Thomas Hone, Valeria Saraceni, Claudia Medina Coeli, Anete Trajman, Davide Rasella, Christopher Millett, Betina Durovni
Abstract
Expanding delivery of primary healthcare to urban poor populations is a priority in many low- and middle-income countries. This remains a key challenge in Brazil despite expansion of the country’s internationally recognized Family Health Strategy (FHS) over the past two decades. This study evaluates the impact of an ambitious program to rapidly expand FHS coverage in the city of Rio de Janeiro, Brazil, since 2008.
Introduction
Strengthening primary healthcare (PHC) for urban poor populations remains a major global challenge [1]. The urban poor are increasingly burdened by noncommunicable diseases from energy-dense diets and inactive lifestyles, persisting risk of infectious diseases from poor living conditions, and high levels of road traffic accidents, violence, and crime [2]. Yet these populations are often ignored by society, and access to high-quality healthcare is low [1]. Worldwide, one billion poor people live in slums, where barriers to expanding healthcare include poverty (and low ability to pay), hazardous environments, poor infrastructure, violence, and weak political representation [3]. Progress in expanding healthcare to the urban poor is further inhibited by a paucity of evidence examining which models of PHC delivery are acceptable, feasible, and effective in these settings [4] and whether PHC can address social gradients in health among urban poor populations.
Discussion
This study indicates that rapid expansion of the FHS in Rio de Janeiro was associated with substantial reductions in the risk of death in urban poor populations. Those with lower education, in BolsaFamilia–receiving households, or who were black or pardo (mixed-ethnicity) had greater relative and absolute reductions in the risk of death with evidence that the program reduced social gradients in mortality. The associated declined in mortality associated with PHC utilization was greater among those using services more frequently and over longer periods, increasing the plausibility of the findings. Furthermore, reductions in risk of death were generally greater for conditions in which PHC can exert the greater benefit through early detection, prevention, routine management, or timely referral to secondary or emergency care.
Citation: Hone T, Saraceni V, Medina Coeli C, Trajman A, Rasella D, Millett C, et al. (2020) Primary healthcare expansion and mortality in Brazil’s urban poor: A cohort analysis of 1.2 million adults. PLoS Med 17(10): e1003357.
https://doi.org/10.1371/journal.pmed.1003357’
Academic Editor: James Macinko, University of California, Los Angeles, UNITED STATES
Received: May 18, 2020; Accepted: September 11, 2020; Published: October 30, 2020
Copyright: © 2020 Hone et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: Data cannot be shared publicly because the linkage of multiple databases and extensive individual-level and household-level variables could compromise anonymity. Original raw datasets are available by contacting officials at the Secretaria Municipal de Assistência Social (Municipal Secretariat of Social Assistance [SMAS]) and the Secretaria Municipal de Saúde (Municipal Health Secretariat; SMS) in Rio de Janeiro. http://www.rio.rj.gov.br/web/smasdh http://www.rio.rj.gov.br/web/sms The study authors are committed to helping prospective researchers use the linked datasets generated for this study for future use. Please contact them for assistance with access and linkage queries (Kenneth Rochel de Camargo Jr (kanneth@uerj.br)). There are ongoing efforts for data storage in a repository. However, these are being finalized across multiple other sensitive datasets, and the authors are working to conform to the ethical and legal restrictions of the data.
Funding: This study was jointly funded by the UK's Department for International Development (DFID), the Medical Research Council (MRC), the Economic and Social Research Council (ESRC) and Wellcome Trust's Health Systems Research Initiative (HSRI). Grant Number MR/P014593/1. All co-authors were co-investigators on the grant. DB and CM were PIs. https://mrc.ukri.org/funding/browse/hsri-call-7/health-systems-research-initiative-call-7/ The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: I have read the journal's policy and the authors of this manuscript have the following competing interests: BD was Undersecretary of Health Promotion, Surveillance, and Primary Care at the Secretaria Municipal de Saúde, Rio de Janeiro when this project was conceived. VS is a Coordinator of Health Situation Analysis in the Health Surveillance Department, at the Secretaria Municipal de Saúde, Rio de Janeiro. All other authors declare they have no competiing interests.
Abbreviations: CVD, cardiovascular disease; FHS, Family Health Strategy; IPTW-RA, inverse probability treatment weighting and regression adjustment; LMIC, low- and middle-income country; PHC, primary healthcare; RD, risk difference; UHC, universal health coverage.
