the methods we will use to ensure they benefit. This research is intended to benefit three main groups: a) national level stakeholders in Brazil; b) international stakeholders; c) the academic community.
This research will benefit national policy makers implementing the National Programme for Improving Primary Care Access and Quality (PMAQ) in Brazil as well as municipal health managers who are deciding on how to design incentives locally. Evidence on which pay for performance (P4P) incentive designs minimise inequality in funding levels will make it possible to the select designs that encourage a more equitable allocation of resources across teams in different contexts, thereby strengthening the national health system. Similarly, knowledge of how incentive designs affect quality of care will lead to more effective incentive designs that reduce inequalities in quality of care, resulting in health care improvements across the population rather than exclusively for better off groups. The research findings will be disseminated as outlined in the Pathways to Impact through a national dissemination event, a policy brief, and through the Congresso Nacional de Secretarias Municipais de Saúde for municipal stakeholders and conferences in Brazil.
The research team will ensure the continued engagement of the Ministry of Health with the research to maximise its relevance to policy through the establishment of a Steering committee which would meet every 6 months. An initial workshop will be convened bringing the whole research team together with the Ministry of Health to share experiences of P4P from across different settings (UK, Brazil, Africa and China). As a result of these engagements, we will build capacity and understanding within the Ministry of the global evidence on P4P, which may also strengthen implementation of PMAQ within Brazil.
The research will also benefit international stakeholders - national and local governments implementing P4P in other countries and international donors supporting P4P. They will benefit from a better understanding of the impact of different incentive designs on inequalities in funding and quality of care. We expect that given the scale of Brazil and its geographic diversity, the findings will be generalisable to different country contexts and implementers as well as to funders. This will result in improved health systems and reduced inequality in health outcomes across a range of settings. The NHS in England are also very interested on how the design of incentives affects outcomes. As indicated in the Pathways to Impact document, we will reach these stakeholders by using our existing personal networks, a policy brief and through presentations at relevant conferences.
The main academic beneficiaries will be those engaged in the evaluation of primary care reforms and P4P schemes in health, including public health researchers, epidemiologists, behavioural economists and social scientists. The study will also benefit economists and social policy researchers studying the effect of policies on equity, and to researchers evaluating complex interventions seeking to unpack the effect of different programme design components, and to students. The study will benefit these researchers in terms of expanding the evidence base on how incentive designs affect quality of health care and equity, as well as methodologically in how to study and unpack incentive designs in the future. As indicated in the Academic beneficiaries section, we will communicate with these academic beneficiaries through open access peer reviewed publications, presentations at international conferences and national conferences in Brazil and the UK. Students will be reached through taught courses at partner institutions.
 
Description In our recent publication in the Lancet Global Health, we have contributed new knowledge on how pay for performance (bonus rewards for health providers) may impact on the equity of primary care delivery. The article was accompanied by an Editorial and a Commentary in the March edition of the journal. The results have particular relevance for policy because Brazil is currently reforming the way it funds primary care providers. The results suggest that the way health providers are financed can reduce inequalities in the quality of care if programmes are designed to adjust payments for socioeconomic status of the local population. The ODA-relevance of these findings is clear as they apply directly to Brazil, which is a DAC country. However, the findings also have relevance ot many other lower income DAC countries, which have scaled up pay for performance programmes through ODA funds from the World Bank and other donors.
Exploitation Route Going forward to need to disseminate these findings with policymakers in Brazil, both at the national and state level, to get the key messages across. The findings can then be incorporated into current policymaking more effectively. We are also carrying out a follow-on analysis that explores in more detail on variation in the design of pay for performance in Brazil impacts on quality of care and inequality.
Sectors Healthcare

 
Description Some key findings of the research have recently been published and we are in the process of disseminating them amongst policymakers in Brazil and internationally. The findings are most relevant to policymakers in Brazil, which is a DAC country. The findings are well timed as Brazil is currently embarking on a major reform to primary care financing, with equity being a key goal. Our findings provide novel empirical evidence on how pay for performance, if welll designed, can help to address socioeconomic inequalities in the delivery of primary care services. These findings will help inform the new national pay for performance programme that was due to start in 2020 but has been delayed due to the COVID pandemic. Our research is directly addressing questions of inequality. It has indirect implications for gender equality in access to quality primary care services by virtue of the fact that primary care is disproportionately used by women and children. The research team has a good gender balance, with 50% of the UK-based team and almost 50% of the Brazil team being female.
First Year Of Impact 2021
Sector Healthcare
Impact Types Policy & public services

