Investment In Primary Health Care Research Articles

Primary healthcare expansion and mortality in Brazil's urban poor: A cohort analysis of 1.2 million adults.

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.

Funding models and expenditures with primary healthcare in Salvador, Bahia, Brazil metropolitan area

Abstract Background The government investments in quality primary healthcare are the basis to strengthening the health systems and monitoring the public expenditure in this area is a way to assess the effectiveness and efficiency of the public health policies. The Brazil Ministry of Health changed, in 2017, the method of onlending federal resources to states and cities seeking to make the public funds management more flexible. This change, however, suppressed mandatory investments in primary healthcare. This research aims to determine the difference of expenditures on primary healthcare in Salvador, Bahia, Brazil metropolitan area before and after this funding reform, seeking to verify how it can impact the quality of primary healthcare services and programs. Methods This is an ecological time-series study that used data obtained in the Brazil Ministry of Health budget reports. The median and interquartile range of expenditures on primary healthcare (set as the percentage of total public health budget applied in primary care services and programs) of the 13 cities in the Salvador metropolitan area were compared two years before and after the reform. Results The median of expenditures on primary healthcare in Salvador metropolitan area was 25.5% (13,9% - 32,2%) of total public health budget before and 24.8% (20.8% - 30.0%) of total public health budget after the reform (-0.7% difference). Seven cities decreased the expenditures on primary healthcare after the reform, ranging from 1.2% to 10.8% reduction in the primary healthcare budget in five years. Conclusions Expenditures on primary healthcare in Salvador metropolitan area decreased after the 2017 funding reform. Seven of 13 cities reduced the government investments on primary healthcare services and programs in this scenario. Although the overall difference was -0.7%, the budget cuts ranged from 1.2% to 10.8% in the analyzed period and sample. More studies should assess these events in wide areas and with long time ranges. Key messages Public health funding models can impact the primary healthcare settings regardless of the health policy. Reforms in the funding models should consider the possible benefits before implementation. Funding models and methods that require mandatory investments in primary healthcare may be considered over more flexible ones.

Health production: analysis of doctors’ health actions in the More Doctors program

OBJECTIVE Analyze the health actions carried out by the Cuban cooperated physicians and their relationship with socioeconomic characteristics of the municipalities, contained in the first supervision visit report, in 2015. METHODS This is a quantitative research that used secondary data from the reports of the 1st supervision visit of the "More Doctors Program". The dependent variables were the health actions, and the independent variables were the type of municipality, Human Development Index (HDI), Investment in Primary Health Care (PHC), health center coverage, rural population, and total population. Multiple correspondence analysis was used to identify the latent variable, related to the profile of the professional with respect to the actions/procedures carried out to which the characteristics of the municipalities were associated through frequency analysis. RESULTS Three profiles of professionals were obtained, who have their practices associated with the professional training, consolidating as a determining factor for carrying out actions compatible with the actual needs of the population. Such findings were associated with the socioeconomic variables, with emphasis on funding, health center infrastructure, and coverage. CONCLUSIONS From the observed results, we suggest strategies to expand the scope of the practices carried out in Primary Health Care, from the perspective of training and continuing education of health professionals, and the focus on the everyday life of the service being of paramount importance.

More Doctors Program: health work process and socioeconomic indicators.

To analyze the working process of the professionals of the More Doctors Program and its relationship with socioeconomic indicators. It is a quantitative study, in which secondary data from supervision reports of PMM were used. The dependent variable was the quality of work processes in Primary Care facilities, and the independent ones were the type of municipality, education, Gini index, Primary Health Care investments, and health facilities coverage. Data were analyzed with multiple modeling based on Poisson regression with robust variance. 16,000 doctors within 3816 municipalities were analyzed. Variables related to the working process the remained significant in the final model were the investments in Primary Health Care and the health facilities coverage. The results expressed the equity principle, as those municipalities with more vulnerable conditions and with higher coverage are prone to perform more activities in their working process. The implementation of the More Doctors Program and hence the provision of doctors in deprived regions promoted the consolidation of three main aspects, namely the health working process, primary health care and equity, making it possible to carry out a health working process focused on PHC. This implies performing a greater number of activities that are inherent to PHC, which were not carried out due to the absence of doctors. The More Doctors Program fulfills its role in the combat of inequalities, particularly regarding more vulnerable municipalities.

