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This paper employs implementation theory and the political literature on performance measurement to understand how frontline health workers know, participate and evaluate the Brazilian National Program for Improving Access and Quality of Primary Care (PMAQ, 2nd round).

This paper develops an implementation theory-driven qualitative analysis. The research is developed in the city of Goiania (Brazil): a challenging organizational context in primary care (PHC). Interviews were carried out with 25 frontliners – managers, doctors, nurses and community health workers. Data were thematically and hierarchically analysed according to theoretical concepts such as policy knowledge, policy adherence, forms of accountability, alternative logics, organizational capacity and policy feedback.

Results show the need to foster organizational capacity, knowledge, participation and policy feedback at the frontline. Successful implementation would require those adaptations to counteract policy challenges/failures or the emergence of alternative logics.

The study was conducted in only one setting, however, our sample includes different types of professionals working in units with different levels of organization capacity, located in distinct HDs, expressing well the implementation of PMAQ/P4P. Qualitative researches need to be developed for further exploring the same/other factors.

Findings can be used to improve discussions/planning and design of P4P programs in the city and State of Goias.

The majority of analysis of PMAQ are of a quantitative or results-based nature. This article focuses on politically significant and unanswered questions regarding the implementation of PMAQ.

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).

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.

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.

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.

In 2011, Brazil introduced a national pay-for-performance (P4P) scheme called the National Program for Improving Primary Health Care Access and Quality (PMAQ), rolled out over three cycles and reaching more than 5,000 municipalities and 40,000 family health teams (FHTs). There is little evidence on how the PMAQ was implemented locally and whether this variation in implementation affects performance, particularly, in terms of work process indicators. This study compared different cases of municipal-level PMAQ implementation (bonuses paid or not to FHTs) over the last two program cycles to analyze the quality of the work processes, actions and services of FHTs.

This was a cross-sectional analytical study using secondary data from an external evaluation of the Brazilian PMAQ. In total, 27,500 FHTs participated in the evaluation. They were divided into four clusters based on whether or not municipalities paid bonuses to workers during cycles 2 and 3 of the program (2013–2019). Variables regarding work processes, actions and services were classified as “Quality Assurance – QA” or “Continued Quality Improvement – CQI”, and an individual score was assigned based on the average score of each variable.

The four clusters displayed an increase in overall QA and CQI scores between the two program cycles; though this increase was small between the set of primary health care teams that received bonuses and those that did not.

This paper contributes to bridging the gap in the scientific literature for evaluative studies on the relationship between direct payment for performance to health professionals and better quality actions and services in low and middle-income countries.

Drawing on the pay-for-performance (P4P) and job satisfaction literatures through an analysis of qualitative studies published on the topic, the purpose of this study is to investigate the effect of a P4P-based system on job satisfaction and dissatisfaction among health care workers.

A meta-synthesis of the qualitative literature was conducted to investigate health care workers' opinions, perceptions and behaviors and fully understand what processes generate job satisfaction or dissatisfaction under P4P systems.

The findings suggest that P4P systems impact the job (dis-)satisfaction of health care workers based on the institutional, organizational, geographic and cultural context of reference. Specifically, job satisfaction – and thus motivation, occupational well-being and work engagement – can occur when the context is supportive, whereas job dissatisfaction – and thus work stress and pressure, burnout and work-life balance issues and distraction – is generated in the case of unsupportive contexts. Moreover, the findings suggest a virtuous/vicious circle whereby job satisfaction leads to positive performance and further fuels job satisfaction, while conversely job dissatisfaction generates worse performance, and this further worsens worker satisfaction.

There is a lack of studies comparing and analyzing current evidence on the job (dis-)satisfaction of health care workers operating in different contexts based on the reward system. This is the first research to analyze a significant number of studies with reference to the relation between P4P and job (dis-)satisfaction, which are topics in need of further study and investigation in health care settings around the world.

The research outlined in this paper highlights the importance of certain factors related to primary health care buildings’ physical environment, such as the facility size, the functional efficiency, and the health planning of public areas in the health centers to improve the architectural space of health facilities.

This study was performed using a mixed method. Data collection was carried out through observational research and descriptive analysis in six primary health care facilities in Salvador and Lauro de Freitas, Brazil.

Based on this study’s results, facility capacity, functional efficiency and space accessibility have been considered the facilities’ main problems in the investigated context. The impact of the users’ perspective on healthcare facilities was assessed for each of these three criteria to verify the results obtained. Furthermore, most of the parameters were not satisfied, as the buildings analyzed had defects in their physical environment. Therefore, it is necessary to review and pay more attention to the architecture of these cities’ primary health care units.

The present study addresses the architectural environment design in Brazil’s healthcare facilities, which still have gaps. Improving the physical space of a health center ensures that the approach used in this research also applies to other health centers in similar contexts. The awareness that space’s activities and configurations will change according to each territory examined will open up so many investigation worlds.