Primary care and multimorbidity in six Latin American and Caribbean countries.

OBJECTIVES: To describe patterns of multimorbidity in six diverse Latin American and Caribbean countries, examine its effects on primary care experiences, and assess its influence on reported overall health care assessments. METHODS: Cross-sectional data are from the Inter-American Development Bank's international primary care survey, conducted in 2013/2014, and represent the adult populations of Brazil, Colombia, El Salvador, Jamaica, Mexico and Panama. Robust Poisson regression models were used to estimate the extent to which those with multimorbidity receive adequate and appropriate primary care, have confidence in managing their health condition, and are able to afford needed medical care. RESULTS: The prevalence of multimorbidity ranged from 17.5% in Colombia to 37.3% in Jamaica. Most of the examined conditions occur along with others, with diabetes and heart disease being the two problems most associated with other conditions. The proportions of adults with high out-of-pocket payments, problems paying their medical bills, seeing multiple doctors, and being in only fair/poor health were higher among those with greater levels of multimorbidity and poorer primary care experiences. Multimorbidity and difficulties with primary care were positively associated with trouble paying for medical care and managing one's conditions. Nonetheless, adults with multimorbidity were more likely to have received lifestyle advice and to be up to date with preventive exams. CONCLUSIONS: Multimorbidity is reported frequently. Providing adequate care for the growing number of such patients is a major challenge facing most health systems, which will require considerable strengthening of primary care along with financial protection for those most in need.

Primary care and multimorbidity in six Latin American and Caribbean countries

[ABSTRACT]. Objectives. To describe patterns of multimorbidity in six diverse Latin American and Caribbean countries, examine its effects on primary care experiences, and assess its influence on reported overall health care assessments. Methods. Cross-sectional data are from the Inter-American Development Bank’s international primary care survey, conducted in 2013/2014, and represent the adult populations of Brazil, Colombia, El Salvador, Jamaica, Mexico and Panama. Robust Poisson regression models were used to estimate the extent to which those with multimorbidity receive adequate and appropriate primary care, have confidence in managing their health condition, and are able to afford needed medical care. Results. The prevalence of multimorbidity ranged from 17.5% in Colombia to 37.3% in Jamaica. Most of the examined conditions occur along with others, with diabetes and heart disease being the two problems most associated with other conditions. The proportions of adults with high out-of-pocket payments, problems paying their medical bills, seeing multiple doctors, and being in only fair/poor health were higher among those with greater levels of multimorbidity and poorer primary care experiences. Multimorbidity and difficulties with primary care were positively associated with trouble paying for medical care and managing one’s conditions. Nonetheless, adults with multimorbidity were more likely to have received lifestyle advice and to be up to date with preventive exams. Conclusions. Multimorbidity is reported frequently. Providing adequate care for the growing number of such patients is a major challenge facing most health systems, which will require considerable strengthening of primary care along with financial protection for those most in need.

[RESUMEN]. Objetivos. Describir los modelos de multimorbilidad en seis países distintos de América Latina y el Caribe, examinar sus efectos en las experiencias de atención primaria y evaluar su influencia con base en informes sobre evaluaciones generales de atención de salud. Métodos. Los datos transversales son de la encuesta internacional de atención primaria del Banco Interamericano de Desarrollo, realizada en el 2013-2014, y representan la población adulta de Brasil, Colombia, El Salvador, Jamaica, México y Panamá. Se utilizaron modelos robustos de regresión de Poisson en personas con multimorbilidad para estimar hasta qué punto reciben la atención primaria suficiente y apropiada, tienen confianza en que pueden controlar su estado de salud, y pueden costear la atención médica necesaria. Resultados. Se observó que la prevalencia de la multimorbilidad abarcaba desde 17,5% en Colombia hasta 37,3% en Jamaica. La mayoría de las afecciones examinadas se presentan acompañadas de otras, siendo la diabetes y las cardiopatías los dos problemas más asociados con otras afecciones. La proporción de adultos que afrontan pagos directos altos, problemas para pagar sus cuentas médicas, consultas con múltiples médicos y un estado de salud entre aceptable y desmejorado fue mayor en aquellos con niveles de multimorbilidad más altos y experiencias de atención primaria más deficientes. La multimorbilidad y las dificultades concernientes a la atención primaria presentaron una asociación positiva con la dificultad para costear la atención médica y controlar su estado de salud. No obstante, los adultos con multimorbilidad tenían mayores probabilidades de haber recibido asesoramiento sobre su estilo de vida y de estar al día con sus exámenes preventivos. Conclusiones. La multimorbilidad se notifica con frecuencia. Ofrecer un cuidado adecuado para el número cada vez mayor de pacientes con esas características es un reto importante al que se enfrenta la mayoría de los sistemas de salud, que necesitarán un fortalecimiento considerable de la atención primaria y de la protección financiera para atender a aquellos más necesitados.

