Understanding the municipal-level design and adaptation of pay-for-performance schemes across two states of Brazil.

IF 2.9 3区 医学 Q2 HEALTH CARE SCIENCES & SERVICES Health policy and planning Pub Date : 2024-08-08 DOI:10.1093/heapol/czae033
Nasser Fardousi, Garibaldi Dantas Gurgel Junior, Helena Shimizu, Keila Silene de Brito E Silva, Everton Da Silva, Mariana Olivia Santana Dos Santos, Adriana Falangola Benjamin Bezerra, Luciano Gomes, Timothy Powell-Jackson, Juliana Sampaio, Josephine Borghi
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Abstract

The design of complex health systems interventions, such as pay for performance (P4P), can be critical to determining such programmes' success. In P4P programmes, the design of financial incentives is crucial in shaping how these programmes work. However, the design of such schemes is usually homogenous across providers within a given scheme. Consequently, there is a limited understanding of the strengths and weaknesses of P4P design elements from the implementers' perspective. This study takes advantage of the unique context of Brazil, where municipalities adapted the federal incentive design, resulting in variations in incentive design across municipalities. The study aims to understand why municipalities in Brazil chose certain P4P design features, the associated challenges and the local adaptations made to address problems in scheme design. This study was a multiple case study design relying on qualitative data from 20 municipalities from two states in Northeastern Brazil. We conducted two key informant interviews with municipal-level stakeholders and focus group discussions with primary care providers. We also reviewed municipal Primary Care Access and Quality laws in each municipality. We found substantial variation in the design choices made by municipalities regarding 'who was incentivized', the 'payment size' and 'frequency'. Design choices affected relationships within municipalities and within teams. Challenges were chiefly associated with fairness relating to 'who received the incentive', 'what is incentivized' and the 'incentive size'. Adaptations were made to improve fairness, mostly in response to pressure from the healthcare workers. The significant variation in design choices across municipalities and providers' response to them highlights the importance of considering local context in the design and implementation of P4P schemes and ensuring flexibility to accommodate local preferences and emerging needs. Attention is needed to ensure that the choice of 'who is incentivized' and the 'size of incentives' are inclusive and fair and the allocation and 'use of funds' are transparent.

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了解巴西两个州的市级绩效薪酬计划的设计和调整情况。
复杂的卫生系统干预措施(如按绩效计薪)的设计对于决定此类计划的成败至关重要。在 P4P 计划中,经济激励措施的设计对这些计划如何发挥作用至关重要。然而,在某一计划中,不同提供方的计划设计通常是相同的。因此,从实施者的角度来看,对 "采购换进展 "计划设计要素优缺点的了解十分有限。本研究利用了巴西的独特背景,巴西各市对联邦激励机制的设计进行了调整,导致各市的激励机制设计各不相同。本研究旨在了解巴西各市选择某些 P4P 设计特点的原因、相关挑战以及为解决方案设计中的问题而进行的地方调整。本研究采用多案例研究设计,依靠来自巴西东北部两个州 20 个城市的定性数据。我们与市级利益相关者进行了两次关键信息访谈,并与初级保健提供者进行了焦点小组讨论。我们还审查了各市的 PMAQ 法律。我们发现,各市在 "激励对象"、"付款额度 "和 "频率 "方面的设计选择存在很大差异。设计选择影响了市政当局内部和团队内部的关系。面临的挑战主要与 "谁获得激励"、"激励什么 "和 "激励额度 "的公平性有关。为了提高公平性,主要是在医护人员的压力下进行了调整。各城市在设计方案上的巨大差异以及医疗服务提供者对这些方案的反应,都凸显了在设计和实 施 "病有所医 "计划时考虑当地情况并确保其灵活性以适应当地偏好和新需求的重要性。需要注意确保 "激励对象 "和 "激励规模 "的选择具有包容性和公平性,并确保资金的分配和 "使用 "具有透明度。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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来源期刊
Health policy and planning
Health policy and planning 医学-卫生保健
CiteScore
6.00
自引率
3.10%
发文量
98
审稿时长
6 months
期刊介绍: Health Policy and Planning publishes health policy and systems research focusing on low- and middle-income countries. Our journal provides an international forum for publishing original and high-quality research that addresses questions pertinent to policy-makers, public health researchers and practitioners. Health Policy and Planning is published 10 times a year.
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