1. Family Health Program Brazil Coverage and access Aluísio J D Barros Andréa D Bertoldi Juraci Cesar Cesar G Victora Epidemiologic Research Center, UFPel Pelotas, Brazil

2. Brazil: country of inequalities Among the highest in income concentration  Gini = 60.7 Important differences across economic levels in  health  education  employment Centiles of income distribution in Brazil. Values in US dollars. Data: Sample from 2000 Census, IBGE.

3. The Brazilian “Unified Health System” Created by the 1988 Constitution Universal system  covering everyone independent of contribution  offering preventive and curative care simple and complex  decentralized at municipal level

4. Standard primary care Traditionally based on health centers Loose regional coverage Team including  a few doctors (part-time) clinician, pediatrician, gynecologist  nurses and clerical staff Low salary levels

5. Family health program - PSF Health facility with clear geographic coverage Team formed by  full-time general practitioner  registered nurse  nurse  4 community health workers Look after 1000 families (~3000 people) Competitive salary levels

6. PSF implementation Initially deployed in  areas not covered by a health center  poorest areas Next, existing health centers turned into PSF units Eventually, all primary health care to be based on PSF Ministry of Health estimate:  ~35% population covered

7. Main objectives Estimate the what proportion of the covered population is poor (focus); Estimate the percentage of the poor covered by the program (coverage); Estimate the proportion of the covered population that uses the PSF as their primary source of health care.

8. Data sources Site 1: Porto Alegre City (2003)  State capital in South Brazil  population = 1.3 million  x-sectional study with covered population Site 2: Sergipe State (1999)  Poor state in Northeast Brazil  population = 1.8 million  population-based x-sectional study

9. PSF status Porto Alegre  62 units  56 operating for more than 6 months  covered population ~ 140.000  mainly poor peripheral areas  growing fast Sergipe  69 out of 75 municipalities covered  ~ 70% population govnm’t estimate  400 units operating  runs in parallel with Community Health Worker program  PSF + PACS = 3000 CHWs

10. Methods Porto Alegre  x-sectional survey on areas covered by PSF  all ages  45 PSF units x 20 households  900 households = ~3000 individuals Sergipe  x-sectional survey in areas covered by CHW  only children < 5 yrs  30 x 6 x 22 = 3960 households  ~ 1900 with at least 1 child < 5 yrs

11. Economic classification Porto Alegre  wealth index created using 2000 Census sample variables  decile cutpoints calculated for POA  possible to classify the survey sample using the city population as reference (or state, country) Sergipe  principal components assets + schooling of head of hh’d  population divided into quintiles  variables not compatible with the national index used in POA

12. Data collection - similar structured interviews with pre-coded questionnaires interviewing at home about  financing and expenditure  utilization of health services  access to services  evaluation and opinions about PSF (POA)  morbidity, antenatal care, immunization (SE)

13. Results: Porto Alegre Study Residents of all ages in an area covered by PSF

14. Coverage of the poor ~ 19.3% of the poor in POA are covered by the PSF overall coverage ~11%

15. PSF focus* 36% of sample in Q1 = focus sample clearly poorer than the city population <5% in Q5 *Covered individuals are those living in the PSF areas.

16. PSF focus** **Covered individuals are those who actually used the PSF in the previous 6 months.

17. Health service utilization ~ 27% population sought a health service in previous 15 days Women more than men Children and elderly more than teens and adults No difference by economic level 94% succeeded in getting attention

18. Pattern of utilization motive

19. Pattern of utilization type of facility

20. Utilization of primary health care by health insurance

21. Results: PSF in Sergipe Children < 5 years-old

22. Coverage by economic level Child uses PSF for primary care

23. PSF focus Economic distribution among those who use the PSF

24. No antenatal care No antenatal care by economic level Concentration curve CI=-42.1

25. Inadequate* antenatal care Inadequate antenatal care by economic level Concentration curve CI=-18.4 *Adequate = at least 6 consultations starting in the first 3 months of pregnancy

26. Conclusions I Coverage by PSF still low, especially in Porto Alegre Access to health services is high SHS and PSF probably responsible for high access among the poor PSF focus on the poor is compatible with the implementation strategy and decreases as the program increases its coverage

27. Conclusions II Despite universal access, the rich opt out of the system Coverage by health insurance also decreases use of PSF as primary source of attention  ease of access?  higher quality in the private system?

28. Conclusions III Equality in general access is not matched by equality in coverage by programs such as antenatal care Important inequalities in the adequacy of antenatal care Two components?  lower quality of public services  public users seek less and demand less from the program

29. Policy implications Need to monitor program coverage (incidence) among different social groups through low-cost surveys Focus on how to improve  quality of services  preventive services in PSF Need to feed back information to policy makers