[RESUMO]. Objetivos. Descrever os padrões de multimorbidade em seis países da América Latina e Caribe, examinar os efeitos da multimorbidade na prática de atenção primária e avaliar a influência nas avaliações relatadas pelos pacientes atendidos. Métodos. Estudo baseado em dados transversais obtidos de uma pesquisa internacional de atenção primária realizada pelo Banco Interamericano de Desenvolvimento (BID) em 2013–2014, representativos da população adulta do Brasil, Colômbia, El Salvador, Jamaica, México e Panamá. Modelos robustos de regressão de Poisson foram usados para estimar em que medida a atenção primária prestada aos pacientes com multimorbidade é adequada e oportuna, eles se sentem seguros em controlar a própria doença e podem pagar pela atenção médica necessária. Resultados. A prevalência de multimorbidade variou entre 17,5% na Colômbia e 37,3% na Jamaica. A maioria das doenças avaliadas ocorre junto com outros problemas, sendo a diabetes e a doença cardíaca mais comumente associadas a outras doenças. Os percentuais de adultos que relataram grandes desembolsos por conta própria, dificuldade para pagar as contas médicas, consultas a vários médicos distintos e estado de saúde regular/ruim foram maiores nos pacientes com maior número de doenças e experiências de atendimento piores na atenção primária. A multimorbidade e problemas com a atenção primária tiveram uma associação positiva com a dificuldade de pagar pela atenção médica e controlar a própria doença. Porém, verificou-se uma probabilidade maior de os adultos com multimorbidade receberem orientações sobre estilo de vida e manter em dia os exames preventivos. Conclusões. A multimorbidade é frequente. Proporcionar atenção adequada ao número crescente de pacientes portadores de diversas doenças é um grande desafio enfrentado pela maioria dos sistemas de saúde e requer um reforço substancial da atenção primária e proteção financeira para os mais carentes.

Primary care and multimorbidity in six Latin American and Caribbean countries / Atención primaria y multimorbilidad en seis países de América Latina y el Caribe / Atenção primária e multimorbidade em seis países da América Latina e Caribe

ABSTRACT Objectives To describe patterns of multimorbidity in six diverse Latin American and Caribbean countries, examine its effects on primary care experiences, and assess its influence on reported overall health care assessments. Methods Cross-sectional data are from the Inter-American Development Bank's international primary care survey, conducted in 2013/2014, and represent the adult populations of Brazil, Colombia, El Salvador, Jamaica, Mexico and Panama. Robust Poisson regression models were used to estimate the extent to which those with multimorbidity receive adequate and appropriate primary care, have confidence in managing their health condition, and are able to afford needed medical care. Results The prevalence of multimorbidity ranged from 17.5% in Colombia to 37.3% in Jamaica. Most of the examined conditions occur along with others, with diabetes and heart disease being the two problems most associated with other conditions. The proportions of adults with high out-of-pocket payments, problems paying their medical bills, seeing multiple doctors, and being in only fair/poor health were higher among those with greater levels of multimorbidity and poorer primary care experiences. Multimorbidity and difficulties with primary care were positively associated with trouble paying for medical care and managing one's conditions. Nonetheless, adults with multimorbidity were more likely to have received lifestyle advice and to be up to date with preventive exams. Conclusions Multimorbidity is reported frequently. Providing adequate care for the growing number of such patients is a major challenge facing most health systems, which will require considerable strengthening of primary care along with financial protection for those most in need.

