Primary Care Coverage Research Articles

Pay-for-performance and dental procedures: A longitudinal analysis of the Brazilian Program for the Improvement of Access and Quality of Dental Specialities Centres.

Evaluate the impact of a pay-for-performance program on changes in the number of dental procedures performed by public secondary dental care services in Brazil. A longitudinal study was carried out with 932 public Dental Specialities Centres (Centro de Especialidades Odontológicas - CEO) that participated in the pay-for-performance Program for the Improvement of Access and Quality of Dental Specialities Centres Services (PMAQ/CEO) and 379 non-CEO centres with secondary dental production. The non-CEO and a group of CEOs did not receive financial incentives from the PMAQ-CEO and served as control groups. Three CEOs groups received additional financial incentives of 20%, 60% or 100% over maintenance values, based on their performance scores. The outcome was the increase (yes/no) in the number of dental procedures between 2011/2013 and 2015/2017. Analyses were carried out using logistic regressions. The number of specialized procedures increased in 48.4% of the services, 44.6% among non-CEO, 52.3% among CEO with no financial incentive and 59.1% among CEO with 100% incentive. The fully adjusted model showed that CEOs receiving 100% of the financial incentive had greater odds of increasing the production of dental procedures (OR=1.65, 95%CI: 1.09-2.51). Services that increased the number of specialist dentists had (OR=2.35, 95%CI 1.88-2.94). Municipalities that increased in coverage of private dental insurance had OR=0.98 (95%CI: 0.94-1.02), and those with higher coverage of primary dental care had OR=1.02 (95%CI: 0.99-1.05). Pay-for-performance may increase the production of dental procedures by CEOs, and mechanisms explaining it must be further investigated.

Monitoring inequalities is a key part of the efforts to end AIDS, tuberculosis, and malaria

HIV/AIDS, tuberculosis, and malaria kill more than 2 million people every year1–3 and cause a disproportionate burden on the world's most disadvantaged people. WHO recognises the urgency of tackling inequities and redoubling efforts to prevent and control these diseases during the COVID-19 pandemic and looking ahead to post-pandemic recovery. The uneven progress to date in addressing inequalities in HIV/AIDS, tuberculosis, and malaria is a complex issue and requires strengthening of people-centred primary health care and universal health coverage, as well as multisectoral actions on the social determinants of health.

Primary care coverage and individual health: evidence from a likelihood\xa0model using biomarkers in Brazil

BackgroundAlthough the use of biomarkers to assess health outcomes has recently gained momentum, literature is still scarce for low- to middle-income countries. This paper explores the relationship between primary care coverage and individual health in Brazil using a dataset of blood-based biomarkers collected by the Brazilian National Health Survey. Both survey data and laboratory results were crossed with coverage data from the Family Health Strategy (ESF) program, the most important primary care program in Brazil; the coverage measures aim to capture both direct (household) and indirect (spill-over) effects.MethodsThe empirical strategy used a probit model to estimate the relationship between ESF program coverage and the likelihood of abnormal biomarker levels while controlling for a rich set of individual and household characteristics based on data from the national survey.ResultsHousehold ESF coverage was associated with a lower likelihood of abnormal results for biomarkers related to anemia (marginal effect between − 2.16 and − 2.18 percentage points), kidney failure (between − 1.01 and − 1.19 p.p.), and arterial hypertension (between − 1.48 and − 1.64 p.p). The likelihood of abnormal levels of white blood cells and thrombocytes was negatively related to primary care coverage (marginal effect between − 1.8 and − 2 p.p.). The spillover effects were relevant for kidney failure and arterial hypertension, depending on the regional level. Although not sensitive to household coverage, diabetes mellitus was negatively associated with the state supply of primary care, and abnormal cholesterol levels did not present any relationship with ESF program coverage.ConclusionsThe presence of spillover effects of ESF program coverage regarding these conditions reveals that the strengthening of primary care by increasing the household registration and the regional density of ESF teams is an efficient strategy to address important comorbidities.

COVID-19 in Brazilian cities: Impact of social determinants, coverage and quality of primary health care.

