Transition to universal primary health care coverage in Brazil: Analysis of uptake and expansion patterns of Brazil's Family Health Strategy (1998-2012)

Abstract

Family Health Strategy, the primary health care program in Brazil, has been scaled up throughout the country, but its expansion has been heterogeneous across municipalities. We investigate if there are unique municipal characteristics that can explain the timing of uptake and the pattern of expansion of the Family Health Strategy from years 1998 to 2012. We categorized municipalities in six groups based on the relative speed of the Family Health Strategy uptake and the pattern of Family Health Strategy coverage expansion. We assembled data for 11 indicators for years 2000 and 2010, for 5,507 municipalities, and assessed differences in indicators across the six groups, which we mapped to examine spatial heterogeneities. Important factors differentiating early and late adopters of the Family Health Strategy were supply of doctors and population density. Sustained coverage expansion was related mainly to population size, marginal benefits of the program and doctors' supply. The uptake was widespread nationwide with no distinct patterns among regions, but highly heterogeneous at the state and municipal level. The Brazilian experience of expanding primary health care offers three lessons in relation to factors influencing diffusion of primary health care. First, the funding mechanism is critical for program implementation, and must be accompanied by ways to support the supply of primary care physicians in low density areas. Second, in more developed and bigger areas the main challenge is lack of incentives to pursue universal coverage, especially due to the availability of private insurance. Third, population size is a crucial element to guarantee coverage sustainability over time.

Fig 1. Proposed typology to describe the FHS uptake and coverage expansion in Brazil over 15 years (1998–2012).

Criteria to classify municipalities in each of the six categories included: US–consistently expanded coverage, with only one negative annual growth rate of coverage in the 15-year period, reaching universal (> 95%) coverage in 2012; UU–expanded in an unstable trajectory, with more than one negative annual growth rate of coverage in the 15-year period, but reached universal (> 95%) coverage in 2012; CT–did not reach universal coverage in 2012; EA–implemented the FHS until 2000; and LG–implemented the FHS after 2000.

Fig 2. Municipal distribution of the typology.

Color code for the six groups follows the color scheme shown in Fig 1. Shades of blue represent early adoption and faster expansion; shades of red indicate late adoption and constrained expansion.

Fig 3. Municipal distribution of the typology considering the type of FHS uptake, and the type of FHS coverage expansion.

Color code for the typology groups follows the color scheme shown in Fig 1. Shades of blue represent early adoption and faster expansion; shades of red indicate late adoption and constrained expansion.

Fig 4. Selected municipal characteristics by the type of FHS uptake, and the type of FHS coverage expansion– 2000 and 2010.

Data on access to private insurance refer to 2004 and 2010 (no reliable data available prior to 2004). Private insurance, poverty, illiteracy, Gini Index, population under 5,000, sewage, and ill-defined cause indicate percentages; all the remaining indicators were re-scaled to vary between 0–100. For all variables, a value of 100 represents the most favorable situation in both years taking into account the six groups of municipalities.