RESUMEN Objetivos Describir los modelos de multimorbilidad en seis países distintos de América Latina y el Caribe, examinar sus efectos en las experiencias de atención primaria y evaluar su influencia con base en informes sobre evaluaciones generales de atención de salud. Métodos Los datos transversales son de la encuesta internacional de atención primaria del Banco Interamericano de Desarrollo, realizada en el 2013-2014, y representan la población adulta de Brasil, Colombia, El Salvador, Jamaica, México y Panamá. Se utilizaron modelos robustos de regresión de Poisson en personas con multimorbilidad para estimar hasta qué punto reciben la atención primaria suficiente y apropiada, tienen confianza en que pueden controlar su estado de salud, y pueden costear la atención médica necesaria. Resultados Se observó que la prevalencia de la multimorbilidad abarcaba desde 17,5% en Colombia hasta 37,3% en Jamaica. La mayoría de las afecciones examinadas se presentan acompañadas de otras, siendo la diabetes y las cardiopatías los dos problemas más asociados con otras afecciones. La proporción de adultos que afrontan pagos directos altos, problemas para pagar sus cuentas médicas, consultas con múltiples médicos y un estado de salud entre aceptable y desmejorado fue mayor en aquellos con niveles de multimorbilidad más altos y experiencias de atención primaria más deficientes. La multimorbilidad y las dificultades concernientes a la atención primaria presentaron una asociación positiva con la dificultad para costear la atención médica y controlar su estado de salud. No obstante, los adultos con multimorbilidad tenían mayores probabilidades de haber recibido asesoramiento sobre su estilo de vida y de estar al día con sus exámenes preventivos. Conclusiones La multimorbilidad se notifica con frecuencia. Ofrecer un cuidado adecuado para el número cada vez mayor de pacientes con esas características es un reto importante al que se enfrenta la mayoría de los sistemas de salud, que necesitarán un fortalecimiento considerable de la atención primaria y de la protección financiera para atender a aquellos más necesitados.

RESUMO Objetivos Descrever os padrões de multimorbidade em seis países da América Latina e Caribe, examinar os efeitos da multimorbidade na prática de atenção primária e avaliar a influência nas avaliações relatadas pelos pacientes atendidos. Métodos Estudo baseado em dados transversais obtidos de uma pesquisa internacional de atenção primária realizada pelo Banco Interamericano de Desenvolvimento (BID) em 2013-2014, representativos da população adulta do Brasil, Colômbia, El Salvador, Jamaica, México e Panamá. Modelos robustos de regressão de Poisson foram usados para estimar em que medida a atenção primária prestada aos pacientes com multimorbidade é adequada e oportuna, eles se sentem seguros em controlar a própria doença e podem pagar pela atenção médica necessária. Resultados A prevalência de multimorbidade variou entre 17,5% na Colômbia e 37,3% na Jamaica. A maioria das doenças avaliadas ocorre junto com outros problemas, sendo a diabetes e a doença cardíaca mais comumente associadas a outras doenças. Os percentuais de adultos que relataram grandes desembolsos por conta própria, dificuldade para pagar as contas médicas, consultas a vários médicos distintos e estado de saúde regular/ruim foram maiores nos pacientes com maior número de doenças e experiências de atendimento piores na atenção primária. A multimorbidade e problemas com a atenção primária tiveram uma associação positiva com a dificuldade de pagar pela atenção médica e controlar a própria doença. Porém, verificou-se uma probabilidade maior de os adultos com multimorbidade receberem orientações sobre estilo de vida e manter em dia os exames preventivos. Conclusões A multimorbidade é frequente. Proporcionar atenção adequada ao número crescente de pacientes portadores de diversas doenças é um grande desafio enfrentado pela maioria dos sistemas de saúde e requer um reforço substancial da atenção primária e proteção financeira para os mais carentes.

Understanding public perception of the need for major change in Latin American healthcare systems.