Brazil, as many other countries, have been heavily affected by COVID-19. This study aimed to analyze the impact of Primary health care and the family health strategy (FHS) coverage, the scores of the National Program for Improving Primary Care Access and Quality (PMAQ), and socioeconomic and social indicators in the number of COVID-19 cases in Brazilian largest cities. This is an ecological study, carried out through the analysis of secondary data on the population of all Brazilian main cities, based on the analysis of a 26-week epidemiological epidemic week series by COVID-19. Statistical analysis was performed using Generalized Linear Models with an Autoregressive work correlation matrix. It was shown that greater PHC coverage and greater FHS coverage together with an above average PMAQ score are associated with slower dissemination and lower burden of COVID-19. It is evident that cities with less social inequality and restrictions of social protection combined with social development have a milder pandemic scenario. It is necessary to act quickly on these conditions for COVID-19 dissemination by timely actions with high capillarity. Expanding access to PHC and social support strategies for the vulnerable are essential.

Cohort study of ageing from Bag\xe9 (SIGa-Bag\xe9), Brazil: profile and methodology

BackgroundThe Bagé Cohort Study of Ageing is a population-based cohort study that has recently completed the first follow-up of a representative sample of older adults from Bagé, a city with more than 100,000 inhabitants located in the state of Rio Grande do Sul, Brazil. This is one of the first longitudinal studies to assess the impact of primary health care coverage on health conditions and inequalities. Our aim is to investigate the prevalence, incidence and trends of risk factors, health behaviours, social relationships, non-communicable diseases, geriatric diseases and disorders, hospitalisation, self-perceived health, and all-cause and specific-cause mortality. In addition, we aim to evaluate socioeconomic and health inequalities and the impact of primary health care on the outcomes under study.Methods/designThe study covers participants aged 60 or over, selected by probabilistic (representative) sampling of the urban area of the city of Bagé, which is covered by Primary Health Care Services. The baseline examination included 1593 older adults and was conducted from July 2008 to November 2008. After eight to nine years (2016/2017), the first follow-up was conducted from September 2016 to August 2017. All participants underwent an extensive core assessment programme including structured interviews, questionnaires, cognitive testing (baseline and follow-up), physical examinations and anthropometric measurements (follow-up).ResultsOf the original participants, 1395 (87.6%) were located for follow-up: 757 elderly individuals (47.5%) were re-interviewed, but losses in data transfer occurred for 22. The remaining 638 (40.1%) had died. In addition, we had 81 (5.1%) refusals and 117 (7.3%) losses. Among the 1373 older adults who were followed down, there was a higher proportion of female interviewees (p=0.042) and a higher proportion of male deaths (p=0.001) in 2016/2017. There were no differences in losses and refusals according to gender (p=0.102). There was a difference in average age between the interviewees (68.8 years; SD ±6.5) and non-interviewees (73.2 years; SD ±9.0) (p<0.001). Data are available at the Department of Social Medicine in Federal University of Pelotas, Rio Grande do Sul, Brazil, for any collaboration.

Clinical trials landscape in Sri Lanka

Sri Lanka is an ideal destination for the global clinical trial industry due to its favorable national policies, growing economy, and rapid digitalization directly influencing the increasing global market size of clinical trials. Its comprehensive primary health care coverage, educated population, free standard of care, non-communicable disease burden equals to western countries, qualified medical practitioners, and a core of competent and committed clinical researchers combined with its population’s proficiency in English also make this South Asian nation a potentially excellent regional clinical trials destination. Making an environment favorable to research partnership while guaranteeing the safe and ethical conduct of clinical trials has been a repetitive subject for conversation and discussion in the nation. A robust regulatory framework and ethical reviewing process have minimized legal loopholes ensuring the rights, safety, and well-being of trial participants that are protected. The Sri Lanka Clinical Trials Registry is a non-revenue driven registry and it can be considered a key stimulus to the ongoing discussions on clinical trials in Sri Lanka. Moreover, the adoption of new technology in clinical research and the rise of the pharmaceutical industry encourages and creates opportunities for more clinical trials to be conducted in Sri Lanka which, in turn, influences the growth of the industry.

Health insurance, pediatric asthma, and emergency department usage.