Factors Associated with the Detection of Childhood and Adolescent Cancer in Primary Health Care: A Prospective Cross-Sectional Study.

BackgroundThe treatment of childhood cancer has achieved important advances evidencing a significant increase in overall survival; however, the diagnosis of these cases still seems late. Among the main causes for the delay in diagnosis are the issues related to the health system and the first professional who performs the care. The objective of this study is to evaluate the knowledge of primary care physicians and nurses about the most common signs and symptoms of pediatric cancers, as well as the factors related to the obtained scores.MethodsThis is a prospective cross-sectional study, developed in municipalities in the northeastern region of Brazil. Fifty-one professionals (physicians and nurses) were interviewed through a questionnaire structured as a quiz game about knowledge, training and attitudes regarding the signs and symptoms of childhood cancer. Multiple linear regression analysis was used to evaluate the effect of professional characteristics on the number of correct answers on the implemented questionnaire on knowledge of childhood and adolescent cancer.ResultsIn the bivariate analysis, the results indicated that the type of employment relationship influences the number of correct answers in the questionnaire used. However, when adjusted for covariates, only the professional category, which means being a medical professional, showed a significant effect on the number of correct answers (β=−7.50, p=0.001).ConclusionThe type of employment relationship of medical professionals and nurses working in primary care had an influence on the number of correct answers for knowledge of childhood and adolescent cancer, but only the professional category (physician) was associated with the highest number when controlled by covariables, thereby justifying the need to improve the curricular training of nurses and greater investments in primary health care for continuing health education that includes infant and adolescent oncology.

Offline: What is the point of gender equality anyway?

Two of the great global health issues of the 21st century are the climate emergency and gender inequality. The first is an incipient mass extinction event facing the biosphere. The second is a disfiguring moral injustice that, unless addressed, will severely limit possibilities for advancing the health and wellbeing of all peoples. But while the climate crisis has recently achieved wider awareness, triggering public concern and even (admittedly inadequate) political action, gender inequality remains marginal to the central discourse of society. Several attempts have been made to catapult gender into the mainstream of national politics and international affairs. The most important was the 1995 Beijing Declaration and Platform for Action, celebrating its 25th anniversary next year. The Declaration called for “the advancement and empowerment of women all over the world”. This proposition was grounded on the principles of sustainable development—economic growth, social development, environmental protection, and social justice. Sustained economic growth would provide the basis for investments in primary health care. And those principles would also mean that women must have “equal access to economic resources”, including access to markets. In 2020, there will be a major review of progress towards these commitments—Beijing+25. Next year will be the most important opportunity for a generation to accelerate action to improve the health of women and girls. But that opportunity cannot be seized by taking a business-as-usual approach to gender inequality, an approach unfortunately endorsed and institutionalised by the Beijing Declaration's advocacy for economic development through market capitalism. As currently conceived, Beijing+25 will fail. A more fundamental question must be asked: what is the point of gender equality? SDG-5 defines gender equality as ending all forms of discrimination and violence against women and girls; eliminating harmful practices (such as early marriage and female genital mutilation); recognising and valuing unpaid care and domestic work; ensuring women's full and effective participation in political, economic, and public life; and ensuring universal access to sexual and reproductive health and rights. These objectives deserve the global health community's full support. But the political and economic frameworks within which these targets exist mean they can never be fully achieved. As Cinzia Arruzza, Tithi Bhattacharya, and Nancy Fraser argue in Feminism for the 99%: A Manifesto (Verso, 2019), “capitalist societies are also by definition wellsprings of gender oppression”. The liberal “lean-in” feminism prevalent today is the “handmaiden of capitalism”. In its “bankruptcy”, liberal feminism offers nothing more than “equal opportunity domination”. Arruzza, Bhattacharya, and Fraser offer 11 theses that draw the contours of an entirely different vision for gender equality. Put simply, capitalism is the problem, not the solution. Capitalist society inherently undervalues women's work, paid and unpaid—“it propounds a market-centred view of equality that dovetails perfectly with the prevailing corporate enthusiasm for ‘diversity’…liberal feminism steadfastly refuses to address the socioeconomic constraints that make freedom and empowerment impossible for the large majority of women”. Instead, liberal feminism “outsources oppression” and envisions a world where “a few privileged souls can attain positions and pay on a par with the men of their own class”. Feminism risks being “a vehicle of self-promotion, deployed less to liberate the many than to elevate the few”. The crucial step that capitalism made to reinvent women's oppression “was to separate the making of people from the making of profit”. The making of people—social reproduction—“relies on gender roles and entrenches gender oppression”. What Arruzza, Bhattacharya, and Fraser propose is “gender justice in an anticapitalist form”. They reject liberal feminism. They embrace “an anticapitalist feminism—a feminism for the 99%”. They also emphasise “the enormous political potential of women's power: the power of those whose paid and unpaid work sustains the world”. Free, universal, not-for-profit health care is foundational to this vision. But it cannot be realised unless capitalism itself becomes a target. And this truth is one that the conveners of Beijing+25 choose to ignore, with fatal consequences for the health of women and girls worldwide.

