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The EQUIPMAQ project has four main objectives (click on each one for more information):

1. To develop a typology of incentive designs adopted by municipalities across the country and investigate the factors underpinning these design choices

A key feature of the PMAQ scheme is the autonomy it gives to municipalities to decide how funds are used. At the start of each cycle, municipalities establish the mechanism for allocating pay-outs across teams within their municipality. In many cases this is established in municipal law. The municipalities can decide whether to distribute resources in kind (training activities, additional drugs and supplies, staff, equipment) or as bonuses to teams. Municipalities can decide whether to distribute pay-outs in relation to team performance (encouraging the best or worst performers) and if so, whether these are in relation to absolute targets or degree of improvement. They can also decide whether to adjust pay-outs to favour teams from more deprived/remote areas. As a result, from the team perspective, the way municipalities choose to disburse funds (the incentive design) is expected to shape their behaviour and performance. 

Under this objective, we are reviewing the design features adopted by each municipality to develop a typology of PMAQ incentive designs that is informed by theory and evidence from behavioural economics and psychology. We are drawing on data from two sources. The first source of data on design comes from the third round of a national external evaluation in which health managers in more than 5,500 municipaliteis were asked a set of questions on the use of PMAQ funds to incentivise family health team performance. The second source of data is a survey we designed and administered in a subsample of more than 800 municipalities, gathering similar but more in-depth information on design.

2. To investigate whether PMAQ affects inequalities in the distribution of primary care funding

We are investigating how the level of health sector funding available to family health teams has changed with the introduction of PMAQ and whether the financial incentive programme affects inequalities in the distribution of funding. We are also examining whether PMAQ funding displaces or is additional to other primary care funding. We draw on administrative data that captures monthly disbursement of federal PMAQ and non-PMAQ funds to each municipality.

3. To examine socioeconomic inequalities in the performance of family health teams following the introduction of the programme, and with respect to variations in scheme design

For this longitudinal study, we are analysing data on the quality of care delivered by family health teams participating in PMAQ over three rounds of implementation: round 1 (November 2011, to March 2013), round 2 (April 2013, to September 2015), and round 3 (October 2015, to December 2019). The main study outcome is the percentage of the maximum performance score obtainable by family health teams (the PMAQ score), based on several hundred (ranging from 598 to 914) indicators of health-care delivery. Using census data on household income of local areas, we are examining the PMAQ score by income group. We use regression analysis to examine the association between PMAQ scores and the income of each local area across implementation rounds, and an analysis of variance to assess geographical variation in PMAQ score.

4. To undertake case studies in 24 municipalities in Permbauco and Paraiba states to explore the factors shaping design choices, and the implementation of PMAQ and mechanisms of impact at the municipal and team levels

We are conducting a comparative case study of municipalities. We selected contrasting cases across pre-defined criteria (e.g. performance outcomes/level of bonus received; choice of incentive design; geographical context and socio-economic status) and conduct 10 case studies for municipalities in Pernambuco and 10 municipalities in Paraiba state.  The case studies involve a series of in-depth interviews with stakeholders at the municipality level, at the team level (sampling 3 teams per municipality), and a selection of providers from other primary care facilities and hospitals. The study team have done 15 interviews per municipality, exploring with respondents the rationale for adopting different incentive designs at municipality level and consequences of these choices. We are also examining how PMAQ affects overall levels of health sector funding and financial flows within the system, and other health system functions, such as staffing levels, governance arrangements at municipal and team levels and the procurement of drugs.