This study synthesized current research on the relationships between type of insurance and emergency department usage for children with asthma in the United States. Thematic analysis is in the context of the Affordable Care Act (ACA). A systematic mapping review yielded 20 articles published in the last 10years on topics of insurance, emergency department usage, and pediatric asthma. Analysis indicates continued trends of increased emergency department use among asthmatic children since enactment of the ACA, running counter to the goal of fiscal efficiency for the healthcare system and reduction of health inequities. Barriers to care persist, particularly among communities of color, despite provisions to improve access to primary and preventive care. Inadequate access to primary care is associated with poor adherence among asthmatic children with public insurance. Those with health insurance through their parents' employer experience barriers due to cost-sharing expenses. This leads to increased asthma severity and low medication adherence, resulting in the need for emergency care. A disconnect between increased health insurance coverage and utilization of primary care in some populations implies unmet service needs that warrant further investigation. Findings inform policymakers and public health leaders of persistent health inequities resulting in preventable emergency department usage.

Oral health indicators and sociodemographic factors in Brazil from 2008 to 2015.

ABSTRACTOBJECTIVE:To evaluate the annual variation of oral health and primary care coverage, the tooth extraction ratio, and the average of supervised toothbrushing in Brazilian municipalities according to social development and population size.METHODS:Public secondary data were analyzed. The outcomes were health service indicators (oral health coverage, primary health care coverage, tooth extraction ratio, and average of supervised tooth brushing) estimated for all Brazilian municipalities annually from 2008 to 2015. Mixed-effect multilevel regression models with random intercept and slopes were fitted with a cross-interaction term to estimate the annual percent variation according to the Municipal Human Development Index (MHDI) and population size.RESULTS:Municipalities with low MHDI presented an annual increase in oral health and primary care coverage of 2.65% and 2.23%, respectively, which was significantly higher than municipalities with medium and high MHDI. Oral health and primary care coverage were 69.26% and 35.00% lower among municipalities with a large population. Municipalities with medium and high MHDI showed an annual decrease in tooth extractions of 5.15% and 5.02%, respectively. An annual decrease was observed in the average of supervised toothbrushing of 9.81% and 4.57% in municipalities with low and medium MHDI, respectively. The tooth extraction ratio was higher among larger municipalities; the relation is inverse for supervised toothbrushing.CONCLUSIONS:The access to primary care and oral health services increased in Brazil, while a decrease occurred in mutilating treatment and provision of preventive actions, with disparities among municipalities with different MHDI levels over time.

Primary health care and social isolation against COVID-19 in Northeastern Brazil: Ecological time-series study.

Brazil is witnessing a massive increase of corona virus disease (COVID-19). Its peculiar primary health care (PHC) system faces a burden due to the contagion occurring in the community environment. Then, the aim is to estimate the effect of the coverage of primary health care and social isolation on the evolution of confirmed cases and deaths by COVID-19, controlling sociodemographic, economic and health system aspects. A time series design was designed with data on diagnosed cases of COVID-19 and their deaths as outcomes in the capital cities of the Northeast region of Brazil. Independent variables such as PHC coverage, hospital beds, social isolation, demographic density, Gini index and other indicators were analyzed. A Autoregressive Generalized Linear Model method was applied for model the relationship. We identified an exponential growth of cases (y = 0.00250.71x; p-value<0,001). However, there is a high variability in the occurrence of outcomes. PHC coverage≥75% (χ2 = 9.27; p-value = 0.01) and social isolation rate (χ2 = 365.99; p-value<0.001) proved to be mitigating factors for the spread of COVID-19 and its deaths. Capitals with hospital beds ≥ 3.2 per thousand inhabitants had fewer deaths (χ2 = 9.02; p-value = 0.003), but this was influenced by PHC coverage (χ2 = 30,87; p-value<0.001). PHC mitigates the occurrence of Covid-19 and its deaths in a region of social vulnerability in Brazil together with social isolation. However, it is not known until when the system will withstand the overload in view of the low adhesion to social isolation, the lack of support and appropriate direction from the government to its population.

Impact of COAP on access to primary care in Ceará and Mato Grosso do Sul through the analysis of interrupted time series.

