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PAY-FOR-PERFORMANCE FOR PRIMARY HEALTH CARE IN BRAZIL: A COMPARISON WITH ENGLAND’S QUALITY OUTCOMES FRAMEWORK AND LESSONS FOR THE FUTURE
Author
Gurgel Júnior, Garibaldi Dantas
Kristensen, Søren Rud
Silva, Everton Nunes da
Gomes, Luciano Bezerra
Barreto, Jorge Otávio Maia
Kovacs, Roxanne
Sampaio, Juliana
Bezerra, Adriana Falangola Benjamin
Silva, Keila Silene de Brito e
Shimizu, Helena Eri
Sousa, Allan Nuno Alves de
Fardousi, Nasser
Borghi, Josephine
Powell-Jackson, Timothy
Kristensen, Søren Rud
Silva, Everton Nunes da
Gomes, Luciano Bezerra
Barreto, Jorge Otávio Maia
Kovacs, Roxanne
Sampaio, Juliana
Bezerra, Adriana Falangola Benjamin
Silva, Keila Silene de Brito e
Shimizu, Helena Eri
Sousa, Allan Nuno Alves de
Fardousi, Nasser
Borghi, Josephine
Powell-Jackson, Timothy
Affilliation
Fundação Oswaldo Cruz. Instituto Aggeu Magalhães. Recife, PE, Brasil.
Institute of Global Health Innovation, Imperial College London, London, United Kingdom / University of Southern Denmark. Centre for Health Economics. Odense, Denmark.
University of Brasilia. Faculty of Ceilandia. Brasilia, DF, Brazil.
Federal University of Paraiba. Department of Health Promotion. João Pessoa, PB, Brazil.
Fundação Oswaldo Cruz. Fiocruz Brasília. Brasília, DF, Brasil.
London School of Hygiene and Tropical Medicine. Department of Global Health and Development. London, United Kingdom.
Federal University of Paraiba. Department of Health Promotion. João Pessoa, PB, Brazil.
Federal University of Pernambuco. Department of Social Medicine. Recife, PE, Brazil.
Federal University of Pernambuco. Academic Center of Vitória. Collective Health Nucleous. Recife, PE, Brazil.
University of Brasilia. Department of Collective Health. Brasília, DF, Brazil.
Ministry of Health. Brasília, DF, Brazil.
London School of Hygiene and Tropical Medicine. Department of Global Health and Development. London, United Kingdom.
London School of Hygiene and Tropical Medicine. Department of Global Health and Development. London, United Kingdom.
London School of Hygiene and Tropical Medicine. Department of Global Health and Development. London, United Kingdom.
Institute of Global Health Innovation, Imperial College London, London, United Kingdom / University of Southern Denmark. Centre for Health Economics. Odense, Denmark.
University of Brasilia. Faculty of Ceilandia. Brasilia, DF, Brazil.
Federal University of Paraiba. Department of Health Promotion. João Pessoa, PB, Brazil.
Fundação Oswaldo Cruz. Fiocruz Brasília. Brasília, DF, Brasil.
London School of Hygiene and Tropical Medicine. Department of Global Health and Development. London, United Kingdom.
Federal University of Paraiba. Department of Health Promotion. João Pessoa, PB, Brazil.
Federal University of Pernambuco. Department of Social Medicine. Recife, PE, Brazil.
Federal University of Pernambuco. Academic Center of Vitória. Collective Health Nucleous. Recife, PE, Brazil.
University of Brasilia. Department of Collective Health. Brasília, DF, Brazil.
Ministry of Health. Brasília, DF, Brazil.
London School of Hygiene and Tropical Medicine. Department of Global Health and Development. London, United Kingdom.
London School of Hygiene and Tropical Medicine. Department of Global Health and Development. London, United Kingdom.
London School of Hygiene and Tropical Medicine. Department of Global Health and Development. London, United Kingdom.
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.
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