The opinions and experiences of the public regarding health services are valuable insights into identifying opportunities to improve healthcare systems. We analyzed the 2012-2013 Public Opinion Health Policy Survey carried out in Brazil (n = 1486), Colombia (n = 1485), El Salvador (n = 1460), Jamaica (n = 1480), México (n = 1492) and Panama (n = 1475). In these countries between 82 and 96% of participants perceived that their health systems needed fundamental changes. The most frequent barrier to access to healthcare was lack of the primary medical home, difficulties in obtaining medical care during the weekends and financial barriers. Type of health insurance and challenges in obtaining medical care during the weekends were associated with an increased opinion for the need for fundamental changes in healthcare systems, whereas having a primary medical home showed a protective effect. Focusing on tackling organizational and financial barriers and ensuring access to a primary medical home should be placed on the agenda of Latin American countries.

Gaps In Primary Care And Health System Performance In Six Latin American And Caribbean Countries.

The rapid demographic and epidemiological transitions occurring in Latin America and the Caribbean have led to high levels of noncommunicable diseases in the region. In addition to reduced risk factors for chronic conditions, a strong health system for managing chronic conditions is vital. This study assessed the extent to which populations in six Latin American and Caribbean countries receive high-quality primary care, and it examined the relationship between experiences with care and perceptions of health system performance. We applied a validated survey on access, use, and satisfaction with health care services to nationally representative samples of the populations of Brazil, Colombia, El Salvador, Jamaica, Mexico, and Panama. Respondents reported considerable gaps in the ways in which primary care is organized, financed, and delivered. Nearly half reported using the emergency department for a condition they considered treatable in a primary care setting. Reports of more primary care problems were associated with worse perceptions of health system performance and quality and less receipt of preventive care. Urgent attention to primary care performance is required as the region's population continues to age at an unprecedented rate.

Attributes of patient-centered primary care associated with the public perception of good healthcare quality in Brazil, Colombia, Mexico and El Salvador.

This study evaluated primary care attributes of patient-centered care associated with the public perception of good quality in Brazil, Colombia, Mexico and El Salvador. We conducted a secondary data analysis of a Latin American survey on public perceptions and experiences with healthcare systems. The primary care attributes examined were access, coordination, provider-patient communication, provision of health-related information and emotional support. A double-weighted multiple Poisson regression with robust variance model was performed. The study included between 1500 and 1503 adults in each country. The results identified four significant gaps in the provision of primary care: not all respondents had a regular place of care or a regular primary care doctor (Brazil 35.7%, Colombia 28.4%, Mexico 22% and El Salvador 45.4%). The communication with the primary care clinic was difficult (Brazil 44.2%, Colombia 41.3%, Mexico 45.1% and El Salvador 56.7%). There was a lack of coordination of care (Brazil 78.4%, Colombia 52.3%, Mexico 48% and El Salvador 55.9%). Also, there was a lack of information about healthy diet (Brazil 21.7%, Colombia 32.9%, Mexico 16.9% and El Salvador 20.8%). The public's perception of good quality was variable (Brazil 67%, Colombia 71.1%, Mexico 79.6% and El Salvador 79.5%). The primary care attributes associated with the perception of good quality were a primary care provider 'who knows relevant information about a patient's medical history', 'solves most of the health problems', 'spends enough time with the patient', 'coordinates healthcare' and a 'primary care clinic that is easy to communicate with'. In conclusion, the public has a positive perception of the quality of primary care, although it has unfulfilled expectations; further efforts are necessary to improve the provision of patient-centered primary care services in these four Latin American countries.

Population experiences of primary care in 11 Organization for Economic Cooperation and Development countries.