ABSTRACTOBJECTIVE:To analyze the impact of implementing the Contrato Organizativo de Ação Pública (COAP – Public Action Organizational Contract) on the expansion of access to primary care in the states of Ceará and Mato Grosso do Sul.METHODS:We used the interrupted time series method to analyze the effect of COAP on primary care coverage (PCCov) and on avoidable hospitalization rates. To analyze the effects of increased PCCov on avoidable hospitalizations, we used non-segmented time series models.RESULTS:The results showed that implementing COAP had a positive impact on increased coverage in both cases, with did not happen in the control states. However, this impact was not reflected in the decrease in hospitalizations due to primary care sensitive conditions (HPCSC) or for acute preventable causes. When we analyzed the effects of the increase in PCCov on avoidable hospitalizations between 2009 and 2016, we observed that coverage had a positive impact on the decrease in the rate of HPCSC only in Ceará, although hospitalizations have a significant trend to decrease in time both in this state and in Mato Grosso do Sul, except for acute respiratory infections.CONCLUSIONS:The COAP continues to be the regulatory instrument of regionalization force, however, the results obtained by adhering to it in the expansion of primary care in Ceará and Mato Grosso do Sul makes us question whether the contractual model, as predicted, is the best instrument for advancing regionalization in the Brazilian Unified Health System.

A PREDICTIVE TOOL FOR FORECASTING ANTI-HYPERTENSION MEDICATION REQUIREMENTS IN LOW- AND MIDDLE-INCOME COUNTRIES

Objective: To develop a mathematical tool for estimating medication requirement that would improve the uninterrupted supply of medications for large-scale hypertension control programs in low- and middle-income countries. Design and method: In a steady state, annual drug procurement forecasts can simply replicate the previous year's consumption. For a new or rapidly growing hypertension control program, however, forecasting drug requirement requires consideration of not only patients currently on medication, but also rates of new patient registration and drop-out. To forecast antihypertensive drug requirements, a simple mathematical tool was developed based on the morbidity method, requiring minimal inputs and assumptions. The tool hinges on use of a standard step-wise treatment protocol which uses specific medications and doses and considers hypertension prevalence, number of existing patients, expected new monthly enrollments, proportion of patients with controlled blood pressure at each protocol step, and expected loss-to-follow up over time. Outputs include forecasted quantities of specific medications for any specific time period and associated budgets. The tool provides flexibility for correction of projected requirements based on programmatic data, thus making the estimation more accurate. Results: The tool was implemented in an Indian hypertension control program starting with a priori assumptions and refined iteratively as program data became available. It was customised for use in specific Indian states based on their treatment protocol, population size and primary health care coverage. The monthly drug requirement projected by the tool helped to quantify drug volumes for periodic procurement, and to overcome shortages observed in some areas in first year of the program. More than 10 states in India have adopted this tool for procurement and budget planning. Conclusions: This simple, pragmatic antihypertension drug forecasting tool can help ensure prudent resource allocation in hypertension control programs and facilitate reliable delivery of medications for patients in low- and middle-income countries. This tool can also quantify the financial implications of alternative treatment protocols, inform protocol design, and be adapted to other chronic disease control programs.

Family Health Strategy, Primary Health Care, and Social Inequalities in Mortality Among Older Adults in Bagé, Southern Brazil.

Objectives. To investigate the role of the Family Health Strategy (FHS) in reducing social inequalities in mortality over a 9-year follow-up period.Methods. We carried out a population-based cohort study of individuals aged 60 years and older from the city of Bagé, Brazil. Of 1593 participants at baseline (2008), 1314 (82.5%) were included in this 9-year follow-up (2017). We assessed type of primary health care (PHC) coverage and other variables at baseline. In 2017, we ascertained 579 deaths through mortality registers. Hazard ratios and their 95% confidence intervals modeled time to death estimated by Cox regression. We also tested the effect modification between PHC and wealth.Results. The FHS had a protective effect on mortality among individuals aged 60 to 64 years, a result not found among those not covered by the FHS. Interaction analysis showed that the FHS modified the effect of wealth on mortality. The FHS protected the poorest from all-cause mortality (hazard ratio [HR] = 0.59; 95% confidence interval [CI] = 0.36, 0.96) and avoidable mortality (HR = 0.46; 95% CI = 0.25, 0.85).Conclusions. FHS coverage reduced social inequalities in mortality among older adults. Our findings highlight the need to guarantee universal health coverage in Brazil by expanding and strengthening the FHS to promote health equity.

