Rosana Aquino

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 the Family Health Program on Infant Mortality in Brazilian Municipalities

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

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

18 to

Major Expansion Of Primary Care In Brazil Linked To Decline In Unnecessary Hospitalization

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.

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

OBJECTIVES We evaluated the effects of the Family Health Program (FHP), a strategy for reorganization of primary health care at a nationwide level in Brazil, on infant mortality at a municipality level. METHODS We collected data on FHP coverage and infant mortality rates for 771 of 5561 Brazilian municipalities from 1996 to 2004. We performed a multivariable regression analysis for panel data with a negative binomial response by using fixed-effects models that controlled for demographic, social, and economic variables. RESULTS We observed a statistically significant negative association between FHP coverage and infant mortality rate. After we controlled for potential confounders, the reduction in the infant mortality rate was 13.0%, 16.0%, and 22.0%, respectively for the 3 levels of FHP coverage. The effect of the FHP was greater in municipalities with a higher infant mortality rate and lower human development index at the beginning of the study period. CONCLUSIONS The FHP had an important effect on reducing the infant mortality rate in Brazilian municipalities from 1996 to 2004. The FHP may also contribute toward reducing health inequalities.

Trends in primary health care-sensitive conditions in Brazil: the role of the Family Health Program (Project ICSAP-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.

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

In 1994 Brazil launched what has since become the worlds largest community-based primary health care program. Under the Family Health Program, teams consisting of at least one physician, one nurse, a medical assistant, and four to six trained community health agents deliver most of their services at community-based clinics. They also make regular home visits and conduct neighborhood health promotion activities. This study finds that during 1999-2007, hospitalizations in Brazil for ambulatory care-sensitive chronic diseases, including cardiovascular disease, stroke, and asthma, fell at a rate that was statistically significant and almost twice the rate of decline in hospitalizations for all other causes. In municipalities with high Family Health Program enrollment, chronic disease hospitalization rates were 13 percent lower than in municipalities with low enrollment, when other factors were held constant. These results suggest that the Family Health Program has improved health system performance in Brazil by reducing the number of potentially avoidable hospitalizations.

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

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.

Principais causas de internação por condições sensíveis à atenção primária no Brasil: uma análise por faixa etária e região

BackgroundThis study describes trends in hospital admission rates for primary healthcare-sensitive conditions (PHCSC) in Brazil. ObjectivesTo evaluate the impact of increased primary healthcare availability through the implementation of the Family Health Program (FHP) on PHCSC admissions rates at the national, regional, and state-levels between 1999 and 2007. Research DesignAn ecologic panel data study was used and a fixed effects multivariate negative binomial model was used to estimate the association of PHCSC admission rate and FHP controlling for other relevant covariates. ResultsIt was shown that, at the national level, PHCSC hospital admissions declined by 24%—over 2.5 times more rapidly than the decline in hospitalizations for all other (non-PHCSC) conditions. Greater reductions in the PHCSC admission rates when compared with the non-PHCSC admission rates were also observed when the data were divided by regions and states. Regression models showed that at the state level the greater the FHP coverage, the less was the PHCSC hospital admissions even when controlling for confounding variables. ConclusionsThe results of this study have important implications for the healthcare model in countries that base their national health systems on primary healthcare. This is the first study to evaluate the association between FHP coverage and PHCSC admissions rates in all the Brazilian states over a long and relevant period for the consolidation of FHP in the country.

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

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.