Policy mechanisms and types of participation in the implementation of the Brazilian pay-for-performance programme PMAQ

Abstract

PurposeThe study compares how distinct mechanisms that connect pre-established policy objectives to professionals' practices, and the health policy implementation context influenced different approaches to frontline staff participation. The authors analysed 26 teams in six cities from two Brazilian states, during the last cycle of the National Program for Improving Access and Quality of Primary Care (PMAQ).Design/methodology/approachAbout 172 in-depth interviews were conducted with frontliners – community health workers (78), nurses (37), doctors (30) – and managers (27). Interview guides were based on key issues identified in the implementation and pay-for-performance (P4P) literature. Drawing on thematic analysis and synthesis of the literature, three types of participation mechanisms were identified: relational, motivational and incremental learning. They were analysed considering distinct contexts at the local level to understand how they influenced different forms of participation: mere adherence, result-oriented and transformative.FindingsAdministrations with stronger institutional organizational structures were able to control work processes and reduce professional discretion. However, sustained participation was more likely where there was greater integration between management and frontline health care teams. Motivation based only on financial incentives could not bring about transformative participation. This depended on the degree of professional's ideational motivation towards primary care. Finally, contexts with unfavourable working conditions tend to demotivate professionals, but incremental learning helps teams cope with these obstacles.Originality/valueThe study overcomes gaps in the literature in relation to PMAQ's implementation process. Overall, the study delves into which/how mechanisms alter frontliners participation in performance-oriented health programs.

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

“…The study by Coelho et al (2023) shed new light on how P4P mechanisms alter frontline staff participation in performance-oriented health programmes in Brazil. The study compares how diverse contexts and policy mechanisms generated different approaches to frontline staff participation during the implementation of a Brazilian P4P programme.…”

“…This special issue gathers three types of comparative studies: cross-country comparisons (Zitti et al , 2023; Andersen, 2023), intra country comparisons (Aktas et al , 2023; Srinivasan and Sarin, 2023; Coelho et al , 2023; Dos Anjos et al , 2023) and world-wide meta-analysis from existing literature (Kristensen et al , 2023; Briganti et al, 2023 ). Authors carry out policy process analyses, employing qualitative, mixed methods and review techniques, combined with comparative analytical descriptive accounts.…”

“…Another block of four papers develops in depth single country studies, breaking the analysis into smaller analytical units in different locations, examining sub-national or sub-regional aspects or administrative variations within a country. They develop cases analysis of original or new data focusing on Turkey (Aktas et al , 2023), India (Srinivasan and Sarin, 2023) and Brazil (Coelho et al , 2023; Dos Anjos et al , 2023).…”

“…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.…”