Davide Rasella

Effect of a conditional cash transfer programme on childhood mortality: a nationwide analysis of Brazilian municipalities

BACKGROUND In the past 15 years, Brazil has undergone notable social and public health changes, including a large reduction in child mortality. The Bolsa Familia Programme (BFP) is a widespread conditional cash transfer programme, launched in 2003, which transfers cash to poor households (maximum income US

Impact of primary health care on mortality from heart and cerebrovascular diseases in Brazil: a nationwide analysis of longitudinal data

70 per person a month) when they comply with conditions related to health and education. Transfers range from

Reducing childhood mortality from diarrhea and lower respiratory tract infections in Brazil.

18 to

Impact of the Family Health Program on the quality of vital information and reduction of child unattended deaths in Brazil: an ecological longitudinal study

175 per month, depending on the income and composition of the family. We aimed to assess the effect of the BFP on deaths of children younger than 5 years (under-5), overall and resulting from specific causes associated with poverty: malnutrition, diarrhoea, and lower respiratory infections. METHODS The study had a mixed ecological design. It covered the period from 2004-09 and included 2853 (of 5565) municipalities with death and livebirth statistics of adequate quality. We used government sources to calculate all-cause under-5 mortality rates and under-5 mortality rates for selected causes. BFP coverage was classified as low (0·0-17·1%), intermediate (17·2-32·0%), high (>32·0%), or consolidated (>32·0% and target population coverage ≥100% for at least 4 years). We did multivariable regression analyses of panel data with fixed-effects negative binomial models, adjusted for relevant social and economic covariates, and for the effect of the largest primary health-care scheme in the country (Family Health Programme). FINDINGS Under-5 mortality rate, overall and resulting from poverty-related causes, decreased as BFP coverage increased. The rate ratios (RR) for the effect of the BFP on overall under-5 mortality rate were 0·94 (95% CI 0·92-0·96) for intermediate coverage, 0·88 (0·85-0·91) for high coverage, and 0·83 (0·79-0·88) for consolidated coverage. The effect of consolidated BFP coverage was highest on under-5 mortality resulting from malnutrition (RR 0·35; 95% CI 0·24-0·50) and diarrhoea (0·47; 0·37-0·61). INTERPRETATION A conditional cash transfer programme can greatly contribute to a decrease in childhood mortality overall, and in particular for deaths attributable to poverty-related causes such as malnutrition and diarrhoea, in a large middle-income country such as Brazil. FUNDING National Institutes of Science and Technology Programme, Ministry of Science and Technology, and Council for Scientific and Technological Development Programme (CNPq), Brazil.

Impact of income inequality on life expectancy in a highly unequal developing country: the case of Brazil

Objectives To evaluate the impact of Brazil’s recently implemented Family Health Program (FHP), the largest primary health care programme in the world, on heart and cerebrovascular disease mortality across Brazil from 2000 to 2009. Design Ecological longitudinal design, evaluating the impact of FHP using negative binomial regression models for panel data with fixed effects specifications. Setting Nationwide analysis of data from Brazilian municipalities covering the period from 2000 to 2009. Data sources 1622 Brazilian municipalities with vital statistics of adequate quality. Main outcome measures The annual FHP coverage and the average FHP coverage in previous years were used as main independent variables and classified as none (0%), incipient (<30%), intermediate (30-69%), or consolidated (≥70%). Age standardised mortality rates from causes in the group of cerebrovascular (ICD-10 codes I60-69), ischaemic (ICD-10 I20-25), and other forms of heart diseases (ICD-10 I30-52), which were included in the national list of ambulatory care-sensitive conditions, were calculated for each municipality for each year. They accounted for 40% of all deaths from these groups during the study period. Results FHP coverage was negatively associated with mortality rates from cerebrovascular and heart diseases (ambulatory care-sensitive conditions) in both unadjusted and adjusted models for demographic, social, and economic confounders. The FHP had no effect on the mortality rate for accidents, used as a control. The rate ratio for the effect of consolidated annual FHP coverage on cerebrovascular disease mortality and on heart disease mortality was 0.82 (95% confidence interval 0.79 to 0.86) and 0.79 (0.75 to 0.80) respectively, reaching the value of 0.69 (0.66 to 0.73) and 0.64 (0.59 to 0.68) when the coverage was consolidated during all the previous eight years. Moreover, FHP coverage increased the number of health education activities, domiciliary visits, and medical consultations and reduced hospitalisation rates for cerebrovascular and heart disease. Several complementary analyses showed quantitatively similar results. Conclusions Comprehensive and community based primary health care programmes, such as the FHP in Brazil, acting through cardiovascular disease prevention, care, and follow-up can contribute to decreased cardiovascular disease morbidity and mortality in a developing country such as Brazil.

