The challenges of payment for performance under Brazil's PMAQ

In 2020, the Brazilian Unified Health System (Sistema Único de Saúde; SUS) celebrated 30 years. However, adequate government funding allocation to continue supporting SUS's universal health coverage goal remains a challenge be addressed.1Silva PJ Sistema Saúde (SUS) aos anos.Ciênc Coletiva. 2018; 23: 1723-1728Crossref PubMed Scopus (62) Google Scholar Payment for performance (P4P) was strategy proposed strengthen primary care with implementation of Brazil's National Programme Improving Primary Care Access and Quality (PMAQ), federal public policy that started in 2011, three rounds completed 2019.2Macinko J Harris MJ Rocha MG Program (PMAQ): fulfilling potential world's largest payment system care.J Ambul Manage. 2017; 40: S4-11Crossref (38) Scholar, 3Saddi FC Peckham S Performance (PMAQ) seen from global perspective.J 41: 25-33Crossref (11) The Lancet Global Health, Roxanne Kovacs colleagues4Kovacs R Barreto JOM Nunes da Silva E et al.Socioeconomic inequalities quality under national pay-for-performance programme: longitudinal study family teams.Lancet Glob Health. 2021; 9: e331-e339Summary Full Text PDF (10) highlight effort support decentralise resources health-care teams, most them organised through Family Strategy (FHS). This aims provide preventive basic approximately 1000 households defined area multidisciplinary professional team, usually consisting physician, nurse, about six community workers. Through PMAQ, became continuous progressive process directly associated incentive policy, based on transfer financial municipalities by monitoring selected group indicators obtained (health-care team self-evaluation manager external evaluation) secondary databases (national information system).2Macinko Secondary data have some limitations, such as incomplete poor electronic medical records linkage. Therefore, it is important consider complexity P4P programme rolled out Brazil during PMAQ waves evaluation researchers universities collaboration local managers stakeholders. analysed delivered teams participating over implementation. Then, using census household income areas, authors examined score ventile, association between scores each across rounds, geographical variation score. colleagues included 13 934 participated located 11 472 areas serving 48 million people. round 1 observed positive socioeconomic gradient, mean lower poorest higher richest areas. Between 3, increased significantly decreased slightly group, gap narrowing 7·5 percentage points (95% CI 6·5–8·5) –0·4 same period (–1·6 0·8). These results show decrease inequality regions cash according their performance. An aspect requires further investigation relates how stakeholders used achieve improve access centres, well which specific interventions initiatives were done FHS could explain level territory (census sector) reduce social inequalities. It also assess much own invested health, considering shared responsibility local, state, SUS. Measures assessment teams’ decision at municipality level. first states better systems. Additionally, an audit, part criteria, voluntary. presence selection bias needs acknowledged. Furthermore, best who believed they would good evaluation. designed analytical strategy, main findings presented maps allow understanding different country. showed reduction PMAQ. corresponds whose (or territory) does not necessarily correspond sector. indicators. political contexts strong influence success programmes,5Bertone MP Falisse J-B Russo G Witter Context matters (but why?): hypothesis-led literature review financing fragile conflict-affected systems.PLoS One. 13e0195301Crossref (28) way schemes are designed, including overall aims, focus target setting, actors involved its conception.6Anselmi L Borghi Brown GW al.Pay performance: reflection perspective enhance research.Int Policy Manag. 2020; 365-369PubMed way, can only achieved investments care, use approach registered population. During 8 years possible verify improvements infrastructure, supplies, medications, outcomes.2Macinko Unfortunately, 2019, made interrupt implementing new model changes programme.7Ministry BrazilPortaria n° 2.979, 12 novembro 2019. Institui o Programa Previne Brasil, que estabelece novo modelo financiamento custeio Atenção Primária à no âmbito do Saúde, por meio alteração Portaria Consolidação 6/GM/MS, 28 setembro 2017. Diário Oficial União.https://www.in.gov.br/en/web/dou/-/portaria-n-2.979-de-12-de-novembro-de-2019-227652180Date: 2019Date accessed: January 26, 2021Google effective interruption represents removal opportunity programme's impact outcomes collaborative scientific work among government. We declare competing interests. Socioeconomic teamsExisting delivery eliminated plausibly due design feature adjusted payments there agenda address large inequities health. Full-Text Open