Exploring frontliners' knowledge, participation and evaluation in the implementation of a pay-for-performance program (PMAQ) in primary health care in Brazil

Abstract

PurposeThis paper employs implementation theory and the political literature on performance measurement to understand how frontline health workers know, participate and evaluate the Brazilian National Program for Improving Access and Quality of Primary Care (PMAQ, 2nd round).Design/methodology/approachThis paper develops an implementation theory-driven qualitative analysis. The research is developed in the city of Goiania (Brazil): a challenging organizational context in primary care (PHC). Interviews were carried out with 25 frontliners – managers, doctors, nurses and community health workers. Data were thematically and hierarchically analysed according to theoretical concepts such as policy knowledge, policy adherence, forms of accountability, alternative logics, organizational capacity and policy feedback.FindingsResults show the need to foster organizational capacity, knowledge, participation and policy feedback at the frontline. Successful implementation would require those adaptations to counteract policy challenges/failures or the emergence of alternative logics.Research limitations/implicationsThe study was conducted in only one setting, however, our sample includes different types of professionals working in units with different levels of organization capacity, located in distinct HDs, expressing well the implementation of PMAQ/P4P. Qualitative researches need to be developed for further exploring the same/other factors.Social implicationsFindings can be used to improve discussions/planning and design of P4P programs in the city and State of Goias.Originality/valueThe majority of analysis of PMAQ are of a quantitative or results-based nature. This article focuses on politically significant and unanswered questions regarding the implementation of PMAQ.

Guest editorial: Payment for performance: comparing policy making, design and implementation in health, social care and education

“…To be sure, not all studies have been focusing on impact and several studies have instead focused on the processes and mechanisms triggered by P4P/PBF (De Allegri et al , 2018; Lohmann et al , 2018; Renmans et al , 2020; Singh et al , 2021; Saddi et al , 2021a, b, 2023). This certainly helps us to better understand how these programmes work and even to some extent how context may impact its effectiveness.…”

“…In Brazil, although there have been challenges and failures in the implementation of PMAQ, especially its health education component (Saddi et al , 2021a, b; Coelho et al , 2023), P4P was not removed from the policy agenda. In 2019, Brazil adopted a new P4P scheme in primary care, partially inspired in the UK QOF.…”