Effect of the Brazilian conditional cash transfer and primary health care programs on the new case detection rate of leprosy.

OBJECTIVE: To evaluate the effects of the Family Health Program (FHP), a strategy for reorganization of primary health care in Brazil, on mortality of children younger than 5 years, particularly from diarrheal diseases and lower respiratory tract infections. METHODS: Mortality rates and the extent of FHP coverage from 2000 to 2005 was evaluated from the 2601 (of 5507) Brazilian municipalities with an adequate quality of vital information. A multivariable regression analysis for panel data was conducted by using a negative binomial model with fixed effects, adjusted for relevant demographic and socioeconomic covariates. RESULTS: A statistically significant negative association was observed between FHP coverage levels, classified as none (the reference category), low (<30%), intermediate (≥30% and <70%), or high (≥70%), and all analyzed mortality rates, with a reduction of 4% (95% confidence interval [CI]: 2%–6%), 9% (95% CI: 7%–12%), and 13% (95% CI: 10%–15%), respectively, on mortality rates or children younger than 5. The greatest effect was on postneonatal mortality. Reductions of 31% (95% CI: 20%–40%) and 19% (95% CI: 8%–28%) in mortality rates from diarrheal diseases and lower respiratory infections, respectively, were found in the group of municipalities with the highest FHP coverage. CONCLUSIONS: The FHP, one of the largest comprehensive primary health care programs in the world, was effective in reducing overall mortality of children younger than 5, and particularly deaths related to diarrheal diseases and lower respiratory tract infections.

Effectiveness of a conditional cash transfer programme on TB cure rate: a retrospective cohort study in Brazil.

BackgroundVital information, despite of being an important public health instrument for planning and evaluation, in most of the developing countries have still low quality and coverage. Brazil has recently implemented the Family Health Program (PSF), one of the largest comprehensive primary health care programs in the world, which demonstrated effectiveness on the reduction of infant mortality. In the present study we evaluate the impact of the PSF on mortality rates related to the quality of vital information: the under-five mortality rate due to ill-defined causes and unattended death.MethodsData on mortality rates and PSF coverage was obtained for the total 5,507 Brazilian municipalities from 2000 to 2006. A multivariate regression analysis of panel data was carried out with a negative binomial response by using fixed effects models that control for relevant covariates.ResultsA statistically significant negative association was observed between PSF coverage levels, classified in none (0%, the reference category), low (<30.0%), intermediate (≥ 30.0% and <70.0%) and high (≥ 70.0%), and all analysed mortalities rates, with a reduction of 17% (Rate Ratio [RR]: 0.83; 95% confidence interval [CI]: 0.79 - 0.88), 35% (RR: 0.65; 95% CI: 0.61-0.68) and 50% (RR: 0.50; 95% CI: 0.47-0.53) on under-five mortality due to ill-defined causes, respectively. In the mortality rate for unattended death the reduction was even greater, reaching 60% (RR: 0.40; 95% CI: 0.37-0.44) in the municipalities with the highest PSF coverage. The PSF effect on unattended deaths was slightly stronger in municipalities with a higher human development index.ConclusionsThe PSF, a primary health care program developed mostly in rural and deprived areas, had an important role on reducing the unattended deaths and improving the quality of vital information in Brazil.