Measuring progress towards universal health coverage: national and subnational analysis in Ethiopia

IntroductionAiming for universal health coverage (UHC) as a country-level goal requires that progress is measured and tracked over time. However, few national and subnational studies monitor UHC in low-income countries...

Guide posts for investment in primary health care and projected resource needs in 67 low-income and middle-income countries: a modelling study

SummaryBackgroundPrimary health care (PHC) is a driving force for advancing towards universal health coverage (UHC). PHC-oriented health systems bring enormous benefits but require substantial financial investments. Here, we aim to present measures for PHC investments and project the associated resource needs.MethodsThis modelling study analysed data from 67 low-income and middle-income countries (LMICs). Recognising the variation in PHC services among countries, we propose three measures for PHC, with different scope for included interventions and system strengthening. Measure 1 is centred on public health interventions and outpatient care; measure 2 adds general inpatient care; and measure 3 further adds cross-sectoral activities. Cost components included in each measure were based on the Declaration of Astana, informed by work delineating PHC within health accounts, and finalised through an expert and country validation meeting. We extracted the subset of PHC costs for each measure from WHO's Sustainable Development Goal (SDG) price tag for the 67 LMICs, and projected the associated health impact. Estimates of financial resource need, health workforce, and outpatient visits are presented as PHC investment guide posts for LMICs.FindingsAn estimated additional US$200–328 billion per year is required for the various measures of PHC from 2020 to 2030. For measure 1, an additional $32 is needed per capita across the countries. Needs are greatest in low-income countries where PHC spending per capita needs to increase from $25 to $65. Overall health workforces would need to increase from 5·6 workers per 1000 population to 6·7 per 1000 population, delivering an average of 5·9 outpatient visits per capita per year. Increasing coverage of PHC interventions would avert an estimated 60·1 million deaths and increase average life expectancy by 3·7 years. By 2030, these incremental PHC costs would be about 3·3% of projected gross domestic product (GDP; median 1·7%, range 0·1–20·2). In a business-as-usual financing scenario, 25 of 67 countries will have funding gaps in 2030. If funding for PHC was increased by 1–2% of GDP across all countries, as few as 16 countries would see a funding gap by 2030.InterpretationThe resources required to strengthen PHC vary across countries, depending on demographic trends, disease burden, and health system capacity. The proposed PHC investment guide posts advance discussions around the budgetary implications of strengthening PHC, including relevant system investment needs and achievable health outcomes. Preliminary findings suggest that low-income and lower-middle-income countries would need to at least double current spending on PHC to strengthen their systems and universally provide essential PHC services. Investing in PHC will bring substantial health benefits and build human capital. At country level, PHC interventions need to be explicitly identified, and plans should be made for how to most appropriately reorient the health system towards PHC as a key lever towards achieving UHC and the health-related SDGs.FundingThe Bill & Melinda Gates Foundation.