Predictive Factors for Severe Maternal Morbidity in Brazil: A Case-Control Study.

The maternal mortality or "maternal near miss" ratio in Brazil reflects the socioeconomic indicators as well as the healthcare quality in some areas of this country, pointing out fragile points in the health services. The aim of this study was to estimate the association of diverse variables related to pregnancy and the occurrence of Near Miss in a population of women who were cared in public maternity wards in Brazil. A case-control study was performed. The association between variables and outcomes was verified through a chi-square test. A multiple analysis was carried out, producing odds ratio (OR) estimates with values of p≤0.25 in the univariate model. The results point to the following risk factors for Severe Maternal Morbidity: non-white (<0.001, OR 2.973), family income of up to two minimum wage salaries (<0.001; OR 2.159), not having a partner (<0.001, OR 2.694), obesity (<0.001, OR 20.852), not having received pre-natal care (<0.001, OR 2.843), going to less than six prenatal appointments (<0.001, OR 3.498), undergoing an inter-hospital transfer (<0.001, OR 24.655), and the absence of labor during admission (<0.001, OR 25.205). Although the results vary, the incidence of women with potential life-threatening complications is high in Brazil, which reinforces the need to universalize more complex interventions as well as coverage of primary care. The presence of precarious socio-economic indicators and unqualified obstetric care were risk factors for Severe Maternal Morbidity.

Contextual determinants for use of dental services according to different healthcare financing systems: Andersen's model.

To explore contextual factors associated with overall dental service use, and investigate whether these factors influenced choice of the type of service according to the healthcare financing alternatives (public services; out-of-pocket services; and private health insurance), by adults and older individuals, based on the most recent Andersen's behavioural model. Cross-sectional study with individual data on 17,305 adults from 177 Brazilian municipalities in the National Oral Health Survey (SBBrasil 2010). Municipal-level information was obtained from health information systems and census data. Multilevel multinomial logistic regression was carried out for multivariable analysis. In the previous year, 38.2% of the individuals visited the dentist; of which 21.4% used out-of-pocket spending, 11.6% used public services and 5.2% private dental insurance. Municipalities with population coverage of public primary dental care >80% had higher chances of using public services (OR=1.28, 95%CI:1.00-1.64) than those with ≤60%, but lower chances of using private insurance (OR=0.56, 95%CI:0.38-0.83). Municipalities with population coverage of private dental insurance>5% had lower chances of using public services (OR=0.62, 95%CI:0.47-0.81) than those with <1% coverage, and greater chances of using private insurance (OR=4.33, CI:95% 2.02-9.29). These factors were not associated with out-of-pocket dental services. Municipal coverage of dental services is associated with dental care use, and this is different according to the type of financing system (public or private), as they may change the individual's choice of service. A large public healthcare system may increase public service use for those with reduced access and decrease private service use.

The impact of social health insurance on rural populations

Improving health outcomes of rural populations in low- and middle-income countries represents a significant challenge. A key part of this is ensuring access to health services and protecting households from financial risk caused by unaffordable medical care. In 2003, China introduced a heavily subsidised voluntary social health insurance programme that aimed to provide 800 million rural residents with access to health services and curb medical impoverishment. This paper provides new evidence on the impact of the scheme on health care utilisation and medical expenditure. Given the voluntary nature of the insurance enrolment, we exploit the uneven roll-out of the programme across rural counties as a natural experiment to explore causal inference. We find little effect of the insurance on the use of formal medical care and out-of-pocket health payments. However, there is evidence that it directed people away from informal health care towards village clinics, especially among patients with lower income. The insurance has also led to a reduction in the use of city hospitals among the rich. The shift to village clinics from informal care and higher-level hospitals suggests that the NRCMS has the potential to improve efficiency within the health care system and help patients to obtain less costly primary care. However, the poor quality of primary care and insufficient insurance coverage for outpatient services remains a concern.

