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

医疗服务提供者可以通过多种方式获得报酬。他们可以因同意提供服务而获得年度预算，也可以根据他们所服务的人口规模获得报酬。或者，提供者可以根据特定标准的实现或患者结果来支付报酬。这种方案被称为绩效工资(P4P)方案，并已在各种环境中使用。这些计划试图改变卫生工作者的行为方式。通过提供财政奖励，他们的目标是让卫生工作者及其管理人员专注于对改善卫生保健服务质量和人口健康至关重要的具体成果。这些计划已在联合王国和美国以及越来越多的低收入和中等收入国家实施。虽然P4P计划通常被称为单一计划，但P4P计划的设计因地而异。例如，一些计划奖励个人提供者的表现，而另一些计划奖励团队的表现。一些方案以实现固定目标为奖励基础，另一些方案则根据当前业绩设定目标。一些计划涉及对表现不佳的惩罚，另一些则不涉及。从以往的研究中，我们知道P4P方案的设计是很重要的。然而，我们对P4P计划的设计差异如何影响此类计划的影响知之甚少。特别是，我们不知道设计上的变化如何影响谁从这些计划中受益，无论是在资金水平方面，还是在计划由P4P触发的改善服务交付方面。可能的情况是，一些方案设计主要使富裕社区受益(从而加剧了社会经济不平等)，而另一些方案则使最贫穷的人受益。不幸的是，我们不知道哪些P4P设计具有这种效果。该项目将探讨在巴西逐步推行的P4P计划(PMAQ)如何影响卫生部门向卫生保健提供者的资金分配和向当地社区提供卫生保健服务。我们还将探讨P4P激励的设计是否以及如何影响资金和服务提供的水平。巴西的经验是探讨这一问题的宝贵机会，因为：1)市政当局可以选择如何分配与P4P挂钩的财政奖励；2)有大量关于特定提供者所服务的社区的财富、提供者获得的卫生部门资金和提供者提供的护理质量的数据；3)该计划是世界上最大的计划，在地理环境上有很大的差异。这项研究将首先审查全国市政当局采用的P4P设计，并制定设计分类。然后，该项目将调查PMAQ是否影响了卫生部门资金在医疗保健提供者之间的分配方式，这与他们所服务的社区的财富有何关系；根据市政当局采用的P4P设计，这一点是否有所不同。我们还将研究接受PMAQ资金的提供者是否从其他来源获得更多或更少的卫生保健资金。该项目将考虑卫生保健提供者在向病人提供服务的方式和病人对服务的满意度方面提供的护理质量，以及提供者提供服务的能力如何根据社区财富和市政当局采用的P4P设计而有所不同。最后，我们将对巴西两个州采用不同P4P设计的20个城市进行深入研究，看看它们如何影响医疗融资和医疗质量，以及不同社区的受益或损失方式。这项研究将加强英国和巴西研究人员之间的关系。

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.