Fardousi Nasser, Dantas Gurgel Junior Garibaldi, Shimizu Helena, Silene de Brito E Silva Keila, Da Silva Everton, Dos Santos Mariana Olivia Santana, Falangola Benjamin Bezerra Adriana, Gomes Luciano, Powell-Jackson Timothy, Sampaio Juliana, Borghi Josephine
Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London WC1H 9SH, UK.
Oswaldo Cruz Foundation-Fiocruz, Pernambuco 50740-465, Brazil.
Health Policy Plan. 2024 Aug 8;39(7):661-673. doi: 10.1093/heapol/czae033.
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.
复杂卫生系统干预措施的设计，如按绩效付费（P4P），对于确定此类项目的成功与否至关重要。在P4P项目中，经济激励措施的设计对于塑造这些项目的运作方式至关重要。然而，在给定的方案中，此类计划的设计通常在各提供者之间是同质化的。因此，从实施者的角度来看，对P4P设计要素的优缺点了解有限。本研究利用了巴西的独特背景，在巴西，各市对联邦激励设计进行了调整，导致各市在激励设计上存在差异。该研究旨在了解巴西各市为何选择某些P4P设计特征、相关挑战以及为解决方案设计中的问题而进行的本地调整。本研究采用多案例研究设计，依赖于来自巴西东北部两个州的20个市的定性数据。我们对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。我们还审查了每个市的市级初级保健可及性和质量法律。我们发现，各市在“激励对象”、“支付规模”和“频率”的设计选择上存在很大差异。设计选择影响了市内和团队内部的关系。挑战主要与“谁获得激励”、“激励内容”和“激励规模”的公平性有关。为了提高公平性进行了调整，主要是应对医护人员的压力。各市之间设计选择的显著差异以及提供者对这些选择的反应凸显了在P4P方案的设计和实施中考虑当地情况并确保灵活性以适应当地偏好和新出现需求的重要性。需要注意确保“激励对象”的选择和“激励规模”具有包容性和公平性，以及资金的分配和“使用”是透明的。
