Purpose

The study compares how distinct mechanisms that connect pre-established policy objectives to professionals' practices, and the health policy implementation context influenced different approaches to frontline staff participation. The authors analysed 26 teams in six cities from two Brazilian states, during the last cycle of the National Program for Improving Access and Quality of Primary Care (PMAQ).

Design/methodology/approach

About 172 in-depth interviews were conducted with frontliners – community health workers (78), nurses (37), doctors (30) – and managers (27). Interview guides were based on key issues identified in the implementation and pay-for-performance (P4P) literature. Drawing on thematic analysis and synthesis of the literature, three types of participation mechanisms were identified: relational, motivational and incremental learning. They were analysed considering distinct contexts at the local level to understand how they influenced different forms of participation: mere adherence, result-oriented and transformative.

Findings

Administrations with stronger institutional organizational structures were able to control work processes and reduce professional discretion. However, sustained participation was more likely where there was greater integration between management and frontline health care teams. Motivation based only on financial incentives could not bring about transformative participation. This depended on the degree of professional's ideational motivation towards primary care. Finally, contexts with unfavourable working conditions tend to demotivate professionals, but incremental learning helps teams cope with these obstacles.

Originality/value

The study overcomes gaps in the literature in relation to PMAQ's implementation process. Overall, the study delves into which/how mechanisms alter frontliners participation in performance-oriented health programs.

中文翻译：

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实施巴西绩效工资计划 PMAQ 的政策机制和参与类型

目的

该研究比较了将预先制定的政策目标与专业人员的实践联系起来的不同机制，以及卫生政策实施环境如何影响一线工作人员参与的不同方法。作者分析了巴西两个州六个城市的 26 个团队在国家改善初级保健服务机会和质量计划 (PMAQ) 的最后一个周期中的情况。

设计/方法论/途径

对一线人员进行了约 172 次深度访谈，其中包括社区卫生工作者 (78)、护士 (37)、医生 (30) 和管理人员 (27)。访谈指南基于实施和按绩效付费 (P4P) 文献中确定的关键问题。根据文献的主题分析和综合，确定了三种类型的参与机制：关系型学习、动机型学习和增量学习。考虑到地方层面的不同背景，对它们进行了分析，以了解它们如何影响不同形式的参与：纯粹的遵守、以结果为导向和变革性的。

发现

拥有更强大的机构组织结构的行政部门能够控制工作流程并减少专业自由裁量权。然而，当管理层和一线医疗团队之间有更大的整合时，持续参与的可能性就更大。仅基于经济激励的动机无法带来变革性的参与。这取决于专业人员对初级保健的理念动机程度。最后，不利的工作条件往往会降低专业人员的积极性，但渐进式学习可以帮助团队应对这些障碍。

原创性/价值

该研究克服了与 PMAQ 实施过程相关的文献中的空白。总体而言，该研究深入探讨了哪些机制/如何改变一线人员参与以绩效为导向的健康计划。