family health program brazil coverage and access aluísio j d barros andréa d bertoldi juraci cesar...
Post on 01-Jan-2016
216 Views
Preview:
TRANSCRIPT
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)
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
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
top related