Delivering maternal and childcare at primary healthcare level: The role of PMAQ as a pay for performance strategy in Brazil

Abstract

Background Improving access and quality in health care is a pressing issue worldwide and pay for performance (P4P) strategies have emerged as an alternative to enhance structure, process and outcomes in health. In 2011, Brazil adopted its first P4P scheme at national level, the National Programme for Improving Primary Care Access and Quality (PMAQ). The contribution of PMAQ in achieving the Sustainable Development Goals related to maternal and childcare remains under investigated in Brazil. Objective To estimate the association of PMAQ with the provision of maternal and childcare in Brazil, controlling for socioeconomic, geographic and family health team characteristics. Method We used cross-sectional quantile regression (QR) models for two periods, corresponding to 33,368 Family Health Teams (FHTs) in the first cycle and 39,211 FHTs in the second cycle of PMAQ. FHTs were analysed using data from the Brazilian Ministry of Health (SIAB and CNES) and the Brazilian Institute for Geography and Statistics (IBGE). Results The average number of antenatal consultations per month were positively associated with PMAQ participating teams, with larger effect in the lower tail (10 th and 25 th quantiles) of the conditional distribution of the response variable. There was a positive association between PMAQ and the average number of consultations under 2 years old per month in the 10 th and 25 th quantiles, but a negative association in the upper tail (75 th and 90 th quantiles). For the average number of physician consultations for children under 1 year old per month, PMAQ participating teams were positively associated with the response variable in the lower tail, but different from the previous models, there is no clear evidence that the second cycle gives larger coefficients compared with first cycle. Conclusion PMAQ has contributed to increase the provision of care to pregnant women and children under 2 years at primary healthcare level. Teams with lower average number of antenatal or child consultations benefited the most by participating in PMAQ, which suggests that PMAQ might motivate worse performing health providers to catch up.

Performance assessment of primary health care facilities in Brazil: Concordance between web-based questionnaire and in-person interviews with health personnel

“…This choice is justified because the AE-PMAQ-AB assessment was part of PMAQ, an official program of the Brazilian government for assessing PHC facilities during the period analyzed in this study, and because its criteria, standards, and indicators reflected the technical and political proposals for PHC facilities [ 16 , 23 ]. That choice is also corroborated by the fact that PMAQ has nationwide reach and defines a "baseline" for PHC assessment in Brazil, which is confirmed by the multiple studies and assessments based on AE-PMAQ-AB data [ 14 , 24 – 27 ].…”

“…In Brazil, PHC health facility assessment processes have been carried out using different instruments, with different methodologies, geographic coverage, and assessment focus [11][12][13][14]. In general, these are cross-sectional studies aimed at professionals and/or users based on in-person interviews using structured questionnaires in paper or in digital format, installed on tablets or smartphones that upload the data, or even in the form of online self-response.…”

Pay for performance in primary care: the contribution of the Programme for Improving Access and Quality of Primary Care (PMAQ) on avoidable hospitalisations in Brazil, 2009–2018

“…Despite 9 years of implementation, PMAQ is still underevaluated in terms of its effects on endpoint outcomes. Studies relied mainly on descriptive analyses, 10 based on a subset of data on structure, access, service organisation and management indicators, generally for a specific health condition such as diabetes, 11 antenatal care, 12 cervical cancer screening, 13 user's satisfaction 14 and work processes. 15 Hospitalisation rate for ambulatory care sensitive conditions (ACSCs) have been used as an indirect indicator of the effectiveness and quality of PHC.…”