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

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.

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.

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.