 
Description Advising on financing primary health care in Brazil to CONASEMS
Geographic Reach National 
Policy Influence Type Participation in a national consultation
 
Title Qualitative interview guides 
Description We developed question guides for in-depth qualitative interviews with stakeholders in municipalities and at primary care facilities to understand how the PMAQ scheme design was decided upon and how this played out in terms of financing and the delivery of primary care and equity. 
Type Of Material Improvements to research infrastructure 
Year Produced 2019 
Provided To Others? No  
Impact We are using the tools to collect data from 20 municipalities in Pernambuco and Paraiba states. 
 
Title Survey of municipalities 
Description We developed a survey for municipal health managers to capture the key features of the PMAQ design in their municipality as part of Objective 1. 
Type Of Material Improvements to research infrastructure 
Year Produced 2019 
Provided To Others? Yes  
Impact This tool successfully gathered data from municipalities across Brazil on the PMAQ design. So far 811 municipalities have responded to the survey. 
 
Title Code for: "Socioeconomic inequalities in the quality of primary care under Brazil's national pay-for-performance programme: a longitudinal study of family health teams" 
Description A Stata do file that contains code written to analyse longitudinal data on the quality of care delivered by family health teams participating in Brazil's National Programme for Improving Primary Care Access and Quality (Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica [PMAQ]). The study analysed longitudinal data collected over three rounds of implementation: round 1 (Nov 2011 - Mar 2013), round 2 (Apr 2013 - Sep 2015) and round 3 (Oct 2015 - Dec 2019). The underlying PMAQ data are owned by the Ministry of Health in Brazil and we do not have permission to share the data publicly. However, we provide the codebook for the combined dataset. 
Type Of Material Data analysis technique 
Year Produced 2021 
Provided To Others? Yes  
Impact Supports the analysis presented in the Lancet Global Health article, ensuring greater transparency in research. 
URL https://datacompass.lshtm.ac.uk/id/eprint/2016/
 
Title Data on quality of care and performance for PMAQ 
Description We have data for all primary care facilities in the country for each round of PMAQ (x3) on their performance as rated by PMAQ and a set of quality of care indicators. We obtained these data from PMAQ. We have linked to these data, data on the socio-economic status of the community where the facilities are located, from census data. Hence, we are able to examine socio-economic inequalities in performance and quality, and link this to PMAQ. 
Type Of Material Database/Collection of data 
Year Produced 2019 
Provided To Others? No  
Impact The data are being analysed and a paper being drafted with the results. 
 
Title Dataset on PMAQ design at the municipal level 
Description These are data submitted from municipalities on the design of PMAQ in their locality. 
Type Of Material Database/Collection of data 
Year Produced 2019 
Provided To Others? No  
Impact These data will be used to address objective 1 of the study. 
 
Title Qualitative data from Paraiba 
Description These are the transcripts from qualitative interviews carried out in 10 municipalities in Paraiba. 
Type Of Material Database/Collection of data 
Year Produced 2020 
Provided To Others? No  
Impact These data are currently being analysed. 
 
Description Collaboration with Ministry of Health, Government of Brazil 
Organisation Government of Brazil
Department Ministry of Health Brazil
Country Brazil 
Sector Public 
PI Contribution We have collaborated closely with the Ministry of Health during the research project as they are a key policy stakeholders and beneficiary of the research findings. Early in the project, we held a steering commitee meeting with key Ministry staff while the LSHTM team was visiting Brasilia. We have kept the Ministry informed as the research as progressed.
Collaborator Contribution The Ministry of Health has been instrumental in several ways. First, they gave us access to a new administrative dataset on the quality of care delivered by primary care teams over time. These data provided the foundation for our analysis, as reported in a recent Lancet Global Health Paper. Second, they helped us to administer a national survey of municipality health managers to understand how PMAQ has been implemented at a local level. Third, they have provide important contextual information to help us understand how PMAQ works.
Impact The Lancet Global Health paper on socioeconomic inequality in primary care delivered by family health teams.
Start Year 2018
 