OBJECTIVE: To develop a measure of individual user assessments of primary care and test its association with health system performance and quality indicators. DESIGN: Cross-sectional analysis of secondary survey data collected in 2013. SETTING: Australia, Canada, France, Germany, Netherlands, New Zealand, Norway, Sweden, Switzerland, the UK and the USA. STUDY PARTICIPANTS: 20 045 respondents. MAIN OUTCOME MEASURES: Individual report of financial protection (out of pocket expenses over USD 1000), lack of receipt of appropriate/timely care (use of the emergency room in the past 2 years, having consulted three of more doctors in the past year) and clinical prevention (blood pressure check in past year, cholesterol checked in the past 5 years, receipt of influenza vaccination in past year and report of any medical error). METHODS: A score of users' primary care experiences was constructed from 14 individual survey questions. Multivariable Poisson and augmented inverse-probability weighted regression assess the relationship between the primary care experience score and outcomes. RESULTS: Countries differed regarding the proportion of the population experiencing problems with primary care. In analyses controlling for age, sex, health status, chronic disease, income level and health insurance, users experiencing poorer primary care were significantly more likely to report significant out of pocket expenses, emergency room use in the past 2 years, having consulted more than three doctors in the past year, lower likelihood of blood pressure or cholesterol screening, an annual flu shot and higher reports of medical error. CONCLUSIONS: The measure of individual primary care experience can be used to differentiate among different country's primary care approaches and is strongly associated with overall health system performance and quality indicators.

The combined effects of the expansion of primary health care and conditional cash transfers on infant mortality in Brazil, 1998-2010.

OBJECTIVES: I examined the combined effects of access to primary care through the Family Health Program (FHP) and conditional cash transfers from the Bolsa Familia Program (BFP) on postneonatal infant mortality (PNIM) in Brazil. METHODS: I employed longitudinal ecological analysis using panel data from 4583 Brazilian municipalities from 1998 to 2010, totaling 54 253 observations. I estimated fixed-effects ordinary least squares regressions models with PNIM rate as the dependent variable and FHP, BFP, and their interactions as the main independent variables of interest. RESULTS: The association of higher FHP coverage with lower PNIM became stronger as BFP coverage increased. At the means of all other variables, when BFP coverage was 25%, predicted PNIM was 5.24 (95% confidence interval [CI] = 4.95, 5.53) for FHP coverage = 0% and 3.54 (95% CI = 2.77, 4.31) for FHP coverage = 100%. When BFP coverage was 60%, predicted PNIM was 4.65 (95% CI = 4.36, 4.94) when FHP coverage = 0% and 1.38 (95% CI = 0.88, 1.89) when FHP coverage = 100%. CONCLUSIONS: The effect of the FHP depends on the expansion of the BFP. For impoverished, underserved populations, combining supply- and demand-side interventions may be necessary to improve health outcomes.

[The combined effects of the expansion of primary health care and conditional cash transfers on infant mortality in Brazil, 1998-2010]. / Efectos combinados de la ampliación de la atención primaria de salud y de las transferencias condicionadas de dinero en efectivo sobre la mortalidad infantil en Brasil, 1998-2010.

OBJECTIVES: I examined the combined effects of access to primary care through the Family Health Program (FHP) and conditional cash transfers from the Bolsa Familia Program (BFP) on postneonatal infant mortality (PNIM) in Brazil. METHODS: I employed longitudinal ecological analysis using panel data from 4 583 Brazilian municipalities from 1998 to 2010, totaling 54 253 observations. I estimated fixed-effects ordinary least squares regressions models with PNIM rate as the dependent variable and FHP, BFP, and their interactions as the main independent variables of interest. RESULTS: The association of higher FHP coverage with lower PNIM became stronger as BFP coverage increased. At the means of all other variables, when BFP coverage was 25%, predicted PNIM was 5.24 (95% confidence interval [CI] = 4.95, 5.53) for FHP coverage = 0% and 3.54 (95% CI = 2.77, 4.31) for FHP coverage = 100%. When BFP coverage was 60%, predicted PNIM was 4.65 (95% CI = 4.36, 4.94) when FHP coverage = 0% and 1.38 (95% CI = 0.88, 1.89) when FHP coverage = 100%. CONCLUSIONS: The effect of the FHP depends on the expansion of the BFP. For impoverished, underserved populations, combining supply- and demand-side interventions may be necessary to improve health outcomes.

