Brazil: Incentive Program for Family Health Performance Improvement (PIMESF) Implemented in Piripiri Municipality

Brazil has made significant strides in improving the organization and financing of its health system since the constitutional change establishing the right to health care in 1988. Government health financing was consolidated, the public delivery system was organized into a country-wide system (Unified Health System, or SUS), and programs such as the Basic Health Package (PAB) and Family Health Program (PSF) have shifted the focus from a hospital-heavy system to basic primary care. In 1994, the government further enhanced the provision of primary care by establishing family health teams – a doctor, a nurse, a nurse assistant, and a community health agent (and in some cases one dentist or dental assistant) – for every 800 to 1,000 families (Secretaria de Atenção à Saúde, 2006). Private health care providers are important partners in the public system and supplement public services through contracts with public funds.

In spite of these advances, however, many challenges remain in Brazil’s health care system. Relatively high levels of health spending (nearly 8 percent of GDP) and the massive scale of SUS (87 million people served by 27,000 family health teams) are not supported by adequate governance and management structures, while inefficiencies and bottlenecks limit the achievement of the system(Instituto Brasileiro de Geografia e Estatística). Furthermore, Brazil’s federal structure and the decentralized nature of the SUS make the financial flows difficult to track and monitor, thus limiting accountability. Concerns about inefficiency and poor performance, particularly in public facilities, have motivated new innovative management approaches, including a wide range P4P schemes.

In contrast to these larger, well publicized schemes, the Incentive Program for Family Health Performance Improvement (PIMESF) implemented in Piripiri municipality in the state of Piauí is representative of an initiative to implement P4P schemes in a smaller municipality targeted to primary health care. PIMESF is a unique P4P scheme that is specifically designed to improve integration of basic primary health care services by rewarding family health teams as a group. Unlike several of Brazil’s other more high-profile P4P schemes, PIMESF has received little attention from public authorities at the national or international level. The relatively small scale of the program compared to its other Brazilian counterparts partly explains this lack of visibility. Nonetheless, the commitment of public authorities to improving performance and the originality of the integrated health approach provide some valuable lessons.