Unpacking the effect of the national pay for performance scheme (PMAQ) on inequalities in the financing and delivery of primary care in Brazil.

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Health care providers can be paid in a variety of ways. They can be given an annual budget for agreeing to provide a service or they can be paid on the basis of the size of the population they serve. Alternatively, providers can be paid according to achievement of specific standards or patient outcomes. Such schemes are called Pay for Performance (P4P) schemes and have been used in a variety of setting. These schemes try to change the way health workers behave. By providing financial rewards, they aim to make health workers and their managers focus on specific outcomes that are important for improving the quality of health care services as well as population health. These schemes have been implemented in the United Kingdom and the United States and a growing number of low and middle income countries. Although P4P schemes are usually referred to as a single programme, the design of P4P schemes varies a lot from place to place. For example, some schemes reward the performance of individual providers, whilst others reward the performance of the team. Some schemes base rewards on achieving a fixed target, others set targets relative to current performance. Some schemes involve penalties for poor performance, others do not. From previous research, we know that the design of P4P schemes is important. Yet we understand little about how variations in the design of P4P schemes affect the impact of such programmes. In particular, we don't know how changes in design affect who benefits from these schemes in terms of levels of funding and in terms of the improved delivery of services that is intended to be triggered by P4P. It is possible that some scheme designs primarily benefit rich communities (thereby increasing socio-economic inequalities), whilst others benefit the poorest. Unfortunately, we do not know which P4P designs have that effect. This project will explore how a P4P scheme in Brazil (PMAQ), which was gradually introduced across the country, affected the distribution of health sector funding to health care providers and the delivery of health care services to local communities. We will also explore whether and how the design of P4P incentives affects levels of funding and service delivery. The Brazilian experience is a valuable opportunity to explore this question as: 1) municipalities can choose how to distribute financial rewards linked to P4P, 2) there is a lot of data available on the wealth of communities being served by particular providers and on health sector funding received by providers and quality of care delivered by providers, and 3) the scheme is the largest in the world, with substantial variation in geographical context. The research will begin by reviewing the P4P designs adopted by municipalities nationally and developing a classification of designs. The project will then investigate whether PMAQ has affected the way health sector funding is distributed across health care providers and how this relates to the wealth of the communities they serve; and whether this differs according to the P4P design adopted by municipalities. We will also examine whether providers receiving PMAQ funding receive more or less funding for health care from other sources. The project will consider how the quality of care delivered by health care providers in terms of the way services are delivered to patients and patients satisfaction with services, as well as the capacity of the providers to deliver services, differs according to community wealth and the P4P design adopted by municipalities. Finally, we will carry out an in-depth study of 20 municipalities in 2 Brazilian states that have adopted different P4P designs, to see how they affect health care financing and quality of care and the way different communities benefit or lose out. The study will strengthen relationships between researchers in the UK and in Brazil.