Efectos combinados de la ampliación de la atención primaria de salud y de las transferencias condicionadas de dinero en efectivo sobre la mortalidad infantil en Brasil, 1998 - 2010 / The combined effects of the expansion of primary health care and conditional cash transfers on infant mortality in Brazil, 1998 - 2010

OBJETIVOS: Examiné los efectos combinados del acceso a la atención primaria mediante el Programa de Salud Familiar (PSF) y las transferencias condicionadas de dinero en efectivo del Programa Bolsa Familia (PBF) sobre la mortalidad infantil posneonatal (MIPN) en Brasil. MÉTODOS: Empleé un análisis ecológico longitudinal usando datos en panel de 4 583 municipios brasileños de 1998 al 2010, con 54 253 observaciones en total. Estimé modelos de regresión de efectos fijos por mínimos cuadrados ordinarios, con la tasa de MIPN como la variable dependiente y el PSF, el PBF y sus interacciones como las principales variables independientes de interés. RESULTADOS: La asociación de una mayor cobertura del PSF con una menor tasa de MIPN se volvió más fuerte conforme aumentaba la cobertura del PBF. En los promedios de todas las demás variables, cuando la cobertura de PBF era 25%, la MIPN predicha fue 5,24 (intervalo de confianza [IC] de 95% = 4,95, 5,53) para una cobertura del PSF de 0%, y de 3,54 (IC de 95% = 2,77, 4,31) para una cobertura del PSF de 100%. Cuando la cobertura del PBF era de 60%, la MIPN predicha fue 4,65 (IC de 95% = 4,36, 4,94) para una cobertura del PSF de 0%, y de 1,38 (IC de 95% = 0,88, 1,89) para una cobertura del PSF de 100%. CONCLUSIONES: El efecto del PSF depende de la ampliación del PBF. Para las poblaciones empobrecidas y subatendidas, la combinación de intervenciones tanto del lado de la oferta como del lado de la demanda podría ser necesaria para mejorar los resultados en salud.

OBJECTIVES: I examined the combined effects of access to primary care through the Family Health Program (FHP) and conditional cash transfers from the Bolsa Familia Program (BFP) on postneonatal infant mortality (PNIM) in Brazil. METHODS: I employed longitudinal ecological analysis using panel data from 4 583 Brazilian municipalities from 1998 to 2010, totaling 54 253 observations. I estimated fixed-effects ordinary least squares regressions models with PNIM rate as the dependent variable and FHP, BFP, and their interactions as the main independent variables of interest. RESULTS: The association of higher FHP coverage with lower PNIM became stronger as BFP coverage increased. At the means of all other variables, when BFP coverage was 25%, predicted PNIM was 5.24 (95% confidence interval [CI] = 4.95, 5.53) for FHP coverage = 0% and 3.54 (95% CI = 2.77, 4.31) for FHP coverage = 100%. When BFP coverage was 60%, predicted PNIM was 4.65 (95% CI = 4.36, 4.94) when FHP coverage = 0% and 1.38 (95% CI = 0.88, 1.89) when FHP coverage = 100%. CONCLUSIONS: The effect of the FHP depends on the expansion of the BFP. For impoverished, underserved populations, combining supply- and demand-side interventions may be necessary to improve health outcomes.

Municipal-level covariates of health status in Brazil: a proposed method for data interpolation.

OBJECTIVE: To propose a method for the interpolation of yearly local-level covariates of health status that is suitable for panel data analysis of the effect of health services. METHODS: The proposed method distributes the yearly rate of growth of covariates at the regional level (e.g., state) from household survey data, and applies it to interpolate yearly data at the local level (e.g., municipality) between two consecutive census surveys. The method was applied to municipal-level socioeconomic covariates of health status in Brazil for every year between 2001 and 2009. The data was tested on a previously validated analysis of the effects of the Family Health Program on post-neonatal infant mortality in Brazil. RESULTS: A total of 895 628 values were generated for 20 socioeconomic predictors of health status. Valid data were obtained for 5 057 municipalities in the Northeast, Southeast, South, and Center-West regions of Brazil, from 2001 to 2009, covering 98.89% of the municipalities in these regions and 90.87% of municipalities in the country. A supplemental annex includes the interpolated data from 2001 to 2009, plus the 2000 and 2010 census data, for all 5 057 municipalities. An application on a fixed-effect regression model suggested that, compared to linear interpolation, the proposed method reduced multi-collinearity and improved the precision of the estimates of the effects of health services. CONCLUSIONS: The advantages of the proposed interpolation method suggest that it is a feasible solution for panel data analysis of health services at the local level in Brazil and other countries.