Cuban medical training for South African students: a mixed methods study

BackgroundAchieving universal health care coverage will require greater investment in primary health care, particularly in rural and underserved populations in low and middle-income countries. South Africa has invested in training black students from disadvantaged backgrounds in Cuba and large numbers of these Cuban-trained students are now returning for final year and internship training in South Africa. There is controversy about the scheme, the quality and relevance of training received and the place of Cuban-trained doctors in the health care system. Exploring the experiences of Cuban- and South African-trained students, recent graduates and medical school faculty may help understand and resolve the current controversy.MethodsUsing a mixed methods approach, in-depth interviews and a focus group discussion were held with deans of medical schools, senior faculty, and Cuban-trained and South African-trained students and recent graduates. An online structured questionnaire, adapted from the USA medical student survey, was developed and administered to Cuban- and South African-trained students and recent graduates.ResultsSouth African students trained in Cuba have had beneficial experiences which orientate them towards primary health care and prevention. Their subsequent training in South Africa is intended to fill skill gaps related to TB, HIV and major trauma. However this training is ad hoc and variable in duration and demoralizing for some students. Cuban-trained students have stronger aspirations than those trained in South Africa to work in rural and underserved communities from which many of them are drawn.ConclusionAttempts to assimilate returning Cuban-trained students will require a reframing of the current negative narrative by focusing on positive aspects of their training, orientation towards primary care and public health, and their aspirations to work in rural and under-served urban areas. Cuban-trained doctors could be part of the solution to South Africa’s health workforce problems.

Universal health coverage, a priority or just a slogan?

Universal Health Coverage is defined as preventive, curative and rehabilitation services which are available to all people in the community and can be accessed if needed.Improving health care coverage is directly related to the access and integration of our staff to provide integrated care for the general public. Government investment in Primary Health Care will be the cornerstone of UHC.the implementation of this approach will be challenging, and many developing countries have so far failed to achieve universal coverage due to a lack of adequate management capacity in the insurance sector, or differences in the method of calculating premiums in various organizations which have led to different effects.

After Astana: building the economic case for increased investment in primary health care

After Astana: building the economic case for increased investment in primary health care

Who Needs Big Health Sector Reforms Anyway? Seychelles’ Road to UHC Provides Lessons for Sub-Saharan Africa and Island Nations

The road to universal health coverage (UHC) needs not be driven by big reforms that include the initiation of health insurance, provider–funder separation, results-based financing, or other large health sector reforms advocated in many countries in sub-Saharan Africa and elsewhere. The Seychelles experience, documented through a series of analytical products like public expenditure reviews and supporting surveys with assistance from the World Bank and World Health Organization (WHO), shows an alternative, more incremental reform road to UHC, with important lessons to the region and other small-population or island nations. Done well, in some countries, a basic supply-side funded, publicly owned and operated, and integrated health system can produce excellent health outcomes in a cost-effective and sustainable way. The article traces some of the factors that facilitated this success in the Seychelles, including high political commitment, strong voice and a downward accountability culture, strong public health functions, and an impressive investment in primary health care. These factors help explain past successes and also provide a good basis for adaptation of health systems to dramatic shifts in the epidemiological and demographic transitions, disease outbreaks, and rising public expectation and demand for high quality of care. Once again, how the Seychelles responds can show the way for other countries in the region and elsewhere regardless of the types of reforms countries engage in.