ASSISTÊNCIA À SAÚDE NA ATENÇÃO BÁSICA AOS PORTADORES DE HIPERTENSÃO ARTERIAL SISTÊMICA E DIABETES MELLITUS

Introdução: As doenças são responsável por maior parte das hospitalizações e mortes no mundo. Porém, a maioria delas podem ser previnas por ações realizadas na Atenção Básica. Objetivo: comparar a morbidade e mortalidade por Doenças Crônicas Não Transmissíveis, Hipertensão Arterial e Diabetes Mellitus nos anos 2012-2014 com a cobertura da Atenção Básica na região Nordeste do Brasil. Metodologia: Trata-se de estudo ecológico, retrospectivo, realizado no nordeste brasileiro com dados dos anos de 2012 e 2014 com dados disponíveis no Departamento de Informática do Sistema Único de Saúde. Foi realizada uma análise descritiva e analítica e correlacionada as taxas de internação e óbitos dos agravos estudados com cobertura da Atenção Básica. Resultados: Ao comparar a ocorrência de internação e óbito entre os anos de 2012 e 2014 observou-se redução no nordeste. Todavia, quando correlacionado com a cobertura da Atenção Básica, quanto maior a cobertura maior foi a ocorrência dos agravos. Conclusões: O estudo revelou a necessidade de reflexão e tomada de atitude pelos gestores e profissionais de saúde considerando a continuidade do cuidado ao usuário da Atenção Básica, bem como todos os investimentos financeiros realizados pelo Ministério da Saúde junto aos municípios do Nordeste do Brasil.

The Contribution of Primary Care Expansion to Sustainable Development Goal Three for Health: A Microsimulation of the Fifteen Largest Cities in Brazil

Background: As middle-income countries strive to achieve the Sustainable Development Goals (SDGs), it remains unclear to what degree expanding primary care coverage can help achieve those goals and reduce within-country inequalities in mortality. We estimated the potential impact of primary care expansion on cause-specific mortality in the 15 largest Brazilian cities. Methods: We obtained hazard ratios of death by cause and by demographic group, from a national administrative database linked to the Estrategia de Saude da Familia (Family Health Strategy, FHS) electronic health and death records among 1.2 million residents of Rio de Janeiro (2010-2016). We incorporated these hazard ratios into a microsimulation to estimate the impact of changing primary care coverage. Findings: Increased FHS coverage would be expected to reduce inequalities in mortality among cities (from 2.8 to 2.4 deaths per 1,000 between the highest- and lowest-mortality city, given a 40 percentage point increase in coverage), between welfare recipients and non-recipients (from 1.3 to 1.0 deaths per 1,000), and among race/ethnic groups (between Black and White Brazilians from 1.0 to 0.8 deaths per 1,000). A 40 percentage point increase in coverage would be insufficient to reach SDG targets --reducing premature mortality from non-communicable diseases by 20% (versus the target of 33%), and communicable diseases by 15% (versus 100%). Interpretation: Primary care coverage may be critically beneficial to reducing within-country health inequalities, but reaching SDG targets will likely require coordination between primary care and other sectors. Funding Statement: This work was supported by a grant from the Health Systems Research Initiative with funding from the Foreign, Commonwealth and Development Office, the UK Medical Research Council and Wellcome Trust, in collaboration with the UK Economic and Social Research Council (grant no. MR/P014593/1).DR acknowledges support from the Spanish Ministry of Science and Innovation through the “Centro de Excelencia Severo Ochoa 2019-2023” Program (CEX2018- 000806-S), and support from the Generalitat de Catalunya through the CERCA Program. Declaration of Interests: None. Ethics Approval Statement: Approval for this study was obtained from the Brazilian National Commission for Ethics in Research (Comissao Nacional de Etica em Pesquisa [CONEP]; number 2.689.528) and Imperial College London’s Ethical Comittee.

