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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. Centiles of income distribution in Brazil. Values in US dollars. Data: Sample from 2000 Census, IBGE.

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family health program brazil coverage and access

Family Health ProgramBrazil Coverage and access

Aluísio J D Barros

Andréa D Bertoldi

Juraci Cesar

Cesar G Victora

Epidemiologic Research Center, UFPel

Pelotas, Brazil

brazil country of inequalities

Centiles of income distribution in Brazil. Values in US dollars. Data: Sample from 2000 Census, IBGE.

Brazil: country of inequalities
  • Among the highest in income concentration
    • Gini = 60.7
  • Important differences across economic levels in
    • health
    • education
    • employment
the brazilian unified health system
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
standard primary care
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
family health program psf
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
psf implementation
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
main objectives
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.
data sources
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
psf status
Porto Alegre

62 units

56 operating for more than 6 months

covered population ~ 140.000

mainly poor peripheral areas

growing fast


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

PSF status
Porto Alegre

x-sectional survey on areas covered by PSF

all ages

45 PSF units x 20 households

900 households = ~3000 individuals


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

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)


principal components

assets + schooling of head of hh’d

population divided into quintiles

variables not compatible with the national index used in POA

Economic classification
data collection similar
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)
results porto alegre study

Results: Porto Alegre Study

Residents of all ages in an area covered by PSF

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

psf focus1
PSF focus**

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

health service utilization
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
results psf in sergipe

Results: PSF in Sergipe

Children < 5 years-old

psf focus2
PSF focus

Economic distribution among those who use the PSF

no antenatal care
No antenatal care


Concentration curve

No antenatal care by economic level

inadequate antenatal care
Inadequate* antenatal care


Inadequate antenatal care by economic level

Concentration curve

*Adequate = at least 6 consultations starting in the first 3 months of pregnancy

conclusions i
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
conclusions ii
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?
conclusions iii
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
policy implications
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