TY - JOUR T1 - 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 JF - BMJ Global Health JO - BMJ Global Health DO - 10.1136/bmjgh-2021-005429 VL - 6 IS - 7 SP - e005429 AU - Letícia Xander Russo AU - Timothy Powell-Jackson AU - Jorge Otavio Maia Barreto AU - Josephine Borghi AU - Roxanne Kovacs AU - Garibaldi Dantas Gurgel Junior AU - Luciano Bezerra Gomes AU - Juliana Sampaio AU - Helena Eri Shimizu AU - Allan Nuno Alves de Sousa AU - Adriana Falangola Benjamin Bezerra AU - Airton Tetelbom Stein AU - Everton Nunes Silva Y1 - 2021/07/01 UR - http://gh.bmj.com/content/6/7/e005429.abstract N2 - Background Evidence on the effect of pay-for-performance (P4P) schemes on provider performance is mixed in low-income and middle-income countries. Brazil introduced its first national-level P4P scheme in 2011 (PMAQ-Brazilian National Programme for Improving Primary Care Access and Quality). PMAQ is likely one of the largest P4P schemes in the world. We estimate the association between PMAQ and hospitalisations for ambulatory care sensitive conditions (ACSCs) based on a panel of 5564 municipalities.Methods We conducted a fixed effect panel data analysis over the period of 2009–2018, controlling for coverage of primary healthcare, hospital beds per 10 000 population, education, real gross domestic product per capita and population density. The outcome is the hospitalisation rate for ACSCs among people aged 64 years and under per 10 000 population. Our exposure variable is defined as the percentage of family health teams participating in PMAQ, which captures the roll-out of PMAQ over time. We also provided several sensitivity analyses, by using alternative measures of the exposure and outcome variables, and a placebo test using transport accident hospitalisations instead of ACSCs.Results The results show a negative and statistically significant association between the rollout of PMAQ and ACSC rates for all age groups. An increase in PMAQ participating of one percentage point decreased the hospitalisation rate for ACSC by 0.0356 (SE 0.0123, p=0.004) per 10 000 population (aged 0–64 years). This corresponds to a reduction of approximately 60 829 hospitalisations in 2018. The impact is stronger for children under 5 years (−0.0940, SE 0.0375, p=0.012), representing a reduction of around 11 936 hospitalisations. Our placebo test shows that the association of PMAQ on the hospitalisation rate for transport accidents is not statistically significant, as expected.Conclusion We find that PMAQ was associated with a modest reduction in hospitalisation for ACSCs.Data are available in a public, open access repository. All data are publicly available. ER -