Abstract
BackgroundBrazil has experienced difficulties in attracting health professionals (especially doctors and nurses) to practice at the primary health care (PHC) level and in rural and remote areas. This study presents two case studies, each a current initiative in contracting for primary health services in Brazil: one for the state of Bahia and the other for the city of Rio de Janeiro. The two models differ considerably in context, needs, modalities, and outcomes. This article does not attempt to evaluate the initiatives but to identify their strengths and weaknesses.MethodsAnalysis was based on indicators produced by the Brazilian health care information systems, a review of literature and other documentation, and key informant interviews.ResultsIn the case of Bahia, the state and municipalities decided to create a State Foundation, a new institutional public entity acting under private law that centralizes the hiring of health professionals in order to offer stable positions with career plans and mobility within the state. Results have been mixed as a lower than expected municipal involvement resulted in relatively high administrative costs and consequent default on municipal financial contributions. In the case of Rio de Janeiro, the municipality opted to contract not-for-profit Social Organizations as it made a push to expand access to primary health care in the city. The approach has been successful in expanding coverage, but evidence on cost and performance is weak.ConclusionsBoth cases highlight that improvements in cost and performance data will be critical for meaningful comparative evaluation of delivery arrangements in primary care. Despite the different institutional and implementation arrangements of each model, which make comparison difficult, the analysis provides important lessons for contracting out health professionals for PHC within Brazil and elsewhere.Electronic supplementary materialThe online version of this article (doi:10.1186/s12960-016-0101-3) contains supplementary material, which is available to authorized users.
Highlights
Brazil has experienced difficulties in attracting health professionals to practice at the primary health care (PHC) level and in rural and remote areas
The two case studies were chosen for their importance in defining new milestones in human resource contracting for health in Brazil
The analysis provides some plausible hypothesis to explain this, as, for example, the fact that FESF was more vulnerable to changes in the political scenarios or the loss of autonomy in hiring and managing the workforce by the municipalities contracting with FESF
Summary
Brazil has experienced difficulties in attracting health professionals (especially doctors and nurses) to practice at the primary health care (PHC) level and in rural and remote areas. Ireland et al Human Resources for Health (2016) 14:6 result of policy decisions to “autonomize” providers or contract with the private sector as a means to improve the performance of service delivery. As the experience with contracting has grown, so has the associated literature Part of this literature is concerned with the conditions under which contracting the delivery of public services is likely to be effective, given the uncertainty and information asymmetry that is pervasive in the health sector [3, 4, 6, 14]. There is a growing body of evidence on specific experiences, including efforts to evaluate to what extent the performance of contracted service providers is superior to other models for delivering services (see, e.g., [10,11,12, 15, 16])
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