title: Large Reductions In Amenable Mortality Associated With Brazil's Primary Care Expansion And Strong Health Governance.
abstract: Strong health governance is key to universal health coverage. However, the relationship between governance and health system performance is underexplored. We investigated whether expansion of the Brazilian Estratégia de Saúde da Família (ESF; family health strategy), a community-based primary care program, reduced amenable mortality (mortality avoidable with timely and effective health care) and whether this association varied by municipal health governance. Fixed-effects longitudinal regression models were used to identify the relationship between ESF coverage and amenable mortality rates in 1,622 municipalities in Brazil over the period 2000-12. Municipal health governance was measured using indicators from a public administration survey, and the resulting scores were used in interactions. Overall, increasing ESF coverage from 0 percent to 100 percent was associated with a reduction of 6.8 percent in rates of amenable mortality, compared with no increase in ESF coverage. The reductions were 11.0 percent for municipalities with the highest governance scores and 4.3 percent for those with the lowest scores. These findings suggest that strengthening local health governance may be vital for improving health services effectiveness and health outcomes in decentralized health systems.
authors.affiliation: Thomas Hone (thomas.hone12@imperial.ac.uk) is a PhD student in the Public Health Policy Evaluation Unit, Department of Primary Care and Public Health, School of Public Health, at Imperial College London, in England, and a visiting scholar at the Harvard T. H. Chan School of Public Health, in Boston, Massachusetts.
authors.forename: Thomas
authors.initials: T
authors.lastname: Hone
authors.affiliation: Davide Rasella is a Wellcome Trust Research Fellow at the Centro de Pesquisas Gonçalo Muniz, Fundacão Oswaldo Cruz, in Salvador, Brazil.
authors.forename: Davide
authors.initials: D
authors.lastname: Rasella
authors.affiliation: Mauricio L. Barreto is a senior investigator at the Instituto Gonçalo Muniz, Fundação Oswaldo Cruz, and a professor at the Instituto de Saúde Coletiva, Universidade Federal da Bahia, in Brazil.
authors.forename: Mauricio
authors.initials: M
authors.lastname: Barreto
authors.affiliation: Rifat Atun is a professor of global health systems at Harvard University.
authors.forename: Rifat
authors.initials: R
authors.lastname: Atun
authors.affiliation: Azeem Majeed is a professor of primary care in the Department of Primary Care and Public Health, Imperial College London, and a primary care physician in London.
authors.forename: Azeem
authors.initials: A
authors.lastname: Majeed
authors.affiliation: Christopher Millett is a professor of public health in the Department of Primary Care and Public Health, Imperial College London, and a visiting professor at the Center for Epidemiological Studies in Health and Nutrition, Universidade de São Paulo, and in the Department of Epidemiology, Institute of Social Medicine, at the Universidade do Estado do Rio de Janeiro, both in Brazil.
authors.forename: Christopher
authors.initials: C
authors.lastname: Millett
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001938:Brazil; D002648:Child; D002675:Child, Preschool; D002947:Cities / Q000706:statistics & numerical data*; D003695:Delivery of Health Care / Q000458:organization & administration*; D005192:Family Health; D005260:Female; D006078:Government Programs / Q000706:statistics & numerical data*; D006801:Humans; D007223:Infant; D008297:Male; D008875:Middle Aged; D009026:Mortality / Q000639:trends*; D011320:Primary Health Care / Q000458:organization & administration*; D012959:Socioeconomic Factors; D011795:Surveys and Questionnaires; D019472:Universal Health Insurance
keywords: Brazil; International/global health studies; Primary Care; governance; mortality