Family Health ProgramBrazil Coverage and access

Aluísio J D BarrosAndréa D BertoldiJuraci CesarCesar G Victora

Epidemiologic Research Center, UFPelPelotas, Brazil

Brazil: country of inequalities

Among the highest in income concentration Gini = 60.7

Important differences across economic levels in health education employment

4671188

13

29

58

126

283

0

10

20

30

40

50

60

70

80

90

100

Centiles of income distribution in Brazil. Values in US dollars.

Data: Sample from 2000 Census, IBGE.

The Brazilian “Unified Health System”

Created by the 1988 Constitution Universal system

covering everyone independent of contribution

offering preventive and curative care simple and complex

decentralized at municipal level

Standard primary care

Traditionally based on health centers Loose regional coverage Team including

a few doctors (part-time) clinician, pediatrician, gynecologist

nurses and clerical staff Low salary levels

Family health program - PSF

Health facility with clear geographic coverage

Team formed by full-time general practitioner registered nurse nurse 4 community health workers

Look after 1000 families (~3000 people) Competitive salary levels

PSF implementation

Initially deployed in areas not covered by a health center poorest areas

Next, existing health centers turned into PSF units

Eventually, all primary health care to be based on PSF

Ministry of Health estimate: ~35% population covered

Main objectives

Estimate the what proportion of the covered population is poor (focus);

Estimate the percentage of the poor covered by the program (coverage);

Estimate the proportion of the covered population that uses the PSF as their primary source of health care.

Data sources

Site 1: Porto Alegre City (2003) State capital in South Brazil population = 1.3 million x-sectional study with covered population

Site 2: Sergipe State (1999) Poor state in Northeast Brazil population = 1.8 million population-based x-sectional study

PSF status

Porto Alegre 62 units 56 operating for

more than 6 months

covered population ~ 140.000

mainly poor peripheral areas

growing fast

Sergipe 69 out of 75

municipalities covered

~ 70% population govnm’t estimate

400 units operating runs in parallel with

Community Health Worker program

PSF + PACS = 3000 CHWs

Methods

Porto Alegre x-sectional survey

on areas covered by PSF

all ages 45 PSF units x 20

households 900 households =

~3000 individuals

Sergipe x-sectional survey

in areas covered by CHW

only children < 5 yrs

30 x 6 x 22 = 3960 households

~ 1900 with at least 1 child < 5 yrs

Economic classification

Porto Alegre wealth index created

using 2000 Census sample variables

decile cutpoints calculated for POA

possible to classify the survey sample using the city population as reference (or state, country)

Sergipe principal components

assets + schooling of head of hh’d

population divided into quintiles

variables not compatible with the national index used in POA

Data collection - similar

structured interviews with pre-coded questionnaires

interviewing at home about

financing and expenditure utilization of health services access to services evaluation and opinions about PSF (POA) morbidity, antenatal care, immunization (SE)

Results: Porto Alegre Study

Residents of all ages in an area covered by PSF

Coverage of the poor

~ 19.3% of the poor in POA are covered by the PSF

overall coverage ~11%

PSF focus*

36% of sample in Q1 = focus

sample clearly poorer than the city population

<5% in Q5

Population distribution by reference quintile

0

5

10

15

20

25

30

35

40

1 2 3 4 5

Reference quintile/POA

*Covered individuals are those living in the PSF areas.

PSF focus**

Utilization of PSF in the previous 6 months

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Q1 Q2 Q3 Q4 Q5

Reference quintile/POA

**Covered individuals are those who actually used the PSF in the previous 6 months.

Health service utilization

~ 27% population sought a health service in previous 15 days

Women more than men Children and elderly more than teens

and adults No difference by economic level 94% succeeded in getting attention

Pattern of utilization type of facility

0%

20%

40%

60%

80%

100%

q1 q2 q3 q4 q5Reference quintiles/POA

other

private care /insurancehospital

health center

Utilization of primary health care by health insurance

0%

20%

40%

60%

80%

100%

1 2 3 4 5

Reference quintiles/POA

Non-insuredInsured

Results: PSF in Sergipe

Children < 5 years-old

Coverage by economic levelChild uses PSF for primary care

0

0.1

0.2

0.3

0.4

0.5

0.6

Q1 Q2 Q3 Q4 Q5 All

PSF focus

0%

5%

10%

15%

20%

25%

30%

Q1 Q2 Q3 Q4 Q5

Economic distribution among those who use the PSF

No antenatal care

0%

5%

10%

15%

20%

25%

Q1 Q2 Q3 Q4 Q5

Cum

ulat

ive

perc

ent

Cumulative percent ranked by economic status0 .2 .4 .6 .8 1

0

.2

.4

.6

.8

1

No antenatal care by economic level Concentration curve

CI=-42.1

Cum

ulat

ive

perc

ent

Cumulative percent ranked by economic status0 .2 .4 .6 .8 1

0

.2

.4

.6

.8

1

Inadequate* antenatal care

0%

10%

20%

30%

40%

50%

60%

Q1 Q2 Q3 Q4 Q5

Inadequate antenatal care by economic level

Concentration curve

CI=-18.4

*Adequate = at least 6 consultations starting in the first 3 months of pregnancy

Conclusions I

Coverage by PSF still low, especially in Porto Alegre

Access to health services is high SHS and PSF probably responsible for high

access among the poor PSF focus on the poor is compatible with

the implementation strategy and decreases as the program increases its coverage

Conclusions II

Despite universal access, the rich opt out of the system

Coverage by health insurance also decreases use of PSF as primary source of attention ease of access? higher quality in the private system?

Conclusions III

Equality in general access is not matched by equality in coverage by programs such as antenatal care

Important inequalities in the adequacy of antenatal care

Two components? lower quality of public services public users seek less and demand less

from the program

Policy implications

Need to monitor program coverage (incidence) among different social groups through low-cost surveys

Focus on how to improve quality of services preventive services in PSF

Need to feed back information to policy makers