Description Collaboration with research partners in Brazil as part of original application 
Organisation Federal University of Campina Grande
Country Brazil 
Sector Academic/University 
PI Contribution We are the lead organisation in managing the project and collaboration between a large number of universities, both in the UK and Brazil. We are collaborating with Brazilian colleagues on all the research components and co-producing the research outputs.
Collaborator Contribution Our collaboration partners in Brazil (DAC country) have provide input on the policy context, designing the research studies, facilitating access to government administrative data, collecting new primary data (both quantitative and qualitative data), doing the analysis, preparing academic papers and in dissemination.
Impact All the outputs under this project are the result of this collaboration. The involvement of individuals from all the collaborating institutions in the outputs demonstrates that the partnership is built on principles of equity.
Start Year 2018
 
Description Collaboration with research partners in Brazil as part of original application 
Organisation Federal University of Paraíba
Country Brazil 
Sector Academic/University 
PI Contribution We are the lead organisation in managing the project and collaboration between a large number of universities, both in the UK and Brazil. We are collaborating with Brazilian colleagues on all the research components and co-producing the research outputs.
Collaborator Contribution Our collaboration partners in Brazil (DAC country) have provide input on the policy context, designing the research studies, facilitating access to government administrative data, collecting new primary data (both quantitative and qualitative data), doing the analysis, preparing academic papers and in dissemination.
Impact All the outputs under this project are the result of this collaboration. The involvement of individuals from all the collaborating institutions in the outputs demonstrates that the partnership is built on principles of equity.
Start Year 2018
 
Description Collaboration with research partners in Brazil as part of original application 
Organisation Federal University of Pernambuco
Country Brazil 
Sector Academic/University 
PI Contribution We are the lead organisation in managing the project and collaboration between a large number of universities, both in the UK and Brazil. We are collaborating with Brazilian colleagues on all the research components and co-producing the research outputs.
Collaborator Contribution Our collaboration partners in Brazil (DAC country) have provide input on the policy context, designing the research studies, facilitating access to government administrative data, collecting new primary data (both quantitative and qualitative data), doing the analysis, preparing academic papers and in dissemination.
Impact All the outputs under this project are the result of this collaboration. The involvement of individuals from all the collaborating institutions in the outputs demonstrates that the partnership is built on principles of equity.
Start Year 2018
 
Description Collaboration with research partners in Brazil as part of original application 
Organisation Imperial College London
Country United Kingdom 
Sector Academic/University 
PI Contribution We are the lead organisation in managing the project and collaboration between a large number of universities, both in the UK and Brazil. We are collaborating with Brazilian colleagues on all the research components and co-producing the research outputs.
Collaborator Contribution Our collaboration partners in Brazil (DAC country) have provide input on the policy context, designing the research studies, facilitating access to government administrative data, collecting new primary data (both quantitative and qualitative data), doing the analysis, preparing academic papers and in dissemination.
Impact All the outputs under this project are the result of this collaboration. The involvement of individuals from all the collaborating institutions in the outputs demonstrates that the partnership is built on principles of equity.
Start Year 2018
 
Description Collaboration with research partners in Brazil as part of original application 
Organisation Oswaldo Cruz Foundation (Fiocruz)
Country Brazil 
Sector Public 
PI Contribution We are the lead organisation in managing the project and collaboration between a large number of universities, both in the UK and Brazil. We are collaborating with Brazilian colleagues on all the research components and co-producing the research outputs.
Collaborator Contribution Our collaboration partners in Brazil (DAC country) have provide input on the policy context, designing the research studies, facilitating access to government administrative data, collecting new primary data (both quantitative and qualitative data), doing the analysis, preparing academic papers and in dissemination.
Impact All the outputs under this project are the result of this collaboration. The involvement of individuals from all the collaborating institutions in the outputs demonstrates that the partnership is built on principles of equity.
Start Year 2018
 
Description Collaboration with research partners in Brazil as part of original application 
Organisation University of Brasilia
Country Brazil 
Sector Academic/University 
PI Contribution We are the lead organisation in managing the project and collaboration between a large number of universities, both in the UK and Brazil. We are collaborating with Brazilian colleagues on all the research components and co-producing the research outputs.
Collaborator Contribution Our collaboration partners in Brazil (DAC country) have provide input on the policy context, designing the research studies, facilitating access to government administrative data, collecting new primary data (both quantitative and qualitative data), doing the analysis, preparing academic papers and in dissemination.
Impact All the outputs under this project are the result of this collaboration. The involvement of individuals from all the collaborating institutions in the outputs demonstrates that the partnership is built on principles of equity.
Start Year 2018
 
