Contribution of primary care expansion to Sustainable Development Goal 3 for health: a microsimulation of the 15 largest cities in Brazil.

ABSTRACT

OBJECTIVES: As middle-income countries strive to achieve the Sustainable Development Goals (SDGs), it remains unclear to what degree expanding primary care coverage can help achieve those goals and reduce within-country inequalities in mortality. Our objective was to estimate the potential impact of primary care expansion on cause-specific mortality in the 15 largest Brazilian cities. DESIGN: Microsimulation model. SETTING: 15 largest cities by population size in Brazil. PARTICIPANTS: Simulated populations. INTERVENTIONS: We performed survival analysis to estimate HRs of death by cause and by demographic group, from a national administrative database linked to the Estratégia de Saúde da Família (Family Health Strategy, FHS) electronic health and death records among 1.2 million residents of Rio de Janeiro (2010-2016). We incorporated the HRs into a microsimulation to estimate the impact of changing primary care coverage in the 15 largest cities by population size in Brazil. PRIMARY AND SECONDARY OUTCOME MEASURES: Crude and age-standardised mortality by cause, infant mortality and under-5 mortality. RESULTS: Increased FHS coverage would be expected to reduce inequalities in mortality among cities (from 2.8 to 2.4 deaths per 1000 between the highest-mortality and lowest-mortality city, given a 40 percentage point increase in coverage), between welfare recipients and non-recipients (from 1.3 to 1.0 deaths per 1,000), and among race/ethnic groups (between Black and White Brazilians from 1.0 to 0.8 deaths per 1,000). Even a 40 percentage point increase in coverage, however, would be insufficient to reach SDG targets alone, as it would be expected to reduce premature mortality from non-communicable diseases by 20% (vs the target of 33%), and communicable diseases by 15% (vs 100%). CONCLUSIONS: FHS primary care coverage may be critically beneficial to reducing within-country health inequalities, but reaching SDG targets will likely require coordination between primary care and other sectors.