Title Page Brazil’s Family Health Strategy: factors associated with program uptake and coverage expansion over 15 years (1998-2012) Monica Viegas Andrade, PhD 1,3 ; Augusto Quaresma Coelho, MD candidate 2 ; Mauro Xavier Neto, MD candidate 2 ; Lucas Resende de Carvalho, MS 1 ; Rifat Atun, FRCP 3 ; Marcia C. Castro, PhD 3* 1 Center for Development and Regional Planning, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil 2 Faculty of Medical Sciences, University of São Paulo, São Paulo, SP, Brazil 3 Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA * Corresponding author: Marcia C. Castro, Harvard T.H. Chan School of Public Health, Department of Global Health and Population, 665 Huntington Avenue, Building I, Room 1113, Boston, MA 02115 (mcastro@hsph.harvard.edu). Phone: +1-617-432-6731. 1
ABSTRACT Background Primary Health Care (PHC) is the cornerstone of strong health care systems. In Brazil, the Family Health Strategy (FHS) was created in 1994 to deliver PHC through the public health system. The FHS has been associated with many health improvements, but gaps in coverage still remain. This paper examines factors associated with the implementation and expansion of the FHS across 5,507 Brazilian municipalities from 1998 to 2012. Methods We used a longitudinal multilevel model for change considering the municipality as the unit of analysis. We considered eight domains that could potentially affect FHS coverage: economic development, health care supply, health care needs/access, private health insurance, political context, geographical isolation, regional characteristics, and population size. Data were obtained from multiple sources. Findings During the 15-year period, the national FHS coverage increased from 4·4% to 54%, with 58% of the municipalities having population coverage of 95% or more. The increase in FHS uptake and coverage was not homogenous across municipalities, and was positively associated with small population size of municipality, low population density, low coverage of private health insurance, low level of economic development, alignment of the political party of the Mayor and the Governor, and availability of healthcare supply. Interpretation Efforts to expand the FHS coverage will need to focus on increasing the availability of health personnel, on devising financial incentives mainly for small municipalities to uptake/expand the FHS, and on devising policies that encompass both private and public sectors. Funding None. 2
RESEARCH IN CONTEXT Evidence before this study We searched on PubMed for relevant articles using the “Family Health Strategy” as search term present in Title or Abstract up to May, 2016. We found 429 articles analyzing Family Health Strategy experience in Brazil; only nine were related to FHS coverage implementation and expansion. Eight of those nine studies focused on specific urban municipalities, and the remaining study was a national comparison of different data sources for FHS coverage. Combined, these studies indicated that potential barriers to the uptake and coverage expansion of the Family Health Strategy (FHS), launched in Brazil in 1994, included shortage of healthcare professionals, municipal budget constraints, lack of proper infrastructure, and availability of other healthcare providers from the private sector. No study conducted a comprehensive analysis of potential factors contributing to the uptake and expansion of the FHS over time and across all Brazilian municipalities, including an assessment of if/how these factors may change over time. Added value of this study From 1998 to 2012 population coverage of FHS increased from 4·4% to 54%, but the expansion was highly heterogeneous, suggesting two groups of municipalities (i) early adopters, mostly smaller municipalities in less developed areas that faster attained universal coverage; and (ii) laggards, mostly larger municipalities that presented a lower expansion of FHS coverage. The uptake and expansion of the FHS from years 1998 to 2012 were positively associated with small population size of a municipality, low population density, low coverage of private health insurance, low level of economic development, alignment of the political party of the Mayor and the state Governor, and the availability of healthcare staff. Regionally, the Northeast presented the faster coverage expansion independently of population size. Implications for all the available evidence Establishing a primary health care program with high coverage is the first step towards achieving universal health coverage. The Brazilian experience shows that scaling up the FHS program is feasible in a context of large socioeconomic heterogeneity, but achieving universal coverage requires designing policies according to population size and economic development. For small and poor municipalities funding mechanisms are likely to guarantee UHC. For larger and richer ones, competing sources of health care are often an obstacle, and thus policies should include mechanisms that encompass both public and private sectors. 3
INTRODUCTION Universal Health Coverage (UHC) is one of the Sustainable Development Goals (SDG). 1 Achieving UHC requires strong health systems that promote and deliver equitable and integrated services thorough primary health care (PHC). 2 Expansion of PHC is a critical first step towards UHC, 1 and it has been associated with better population health outcomes (lower infant and maternal mortality, reduction of mortality from heart and cerebrovascular diseases, reduced hospitalizations, and lower premature deaths from asthma, heart and cerebrovascular diseases, and pneumonia). 3-5 Countries that have successfully expanded PHC have achieved UHC with improved health system outcomes. 6,7 The Brazilian National Unified Health System ( Sistema Unificado de Saúde – SUS), launched in 1988, was designed as a public policy to overcome health inequities. 8 PHC is delivered by SUS through the Family Health Strategy (FHS), created in 1994 (described in the panel). The FHS has been associated with declines in infant mortality; 9 declines in avoidable hospitalizations; 10,11 better health care access and utilization; 12 and reductions in social inequalities in healthcare access. 13,14 Despite these results, two decades after the FHS inception almost 50% of the Brazilian population was not covered. Proposed reasons for this gap include shortage of professionals, municipal budget constraints, lack of proper infrastructure, and availability of private insurance. 15- 18 However, no comprehensive municipal-level analysis of factors associated with the uptake and the expansion of coverage of the FHS over time has been done. To addresses this issue we assembled a 15-year time-series of municipal data from varied sources, and used a multilevel model for change to identify factors associated with the FHS uptake and expansion across 5,419 Brazilian municipalities from 1998 to 2012. We considered eight domains that could potentially affect implementation and coverage expansion: economic development, health care supply, health care needs/access, availability of private insurance, political context, geographical isolation, regional characteristics, and population size. METHODS Data We used several sources to create a longitudinal dataset by municipality covering the years 1998 to 2012. In 1998, Brazil had 5,507 municipalities, and 58 new ones were created until 2012. We used the 1998 political division as reference, and aggregated data for the new municipalities back into the administrative unit they originated from. We excluded 88 municipalities with inconsistent mortality records. Thus, final analysis considered 5,419 municipalities (99·8% of total population). Data on the proportion of the population covered by the FHS were obtained from the Brazilian Ministry of Health. As data are available monthly, we used July (mid-year period) as the reference. Although the FHS was launched in 1994, data are available only from 1998 onwards. This is not a major limitation, as municipalities needed time to hire health professionals. By 1998, the FHS covered 4·4% of the population. 4
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