Oral primary care: an analysis of its impact on the incidence and mortality rates of oral cancer

BackgroundOral cancer is a potentially fatal disease, especially when diagnosed in advanced stages. In Brazil, the primary health care (PHC) system is responsible for promoting oral health in order to prevent oral diseases. However, there is insufficient evidence to assess whether actions of the PHC system have some effect on the morbidity and mortality from oral cancer. The purpose of this study was to analyze the effect of PHC structure and work processes on the incidence and mortality rates of oral cancer after adjusting for contextual variables.MethodsAn ecological, longitudinal and analytical study was carried out. Data were obtained from different secondary data sources, including three surveys that were nationally representative of Brazilian PHC and carried out over the course of 10 years (2002–2012). Data were aggregated at the state level at different times. Oral cancer incidence and mortality rates, standardized by age and gender, served as the dependent variables. Covariables (sociodemographic, structure of basic health units, and work process in oral health) were entered in the regression models using a hierarchical approach based on a theoretical model. Analysis of mixed effects with random intercept model was also conducted (alpha = 5%).ResultsThe oral cancer incidence rate was positively association with the proportion of of adults over 60 years (β = 0.59; p = 0.010) and adult smokers (β = 0.29; p = 0.010). The oral cancer related mortality rate was positively associated with the proportion of of adults over 60 years (β = 0.24; p < 0.001) and the performance of preventative and diagnostic actions for oral cancer (β = 0.02; p = 0.002). Mortality was inversely associated with the coverage of primary care teams (β = −0.01; p < 0.006) and PHC financing (β = −0.52−9; p = 0.014).ConclusionsIn Brazil, the PHC structure and work processes have been shown to help reduce the mortality rate of oral cancer, but not the incidence rate of the disease. We recommend expanding investments in PHC in order to prevent oral cancer related deaths.

Impact of primary care funding on secondary care utilisation and patient outcomes: a retrospective cross-sectional study of English general practice.

In international studies, greater investment in primary health care is associated with improved population health outcomes. To determine whether investment in general practice is associated with secondary care utilisation, patient satisfaction, and clinical outcomes. Retrospective cross-sectional study of general practices in England, 2014-2015. Practice-level data were stratified into three groups according to GP contract type: national General Medical Services (GMS) contracts, with or without the capitation supplement (mean practice income guarantee), or local Personal Medical Services (PMS) contracts. Regression models were used to explore associations between practice funding (capitation payments and capitation supplements) and secondary care usage, patient satisfaction (general practice patient survey scores), and clinical outcomes (Quality and Outcomes Framework [QOF] scores). The authors conducted financial modelling to predict secondary care cost savings associated with notional changes in primary care funding. Mean capitation payments per patient were £69.82 in GMS practices in receipt of capitation supplements (n = 2784), £78.79 in GMS practices without capitation supplements (n = 1672), and £84.43 in PMS practices (n = 3022). The mean capitation supplement was £5.72 per patient. Financial modelling demonstrated little or no relationship between capitation payments and secondary care costs. In contrast, notional investment in capitation supplements was associated with modelled savings in secondary care costs. The relationship between funding and patient satisfaction was inconsistent. QOF performance was not associated with funding in any practice type. Capitation payments appear to be broadly aligned to patient need in terms of secondary care usage. Supplements to the current capitation formula are associated with reduced secondary care costs.

Association between expansion of primary healthcare and racial inequalities in mortality amenable to primary care in Brazil: A national longitudinal analysis.

