Brazilian Payment for Performance (PMAQ) Seen From a Global Health and Public Policy Perspective: What Does it Mean for Research and Policy?

This Supplement of the JACM on the Brazilian PMAQ reveals a relevant gap in the Brazilian literature on pay for performance/PMAQ, and is therefore an opportunity to bring contributions from global health and public policy to the debate. We discuss the relevant gap in the light of developments in evaluation and policy analysis. We afterwards present the state of knowledge regarding global health and public policy in pay for performance, giving attention to diverse themes, methods, types of analyses, theoretical contributions and limitations. Finally, we suggest some possible implications for research and policy in Brazil

Pay for Performance, Formulation, Implementation and Policy Success: in Low, Middle and High Income Countries

Low and middle income countries (LMICs), as well as high income countries (HICs), with different politicaleconomic contexts, varying dependence on external financing, as well as in differentiated stages of development of primary health care (PHC), have adopted payment for performance or performance-based financing programs (P4P/PBF). Addressing the reality of different health systems and contexts, in LMICs and HICs, the rationalbased assumptions supporting the design of P4P/PBF programmes have been theoretically questioned by more realistic political, organizational and motivational assumptions. Empirically, they have been challenged by alternative logics and processes arising from comparatively distinctive implementation and (re)formulation processes, diverse unexpected effects/evidence and a recognition of the need to consider adaptations and long-term sustainable) impacts on health systems. Consequently, P4P/PBF programs have been subject to social sciences, public policy, health policy and health systems research. These analyses have the potential to significantly enrich the debate and knowledge on the operation and impact of P4P/PBF programs and how they could be more effectively designed to support health system performance and strengthening, producing effective/real-world or long-term improvements

Perceptions and evaluations of front-line health workers regarding the Brazilian National Program for Improving Access and Quality to Primary Care (PMAQ): a mixed-method approach

Abstract: Although it is well known that a successful implementation depends on the front-liners’ knowledge and participation, as well as on the organizational capacity of the institutions involved, we still know little about how front-line health workers have been involved in the implementation of the Brazilian National Program for Improving Access and Quality to Primary Care (PMAQ). This paper develops a contingent mixed-method approach to explore the perceptions of front-line health workers - managers, nurses, community health workers, and doctors - regarding the PMAQ (2nd round), and their evaluations concerning health unit organizational capacity. The research is guided by three relevant inter-related concepts from implementation theory: policy knowledge, participation, and organizational capacity. One hundred and twenty-seven health workers from 12 primary health care units in Goiânia, Goiás State, Brazil, answered semi-structured questionnaires, seeking to collect data on reasons for adherence, forms of participation, perceived impact (open-ended questions), and evaluation of organizational capacity (score between 0-10). Content analyses of qualitative data enabled us to categorize the variables “level of perceived impact of PMAQ” and “reasons for adhering to PMAQ”. The calculation and aggregation of the means for the scores given for organizational capacity enabled us to classify distinct levels of organizational capacity. We finally integrated both variables (Perceived-Impact and Organizational-Capacity) through cross-tabulation and the narrative. Results show that nurses are the main type of professional participating. The low organizational capacity and little policy knowledge affected workers participation in and their perceptions of the PMAQ