Qualidade da assistência aos portadores de hipertensão arterial e diabetes no Nordeste após o PMAQ-AB

In order to improve health conditions, a program improving the quality of care in Brazil was created that encourages managers and teams to offer better quality health services to citizens of their territory by proposing strategies for training, monitoring, and evaluating the work of the health teams. The objective of this study was to analyze the morbidity and mortality indicators due to Systemic Arterial Hypertension and Diabetes Mellitus in the Northeast region of Brazil after the implementation of the first two cycles of the National Program to Improve Access and Quality of Primary Care. This is an ecological, retrospective study with spatial analysis, carried out in northeastern Brazil with data collected from the Informatics Department of the Unified Health System between the years 2012 and 2014. It was observed changes occurred in the spatial distribution areas concerning the hospitalization rates and the mortality rates, as well as the reduction of areas with high rates in 2014. When correlating with the Primary Care coverage, the areas with high rates of hospitalization and mortality also had high coverage of Primary Care. Thus, the effectiveness of implementing the aforementioned program reveals the need for plans that involve not only health promotion actions, but also professional training on how to integrate such actions into their daily activities, in order to ensure qualified and integral.

Innovation in primary health care responses to COVID-19 in Sub-Saharan Africa.

In May 2020, the African Journal of Primary Health Care and Family Medicine invited submissions on lessons learnt from responses to the COVID-19 pandemic from primary care providers in Africa. This included descriptions of innovations and good practices, the management of COVID-19 in district health services and responses of communities to the outbreak. To synthesise the lessons learnt from the COVID-19 pandemic in the Africa region. A thematic document analysis was conducted on twenty-seven short report publications from Botswana, Ghana, Nigeria, South Africa, Uganda and Zimbabwe. Findings: Eight major themes were derived from the data: community-based activities; screening and testing; reorganisation of health services; emergency care for COVID-19; maintenance of essential non-COVID-19 health services; caring for the vulnerable; use of information technology; and reframing training opportunities. Community health workers were a vital community resource, delivering medications and other supplies to homes, as well as following up on patients with chronic conditions. More investment in community partnerships and social mobilisation was proposed. Difficulties with procurement of test kits and turn-around times were constraints for most countries. Authors described how services were reorganised for focused COVID-19 activities, sometimes to the detriment of essential services and training of junior doctors. Innovations in use of internet technology for communication and remote consultations were explored. The contribution of family medicine principles in upholding the humanity of patients and their families, clear leadership and planning, multidisciplinary teamwork and continuity of care was emphasised even in the context of providing critical care. The community-orientated primary care approach was emphasised as well as long-term benefits of technological innovations. The pandemic exposed the need to deliver on governmental commitments to strengthening primary health care and universal health coverage.

Tuberculosis in Brazil: one country, multiple realities

ABSTRACTObjective:To identify the determinants of tuberculosis-related variables in the various regions of Brazil and evaluate trends in those variables over the ten-year period preceding the end of the timeframe defined for the United Nations Millennium Development Goals (MDGs). Methods:This was an ecological analytical study in which we utilized eight national public databases to investigate the 716,971 new tuberculosis cases reported between 2006 and 2015. Results:Over the study period, there were slight reductions in the prevalence, incidence, and mortality associated with tuberculosis. Brazil did not reach the MDG for tuberculosis-related mortality. Among the performance indicators of tuberculosis control, there were improvements only in those related to treatment and treatment abandonment. In terms of the magnitude of tuberculosis, substantial regional differences were observed. The tuberculosis incidence rate was highest in the northern region, as were the annual mean temperature and relative air humidity. That region also had the second lowest human development index, primary health care (PHC) coverage, and number of hospitalizations for tuberculosis. The northeastern region had the highest PHC coverage, number of hospitalizations for primary care-sensitive conditions, and tuberculosis-related mortality rate. The southern region showed the smallest reductions in epidemiological indicators, together with the greatest increases in the frequency of treatment abandonment and retreatment. The central-west region showed the lowest overall magnitude of tuberculosis and better monitoring indicators. Conclusions:The situation related to tuberculosis differs among the five regions of Brazil. Those differences can make it difficult to control the disease in the country and could explain the fact that Brazil failed to reach the MDG for tuberculosis-related mortality. Tuberculosis control measures should be adapted to account for regional differences.