BackgroundUniversal health coverage (UHC) can play an important role in achieving Sustainable Development Goal (SDG) 10, which addresses reducing inequalities, but little supporting evidence is available from low- and middle-income countries. Brazil’s Estratégia de Saúde da Família (ESF) (family health strategy) is a community-based primary healthcare (PHC) programme that has been expanding since the 1990s and is the main platform for delivering UHC in the country. We evaluated whether expansion of the ESF was associated with differential reductions in mortality amenable to PHC between racial groups.Methods and findingsMunicipality-level longitudinal fixed-effects panel regressions were used to examine associations between ESF coverage and mortality from ambulatory-care-sensitive conditions (ACSCs) in black/pardo (mixed race) and white individuals over the period 2000–2013. Models were adjusted for socio-economic development and wider health system variables. Over the period 2000–2013, there were 281,877 and 318,030 ACSC deaths (after age standardisation) in the black/pardo and white groups, respectively, in the 1,622 municipalities studied. Age-standardised ACSC mortality fell from 93.3 to 57.9 per 100,000 population in the black/pardo group and from 75.7 to 49.2 per 100,000 population in the white group. ESF expansion (from 0% to 100%) was associated with a 15.4% (rate ratio [RR]: 0.846; 95% CI: 0.796–0.899) reduction in ACSC mortality in the black/pardo group compared with a 6.8% (RR: 0.932; 95% CI: 0.892–0.974) reduction in the white group (coefficients significantly different, p = 0.012). These differential benefits were driven by greater reductions in mortality from infectious diseases, nutritional deficiencies and anaemia, diabetes, and cardiovascular disease in the black/pardo group. Although the analysis is ecological, sensitivity analyses suggest that over 30% of black/pardo deaths would have to be incorrectly coded for the results to be invalid. This study is limited by the use of municipal-aggregate data, which precludes individual-level inference. Omitted variable bias, where factors associated with ESF expansion are also associated with changes in mortality rates, may have influenced our findings, although sensitivity analyses show the robustness of the findings to pre-ESF trends and the inclusion of other municipal-level factors that could be associated with coverage.ConclusionsPHC expansion is associated with reductions in racial group inequalities in mortality in Brazil. These findings highlight the importance of investment in PHC to achieve the SDGs aimed at improving health and reducing inequalities.

The role of structure in manipulating PPP accountability

PurposeThe purpose of this paper is to examine the accounting and governance of public private partnerships (PPPs) that are structured as joint venture partnerships. Drawing on Giddens’ structuration theory, the paper examines how human agents interact with these joint venture structures and analyses the effects on financial disclosures and public accountability for taxpayers’ investments.Design/methodology/approachThe authors adopt a cross-case analysis to investigate two such PPP schemes, which form part of the UK’s programme of investment in primary healthcare, known as the Local Improvement Finance Trust (LIFT) policy. The authors employ a combination of interviews and analysis of financial statements and publicly available official documents.FindingsThe corporate structure of these LIFT schemes is very complicated so that the financial accounting is opaque. The implication is that the joint venture mechanism cannot be relied upon to deliver transparency of reporting. The paper argues that the LIFT structures are deliberately constructed by human agents to act as barriers to transparency about public expenditure.Practical implicationsThe financial reporting undermines public accountability and transparency as both are necessarily restricted. Policy makers should pay attention to not only the private sector technologies but also the manner in which structures are used to reduce transparency and consequently undermine public accountability.Originality/valueThe paper provides detailed analysis from the perspective of structuration theory to show how human agents use structures to impact on financial reporting and public accountability.

A cadeia de valor em saúde: tornar os sistemas de saúde mais sustentáveis

In the current economic crisis, health systems in Portugal and elsewhere in Europe have attempted to increase efficiency in the delivery of health services. However, current approaches to evaluate costs constitute a barrier for creation of value. They lead to cost control measures, which might be ineffective. Cost control without assessment of health outcomes is counterproductive. Although it might result in potential short-term savings, it may limit effectiveness and compromise long-term sustainability. There is evidence that investment in primary health care and disease prevention can reduce the increasing pressure on emergency services, which are more expensive. Attention to health outcomes in relation to costs should define the structure for improvements in the health care system. Focusing on the value of health can release the existing potential for innovation in Portuguese society. A more innovative society will be healthier, more productive, and more resilient to future financial crises.

The Ethiopian Health Extension Program and Variation in Health Systems Performance: What Matters?

