Abstract
BackgroundExpanding 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.Methods and findingsA cohort of 1,241,351 low-income adults (observed January 2010–December 2016; total person-years 6,498,607) with linked FHS utilization and mortality records was analyzed using flexible parametric survival models. Time-to-death from all-causes and selected causes were estimated for FHS users and nonusers. Models employed inverse probability treatment weighting and regression adjustment (IPTW-RA).The cohort was 61% female (751,895) and had a mean age of 36 years (standard deviation 16.4). Only 18,721 individuals (1.5%) had higher education, whereas 102,899 (8%) had no formal education. Two thirds of individuals (827,250; 67%) were in receipt of conditional cash transfers (Bolsa Família). A total of 34,091 deaths were analyzed, of which 8,765 (26%) were due to cardiovascular disease; 5,777 (17%) were due to neoplasms; 5,683 (17%) were due to external causes; 3,152 (9%) were due to respiratory diseases; and 3,115 (9%) were due to infectious and parasitic diseases. One third of the cohort (467,155; 37.6%) used FHS services. In IPTW-RA survival analysis, an average FHS user had a 44% lower hazard of all-cause mortality (HR: 0.56, 95% CI 0.54–0.59, p < 0.001) and a 5-year risk reduction of 8.3 per 1,000 (95% CI 7.8–8.9, p < 0.001) compared with a non-FHS user. There were greater reductions in the risk of death for FHS users who were black (HR 0.50, 95% CI 0.46–0.54, p < 0.001) or pardo (HR 0.57, 95% CI 0.54–0.60, p < 0.001) compared with white (HR 0.59, 95% CI 0.56–0.63, p < 0.001); had lower educational attainment (HR 0.50, 95% CI 0.46–0.55, p < 0.001) for those with no education compared to no significant association for those with higher education (p = 0.758); or were in receipt of conditional cash transfers (Bolsa Família) (HR 0.51, 95% CI 0.49–0.54, p < 0.001) compared with nonrecipients (HR 0.63, 95% CI 0.60–0.67, p < 0.001).Key limitations in this study are potential unobserved confounding through selection into the program and linkage errors, although analytical approaches have minimized the potential for bias.ConclusionsFHS utilization in urban poor populations in Brazil was associated with a lower risk of death, with greater reductions among more deprived race/ethnic and socioeconomic groups. Increased investment in primary healthcare is likely to improve health and reduce health inequalities in urban poor populations globally.
Highlights
Strengthening primary healthcare (PHC) for urban poor populations remains a major global challenge [1]
In inverse probability treatment weighting and regression adjustment (IPTW-RA) survival analysis, an average Family Health Strategy (FHS) user had a 44% lower hazard of all-cause mortality (HR: 0.56, 95% CI 0.54–0.59, p < 0.001) and a 5-year risk
FHS utilization in urban poor populations in Brazil was associated with a lower risk of death, with greater reductions among more deprived race/ethnic and socioeconomic groups
Summary
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] These populations are often ignored by society, and access to high-quality healthcare is low [1]. Brazil has made major progress in expanding access to PHC through expansion of the internationally recognized Estratégia de Saúde da Família (Family Health Strategy [FHS]) [8], coverage has lagged substantially behind in urban poor communities living in cities including São Paulo, Salvador, and Rio de Janeiro (S1 Fig). Expanding delivery of primary healthcare to urban poor populations is a priority in many lowand 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
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