title: Expanding the primary health care workforce through contracting with nongovernmental entities: the cases of Bahia and Rio de Janeiro.
abstract: BACKGROUND
  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. 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.
  
  
  METHODS
  Analysis was based on indicators produced by the Brazilian health care information systems, a review of literature and other documentation, and key informant interviews.
  
  
  RESULTS
  In 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.
  
  
  CONCLUSIONS
  Both 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.
authors.affiliation: Consultant, Health, Nutrition and Population Global Practice, The World Bank Group, Brasilia, Brazil.
authors.forename: Megan
authors.initials: M
authors.lastname: Ireland
authors.affiliation: Medical Sciences College, Rio de Janeiro State University, Rio de Janeiro, Brazil.
authors.forename: Luciana
authors.initials: L
authors.lastname: Cavalini
authors.affiliation: Medical School, Federal University of Minas Gerais, Minas Gerais, Brazil.
authors.forename: Sabado
authors.initials: S
authors.lastname: Girardi
authors.affiliation: Health, Nutrition and Population Global Practice, The World Bank Group, Washington, DC, USA.
authors.forename: Edson C
authors.initials: EC
authors.lastname: Araujo
authors.affiliation: Health, Education, Social Protection and Poverty in Brazil, World Bank Group, Brasilia, Brazil. mlindelow@worldbank.org.
authors.forename: Magnus
authors.initials: M
authors.lastname: Lindelow
mesh_terms: D001938:Brazil; D003284:Contract Services; D006076:Government; D006282:Health Personnel; D006297:Health Services Accessibility; D006801:Humans; D009938:Organizations; D011320:Primary Health Care; D019035:Rural Health Services; D012424:Rural Population; D000078329:Workforce