BackgroundPrimary health care services are fundamental to improving health and health equity, particularly in the context of low and middle-income settings where resources are scarce. During the past decade, Ethiopia undertook an ambitious investment in primary health care known as the Ethiopian Health Extension Program that recorded impressive gains in several health outcomes. Despite this progress, substantial disparities in health outcomes persist across the country. The objective of this study was to understand how variation in the implementation of the primary health care efforts may explain differences in key health outcomes.Methods and FindingsWe conducted a qualitative study of higher-performing and lower-performing woredas using site visits and in-depth interviews undertaken in 7 woredas. We classified woredas as higher-performing or lower-performing based on data on 5 indicators. We conducted a total of 94 open-ended interviews; 12–15 from each woreda. The data were analyzed using the constant comparative method of qualitative data analysis. Substantial contrasts were apparent between higher-performing and lower-performing woredas in use of data for problem solving and performance improvement; collaboration and respectful relationships among health extension workers, community members, and health center staff; and coordination between the woreda health office and higher-level regulatory and financing bodies at the zonal and regional levels. We found similarities in what was reported to motivate or demotivate health extension workers and other staff. Additionally, higher-performing and lower-performing woredas shared concerns about hospitals being isolated from health centers and health posts. Participants from both woredas also highlighted a mismatch between the urban health extension program design and the urban-dwelling communities’ expectations for primary health care.ConclusionsData-informed problem solving, respectful and supportive relationships with the community, and strong support from zonal and regional health bureaus contributed to woreda performance, suggesting avenues for achieving higher performance in primary health care.

An assessment of progress towards universal health coverage in Brazil, Russia, India, China, and South Africa (BRICS)

SummaryBrazil, Russia, India, China, and South Africa (BRICS) represent almost half the world's population, and all five national governments recently committed to work nationally, regionally, and globally to ensure that universal health coverage (UHC) is achieved. This analysis reviews national efforts to achieve UHC. With a broad range of health indicators, life expectancy (ranging from 53 years to 73 years), and mortality rate in children younger than 5 years (ranging from 10·3 to 44·6 deaths per 1000 livebirths), a review of progress in each of the BRICS countries shows that each has some way to go before achieving UHC. The BRICS countries show substantial, and often similar, challenges in moving towards UHC. On the basis of a review of each country, the most pressing problems are: raising insufficient public spending; stewarding mixed private and public health systems; ensuring equity; meeting the demands for more human resources; managing changing demographics and disease burdens; and addressing the social determinants of health. Increases in public funding can be used to show how BRICS health ministries could accelerate progress to achieve UHC. Although all the BRICS countries have devoted increased resources to health, the biggest increase has been in China, which was probably facilitated by China's rapid economic growth. However, the BRICS country with the second highest economic growth, India, has had the least improvement in public funding for health. Future research to understand such different levels of prioritisation of the health sector in these countries could be useful. Similarly, the role of strategic purchasing in working with powerful private sectors, the effect of federal structures, and the implications of investment in primary health care as a foundation for UHC could be explored. These issues could serve as the basis on which BRICS countries focus their efforts to share ideas and strategies.

Contracting urban primary healthcare services in Bangladesh – effect on use, efficiency, equity and quality of care

To evaluate a large, ongoing effort to improve urban primary health care (PHC) in Bangladesh through expansion of publicly funded urban health facilities and contracting with partner non-governmental organisations (NGOs). A part of Chittagong was assigned to a contracted NGO while the other parts of the city were contracted to the local government. Performance was assessed by baseline and follow-on household surveys, an endline health facility survey and routinely collected data. The results of a health facility survey indicated that overall quality of care was better in the NGO area, and routinely collected data showed that the NGO provided many more services per capita. Based on household survey data, the NGO area of Chittagong was poorer and had lower coverage at baseline. There were significant improvements in both government and NGO-run areas. However, larger improvements were observed on some coverage indicators in the NGO area compared to the government area. Improvements in coverage among the poorest 50% of the population were greater in the NGO-run area. The cost per service delivered was 47% lower in the NGO area. Investments in urban PHC led to an improvement in the coverage of basic services. Contracting with an NGO had an additional effect in terms of improving coverage, equity, quality of care and efficiency. Increased investments in PHC facilities and contracting with NGOs may be effective in improving urban health services.