Description Collaboration with research partners in Brazil as part of original application 
Organisation University of Manchester
Country United Kingdom 
Sector Academic/University 
PI Contribution We are the lead organisation in managing the project and collaboration between a large number of universities, both in the UK and Brazil. We are collaborating with Brazilian colleagues on all the research components and co-producing the research outputs.
Collaborator Contribution Our collaboration partners in Brazil (DAC country) have provide input on the policy context, designing the research studies, facilitating access to government administrative data, collecting new primary data (both quantitative and qualitative data), doing the analysis, preparing academic papers and in dissemination.
Impact All the outputs under this project are the result of this collaboration. The involvement of individuals from all the collaborating institutions in the outputs demonstrates that the partnership is built on principles of equity.
Start Year 2018
 
Description Meetings with the Ministry of Health and CONASEMS (National Council of Municipal Health Secretaries) 
Organisation Government of Brazil
Department Ministry of Health Brazil
Country Brazil 
Sector Public 
PI Contribution The Brazilian research team had several meetings (about 15 meetings along the project execution) with representatives of Ministry of Health and CONASEMS (National Council of Municipal Health Secretaries). The Brazilian and UK team had a meeting with the project Steering Committee in September 2018 (first meeting in Brasilia), which is composed by representatives of Ministry of Health and PAHO.
Collaborator Contribution The partners gave feedback on the project objectives, data and methods.
Impact Meetings took place.
Start Year 2018
 
Description Partnership with researchers at the University of Kent 
Organisation Federal University of Goiás
Country Brazil 
Sector Academic/University 
PI Contribution Jo Borghi and Roxanna Kovacs and Tim Powell-Jackson and Loveday Penn were asked to participate as presenters and discussants at a London Seminar Payment for Performance in England and Brazil (3rd April).
Collaborator Contribution Stephen Peckham from Kent and Fabiana Saddi from the federal University of Goais Brazil approached us to collaborate in this session.
Impact Participation in a workshop on April 3rd in London as a panel discussant.
Start Year 2019
 
Description Partnership with researchers at the University of Kent 
Organisation University of Kent
Country United Kingdom 
Sector Academic/University 
PI Contribution Jo Borghi and Roxanna Kovacs and Tim Powell-Jackson and Loveday Penn were asked to participate as presenters and discussants at a London Seminar Payment for Performance in England and Brazil (3rd April).
Collaborator Contribution Stephen Peckham from Kent and Fabiana Saddi from the federal University of Goais Brazil approached us to collaborate in this session.
Impact Participation in a workshop on April 3rd in London as a panel discussant.
Start Year 2019
 
Description Engagement with CONASEMS 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact Our Brazilian colleagues presented our proposal twice at CONARES meeting, which brings together the board of CONASEMS. The first presentation was in March 2019, and Garibaldi and Everton presented the proposal in order to get CONASEMS support to apply implement the questionnaire on typology design to all Brazilian municipalities. The second presentation took place in Brasilia on 16th September 2019. The preliminary results of typology design (pilot study) were presented.
Year(s) Of Engagement Activity 2019
 
Description Policy roundtable on pay for performance in primary care in England and Brazil 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact We participated in an event supported by a British Academy Newton Advanced project studying the formulation and implementation process of a Brazilian payment for performance programme (The PMAQ) and its impact on performance drivers and system strengthening. Given the fact that Brazil has launched a new pay for performance programme (in mid-November 2019) inspired in the English "Quality and Outcome Framework" (the QOF), this event gave an opportunity for policymakers, researchers and general audience to discuss payment for performance programmes in both countries, taking into account their similarities and distinctiveness in primary care. This unique event brought together leading researchers in both the UK and Brazil (DAC country) to share experience of P4P in primary care. About half the participants were from Brazil (DAC country), including policymakers from the Ministry of Health.
Year(s) Of Engagement Activity 2020
URL https://www.facebook.com/politicshealth/
 
Description Steering committee meeting 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact We discuss our project with our Steering Committee on September 2018 (meeting in Brasilia), which is composed by representatives of Ministry of Health and PAHO, this was a 2 day meeting. The meeting informed the next steps of the project, including a method to identify the design typologies across all municipalities in Brazil.
Year(s) Of Engagement Activity 2018