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

Author

Listed:
  • Nasser Fardousi
  • Everton Nunes da Silva
  • Roxanne Kovacs
  • Josephine Borghi
  • Jorge O M Barreto
  • Søren Rud Kristensen
  • Juliana Sampaio
  • Helena Eri Shimizu
  • Luciano B Gomes
  • Letícia Xander Russo
  • Garibaldi D Gurgel
  • Timothy Powell-Jackson

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

Suggested Citation

  • Nasser Fardousi & Everton Nunes da Silva & Roxanne Kovacs & Josephine Borghi & Jorge O M Barreto & Søren Rud Kristensen & Juliana Sampaio & Helena Eri Shimizu & Luciano B Gomes & Letícia Xander Russo , 2022. "Performance bonuses and the quality of primary health care delivered by family health teams in Brazil: A difference-in-differences analysis," PLOS Medicine, Public Library of Science, vol. 19(7), pages 1-19, July.
    • Handle: RePEc:plo:pmed00:1004033
    DOI: 10.1371/journal.pmed.1004033
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    References listed on IDEAS

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    2. Thomas Hone & Davide Rasella & Mauricio L Barreto & Azeem Majeed & Christopher Millett, 2017. "Association between expansion of primary healthcare and racial inequalities in mortality amenable to primary care in Brazil: A national longitudinal analysis," PLOS Medicine, Public Library of Science, vol. 14(5), pages 1-19, May.
    3. Ariella Kahn-Lang & Kevin Lang, 2020. "The Promise and Pitfalls of Differences-in-Differences: Reflections on 16 and Pregnant and Other Applications," Journal of Business & Economic Statistics, Taylor & Francis Journals, vol. 38(3), pages 613-620, July.
    4. Ogundeji, Yewande Kofoworola & Bland, John Martin & Sheldon, Trevor Andrew, 2016. "The effectiveness of payment for performance in health care: A meta-analysis and exploration of variation in outcomes," Health Policy, Elsevier, vol. 120(10), pages 1141-1150.
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