Reduced asthma morbidity in endemic areas for helminth infections: a longitudinal ecological study in Brazil

Background Few studies have analysed the effects of income inequality on health in developing countries, particularly during economic growth, reduction of social disparities and reinforcement of the welfare and healthcare system. We evaluated the association between income inequality and life expectancy in Brazil, including the effect of social and health interventions, in the period 2000–2009. Methods A panel dataset was created for the 27 Brazilian states over the referred time period. Multivariable linear regressions were performed using fixed-effects estimation with heteroscedasticity and serial correlation robust SEs. Models were fitted for life expectancy as a dependent variable, using the Gini index or a percentile income dispersion ratio as the main independent variable, and for demographic, socioeconomic and healthcare-related determinants as covariates. Results The Gini index, as the other measure of income inequality, was negatively associated with life expectancy (p<0.05), even after adjustment for all the socioeconomic and health-related covariates. The Family Health Program, the main primary healthcare (PHC) programme of the country, was positively associated with life expectancy (p<0.05). Conclusions In recent years, effective social policies have enabled Brazil to partially reduce absolute poverty and income inequality, contributing—together with PHC—to decreasing death rates in the population. Reducing income inequality may represent an important step towards improving health and increasing life expectancy, particularly in developing countries where inequalities are high.

Impacto do Programa Água para Todos (PAT) sobre a morbi-mortalidade por diarreia em crianças do Estado da Bahia, Brasil

Background Social determinants can affect the transmission of leprosy and its progression to disease. Not much is known about the effectiveness of welfare and primary health care policies on the reduction of leprosy occurrence. The aim of this study is to evaluate the impact of the Brazilian cash transfer (Bolsa Família Program-BFP) and primary health care (Family Health Program-FHP) programs on new case detection rate of leprosy. Methodology/Principal Findings We conducted the study with a mixed ecological design, a combination of an ecological multiple-group and time-trend design in the period 2004–2011 with the Brazilian municipalities as unit of analysis. The main independent variables were the BFP and FHP coverage at the municipal level and the outcome was new case detection rate of leprosy. Leprosy new cases, BFP and FHP coverage, population and other relevant socio-demographic covariates were obtained from national databases. We used fixed-effects negative binomial models for panel data adjusted for relevant socio-demographic covariates. A total of 1,358 municipalities were included in the analysis. In the studied period, while the municipal coverage of BFP and FHP increased, the new case detection rate of leprosy decreased. Leprosy new case detection rate was significantly reduced in municipalities with consolidated BFP coverage (Risk Ratio 0.79; 95% CI  = 0.74–0.83) and significantly increased in municipalities with FHP coverage in the medium (72–95%) (Risk Ratio 1.05; 95% CI  = 1.02–1.09) and higher coverage tertiles (>95%) (Risk Ratio 1.12; 95% CI  = 1.08–1.17). Conclusions At the same time the Family Health Program had been effective in increasing the new case detection rate of leprosy in Brazil, the Bolsa Família Program was associated with a reduction of the new case detection rate of leprosy that we propose reflects a reduction in leprosy incidence.

Effect of Brazil's conditional cash transfer programme on tuberculosis incidence.

BACKGROUND Despite the efforts of the National Tuberculosis Programme, TB cure rates in Brazil are sub-optimal. The End TB Strategy for post-2015 identifies conditional cash transfer interventions as powerful tools to improve TB control indicators, including TB cure rate. This study aims to inform the new policy by evaluating the role of the Bolsa Familia Programme (BFP), one of the largest conditional cash transfer programmes in the world, on TB cure rates in Brazil. METHODS We undertook a retrospective cohort study, based on an unprecedented record linkage of socioeconomic and health data, to compare cases of patients newly diagnosed with TB in 2010 receiving BFP cash benefits (n=5788) with those who did not (n=1467) during TB treatment. We used Poisson regression with robust variance to estimate the relative risks for TB cure adjusted for known confounders. RESULTS The cure rate among patients exposed to BFP during TB treatment was 82.1% (4752/5788), 5.2% higher than among those not exposed. This was confirmed after controlling for TB type, diabetes mellitus, HIV status and other relevant clinical and socioeconomic covariates (RR=1.07, 95% CI 1.04 to 1.11 for cure rates among BFP beneficiaries). This association seemed higher for patients not under directly observed treatment (RR=1.11; 95% CI 1.05 to 1.16). CONCLUSIONS Although further research is needed, this study suggests that conditional cash transfer programmes can contribute to improve TB cure rate in Brazil.