The combined effects of the expansion of primary health care and conditional cash transfers on infant mortality in Brazil, 1998-2010.

OBJECTIVES: I examined the combined effects of access to primary care through the Family Health Program (FHP) and conditional cash transfers from the Bolsa Familia Program (BFP) on postneonatal infant mortality (PNIM) in Brazil. METHODS: I employed longitudinal ecological analysis using panel data from 4583 Brazilian municipalities from 1998 to 2010, totaling 54,253 observations. I estimated fixed-effects ordinary least squares regressions models with PNIM rate as the dependent variable and FHP, BFP, and their interactions as the main independent variables of interest. RESULTS: The association of higher FHP coverage with lower PNIM became stronger as BFP coverage increased. At the means of all other variables, when BFP coverage was 25%, predicted PNIM was 5.24 (95% confidence interval [CI] = 4.95, 5.53) for FHP coverage = 0% and 3.54 (95% CI = 2.77, 4.31) for FHP coverage = 100%. When BFP coverage was 60%, predicted PNIM was 4.65 (95% CI = 4.36, 4.94) when FHP coverage = 0% and 1.38 (95% CI = 0.88, 1.89) when FHP coverage = 100%. CONCLUSIONS: The effect of the FHP depends on the expansion of the BFP. For impoverished, underserved populations, combining supply- and demand-side interventions may be necessary to improve health outcomes.

Municipal-level covariates of health status in Brazil: a proposed method for data interpolation / Covariables a escala municipal del estado de salud en el Brasil: propuesta de un método para la interpolación de datos

OBJECTIVE: To propose a method for the interpolation of yearly local-level covariates of health status that is suitable for panel data analysis of the effect of health services. METHODS: The proposed method distributes the yearly rate of growth of covariates at the regional level (e.g., state) from household survey data, and applies it to interpolate yearly data at the local level (e.g., municipality) between two consecutive census surveys. The method was applied to municipal-level socioeconomic covariates of health status in Brazil for every year between 2001 and 2009. The data was tested on a previously validated analysis of the effects of the Family Health Program on post-neonatal infant mortality in Brazil. RESULTS: A total of 895 628 values were generated for 20 socioeconomic predictors of health status. Valid data were obtained for 5 057 municipalities in the Northeast, Southeast, South, and Center-West regions of Brazil, from 2001 to 2009, covering 98.89% of the municipalities in these regions and 90.87% of municipalities in the country. A supplemental annex includes the interpolated data from 2001 to 2009, plus the 2000 and 2010 census data, for all 5 057 municipalities. An application on a fixed-effect regression model suggested that, compared to linear interpolation, the proposed method reduced multi-collinearity and improved the precision of the estimates of the effects of health services. CONCLUSIONS: The advantages of the proposed interpolation method suggest that it is a feasible solution for panel data analysis of health services at the local level in Brazil and other countries.

