Performance bonuses and the quality of primary health care delivered by family health teams in Brazil: A difference-in-differences analysis

Abstract

Background Pay-for-performance (P4P) programmes to incentivise health providers to improve quality of care have been widely implemented globally. Despite intuitive appeal, evidence on the effectiveness of P4P is mixed, potentially due to differences in how schemes are designed. We exploited municipality variation in the design features of Brazil’s National Programme for Improving Primary Care Access and Quality (PMAQ) to examine whether performance bonuses given to family health team workers were associated with changes in the quality of care and whether the size of bonus mattered. Methods and findings For this quasi-experimental study, we used a difference-in-differences approach combined with matching. We compared changes over time in the quality of care delivered by family health teams between (bonus) municipalities that chose to use some or all of the PMAQ money to provide performance-related bonuses to team workers with (nonbonus) municipalities that invested the funds using traditional input-based budgets. The primary outcome was the PMAQ score, a quality of care index on a scale of 0 to 100, based on several hundred indicators (ranging from 598 to 660) of health care delivery. We did one-to-one matching of bonus municipalities to nonbonus municipalities based on baseline demographic and economic characteristics. On the matched sample, we used ordinary least squares regression to estimate the association of any bonus and size of bonus with the prepost change over time (between November 2011 and October 2015) in the PMAQ score. We performed subgroup analyses with respect to the local area income of the family health team. The matched analytical sample comprised 2,346 municipalities (1,173 nonbonus municipalities; 1,173 bonus municipalities), containing 10,275 family health teams that participated in PMAQ from the outset. Bonus municipalities were associated with a 4.6 (95% CI: 2.7 to 6.4; p < 0.001) percentage point increase in the PMAQ score compared with nonbonus municipalities. The association with quality of care increased with the size of bonus: the largest bonus group saw an improvement of 8.2 percentage points (95% CI: 6.2 to 10.2; p < 0.001) compared with the control. The subgroup analysis showed that the observed improvement in performance was most pronounced in the poorest two-fifths of localities. The limitations of the study include the potential for bias from unmeasured time-varying confounding and the fact that the PMAQ score has not been validated as a measure of quality of care. Conclusions Performance bonuses to family health team workers compared with traditional input-based budgets were associated with an improvement in the quality of care.

Pay for performance in Brazilian primary health care: quality of work processes, actions and services

“…One study found a positive association between bonus payments to FHTs based on overall performance in primary health care compared to no bonus. Additionally, the magnitude of the associations increased with the amount paid to FHTs, suggesting a doseresponse relationship (Fardousi et al, 2022). Although the present study identified improved work process performance in FHTs that received PMAQ resources, this was not associated with better results when compared to those that did not.…”

“…Although the present study identified improved work process performance in FHTs that received PMAQ resources, this was not associated with better results when compared to those that did not. Our findings were based on comparisons between Cycles 2 and 3, whereas the aforementioned study (Fardousi et al, 2022) analyzed Cycles 1 and 3, which could partially explain the different results. Moreover, our focus was on work processes, whereas the other authors investigated overall performance, including process, structure and outcome indicators.…”

“…One study found a positive association between bonus payments to FHTs based on overall performance in primary health care compared to no bonus. Additionally, the magnitude of the associations increased with the amount paid to FHTs, suggesting a dose–response relationship (Fardousi et al. , 2022).…”

Pay for performance at a crossroads: lessons from taking a global perspective

“…The relatively small size of payments in HIC as compared to LMICs is worthy of note. Recent research highlights that schemes paying a higher bonus increase performance more (Fardousi et al. , 2022) Schemes in HIC may therefore see improvements with larger bonuses.…”

“…The relatively small size of payments in HIC as compared to LMICs is worthy of note. Recent research highlights that schemes paying a higher bonus increase performance more (Fardousi et al, 2022) Schemes in HIC may therefore see improvements with larger bonuses. Conversely, the same research found that providers in poorer areas increased performance even in response to relatively small incentives, suggesting that also smaller incentive sizes could lead to performance improvements in LMIC (ibid), which may increase the efficiency and financial sustainability of these schemes.…”