This supplement of the Journal of Ambulatory Care Management on the Brazilian National Program for Improving Access and Quality of Primary Care (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 afterward 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.

The policy capacity framework offers relevant analytical ideas that can be mobilized for health system strengthening. However, the employment of this framework in the health field constitutes a relevant interdisciplinary gap in knowledge. This themed issue explores the relationships between the policy capacity framework and health system strengthening, in a multidimensional and interdisciplinary way, in high-income and low–middle-income countries. This introduction unpacks the dynamic interrelationships between the policy capacity framework and health system strengthening, bringing together common and distinct elements from both fields and summarizing possible relationships between them. The analysis shows that both fields together can increase our knowledge on health policies and system’s critical themes and reforms. This challenge could be followed by exploring the convergences between them, as far as concepts/themes (types of capacities and other themes) and levels of analysis are concerned. Although in varied ways, papers in this issue (based on European countries, China, Canada, New Zealand, India, Australia, and Brazil) advance the use of the policy capacity framework for health policy or system strengthening. They give two main interdisciplinary contributions. Critical capacities can be incorporated into the policy capacity framework for the analysis of system strengthening—capacity to adapt, contexts of mixed and complex systems, dynamic view of policy capacity, and policy capacity as a relational power. Policy capacity is contextually interpreted (relative to the problem frame) and dynamic and adaptive (processual and relational), in relation to the properties of a health system, particularly with regard to the existing and developing mixed and complex systems.

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.