| dc.description | 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.
Methods and findings
A 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 Famı´lia). 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 Famı´lia) (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.
Conclusions
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.
Increased investment in primary healthcare is likely to improve health and reduce health
inequalities in urban poor populations globally. | |