OBJETIVO: Proponer un método para la interpolación de las covariables locales anuales del estado de salud que sea apropiado para el análisis de datos longitudinales del efecto de los servicios de salud. MÉTODOS: El método propuesto, a partir de los datos de las encuestas llevadas a cabo en los hogares, distribuye la tasa anual de crecimiento de las covariables a escala regional (por ejemplo, un estado) y la utiliza para interpolar los datos anuales a escala local (por ejemplo, un municipio) entre dos encuestas censales consecutivas. El método se aplicó a las covariables socioeconómicas a escala municipal del estado de salud en el Brasil para cada año de los comprendidos entre el 2001 y el 2009. Los datos se sometieron a prueba mediante un análisis previamente validado de los efectos del Programa de Salud Familiar sobre la mortalidad posneonatal en lactantes del Brasil. RESULTADOS: Se generaron un total de 895 628 valores correspondientes a 20 factores predictivos socioeconómicos del estado de salud. Se obtuvieron datos válidos de 5 057 municipios de las regiones del nordeste, sudeste, sur y centro-oeste del Brasil, del 2001 al 2009, que comprendían el 98,89% de los municipios de estas regiones y el 90,87% de los municipios del país. Un anexo suplementario incluye los datos interpolados del 2001 al 2009, y los datos de los censos del 2000 y del 2010 correspondientes a los 5 057 municipios. La aplicación de un modelo de regresión de efectos fijos indicó que, en comparación con la interpolación lineal, el método propuesto redujo la multicolinealidad y mejoró la precisión de los cálculos de los efectos de los servicios de salud. CONCLUSIONES: Las ventajas del método de interpolación propuesto indican que cons- tituye una solución factible para el análisis de datos longitudinales de los servicios de salud a escala local en el Brasil y en otros países.

The influence of primary care and hospital supply on ambulatory care-sensitive hospitalizations among adults in Brazil, 1999-2007.

OBJECTIVES: We assessed the influence of changes in primary care and hospital supply on rates of ambulatory care-sensitive (ACS) hospitalizations among adults in Brazil. METHODS: We aggregated data on nearly 60 million public sector hospitalizations between 1999 and 2007 to Brazil's 558 microregions. We modeled adult ACS hospitalization rates as a function of area-level socioeconomic factors, health services supply, Family Health Program (FHP) availability, and health needs by using dynamic panel estimation techniques to control for endogenous explanatory variables. RESULTS: The ACS hospitalization rates declined by more than 5% annually. When we controlled for other factors, FHP availability was associated with lower ACS hospitalization rates, whereas private or nonprofit hospital beds were associated with higher rates. Areas with highest predicted ACS hospitalization rates were those with the highest private or nonprofit hospital bed supply and with low (< 25%) FHP coverage. The lowest predicted rates were seen for areas with high (> 75%) FHP coverage and very few private or nonprofit hospital beds. CONCLUSIONS: These results highlight the contribution of the FHP to improved health system performance and reflect the complexity of the health reform processes under way in Brazil.

Health equity in Brazil

Article published on 29 November, 2010, at the British Medical Journal - BMJ that considers progress and continued challenges towards health equity in Brazil, including information about the gradients in health status and access to health services.

The health effects of decentralizing primary care in Brazil.

A renewed focus on primary health care could lead to improved health outcomes in developing countries. Moving more control to local authorities, or decentralization, is one approach to expanding primary care's reach. Proponents argue that it increases responsiveness to local needs and helps local resources reach those in need. Critics argue that it might increase fragmentation and disparities and provide opportunities for local economic and political gains that do not improve population health. We explore questions surrounding decentralization using the example of infant mortality in Brazil. Our study of two programs identified positive effects on health outcomes in the context of infant mortality.

Going to scale with community-based primary care: an analysis of the family health program and infant mortality in Brazil, 1999-2004.

This article assesses the effects of an integrated community-based primary care program (Brazil's Family Health Program, known as the PSF) on microregional variations in infant mortality (IMR), neonatal mortality, and post-neonatal mortality rates from 1999 to 2004. The study utilized a pooled cross-sectional ecological analysis using panel data from Brazilian microregions, and controlled for measures of physicians and hospital beds per 1000 population, Hepatitis B coverage, the proportion of women without prenatal care and with no formal education, low birth weight births, population size, and poverty rates. The data covered all the 557 Brazilian microregions over a 6-year period (1999-2004). Results show that IMR declined about 13 percent from 1999 to 2004, while Family Health Program coverage increased from an average of about 14 to nearly 60 percent. Controlling for other health determinants, a 10 percent increase in Family Health Program coverage was associated with a 0.45 percent decrease in IMR, a 0.6 percent decline in post-neonatal mortality, and a 1 percent decline in diarrhea mortality (p<0.05). PSF program coverage was not associated with neonatal mortality rates. Lessons learned from the Brazilian experience may be helpful as other countries consider adopting community-based primary care approaches.