Innovations in Primary Health Care �Lessons from Brazil

DPHICON, Tamil Nadu

December 2022

Edson C. Araujo

Senior Economist

12/6/2022

Summary

1. Health Systems Sustainability and PHC

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2. Brazil’s PHC Reforms

• Service delivery and financing models
• The Family Health Strategy: evolution and challenges
• FHS and Health System’s efficiency

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Fiscal sustainability of health systems �health spending growth has outpaced economic growth in most countries

Growth in health spending per capita and GDP per capita, historical (2001-2015) and projected (2016-2030)

Source: OECD Health Statistics Database (2018); Guillemette and Turner (2018).

Critical to identify cost-effectiveness interventions => Spending Better

More gov spending on PHC is associated higher coverage, but only spending more does not guarantee improved coverage of core PHC services

Government spending on PHC versus UHC index, 2018

Lancet Glob Health 2022; 10: e715–72

Large variations in UHC Index

Improving health system’s efficiency is a global challenge, critical to sustain UHC gains

Efficiency analysis across EU countries suggests that there could be significant scope (25% of total spending) to increase the efficiency of health spending

Fonte: Medeiros and Schwierz, 2015.

Efficiency gains

PHC has potential to improve population health outcomes and improve health system’s efficiency

• The economic case for investing in PHC
• As the first point of contact with health system with potential to address the majority of health needs

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• And to reduce unnecessary use of more expensive specialized services (prevention and coordination of care)

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• PHC can improve the health of individuals and populations, which can in turn have a positive impact on macro-economic indicators (such as employment rates, productivity and economic growth)

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• Since 1994 Brazil has implemented, expanded and consolidated one of the largest PHC network around the world

Summary

1. Health Systems Sustainability and PHC

​

2. Brazil’s PHC Reforms

• Service delivery and financing models
• The Family Health Strategy: evolution and challenges
• FHS and Health System’s efficiency

​

Key features of Brazil’s PHC Network

• The MoH is responsible for the central management, and the 5570 municipalities are responsible for the organization, management and delivery of PHC services

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• The Brazilian SUS offers preventive services and PHC free of charge to its population (private sector => is supplemental)

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• Multi-professional family health teams (FHTs) are responsible for the delivery of PHC services
• Each FHT is assigned a geographic area, covering up to 4 000 individuals located in non-overlapping areas
• The FHT includes physicians, nurses, and up to six community health workers

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• FHTs are expected to be the initial contact point for patients
• does not work as a “gatekeeper” (Brazilians often have bypass to inpatient and outpatient care)

PHC spending is a priority: MoH is mostly financed by municipalities own resources (61%), complemented by MoH (33%)�

Spending in PHC as a share of current health spending, 2019 or nearest year

OECD (2021), Primary Health Care in Brazil, OECD Reviews of Health Systems,

The number of Family Health Teams has increased by nearly 40% over the last decade

Over 52k FHTs

by 2022

OECD (2021), Primary Health Care in Brazil, OECD Reviews of Health Systems,

SOURCE: SIAB - Sistema de Informação da Atenção Básica

Evolution & Distribution of the FHT Teams – Brazil 2006/11

2006

2005

2004

2011

The number of people registered with a FHT has increased since 2018

Over 165 million

by 20222

OECD (2021), Primary Health Care in Brazil, OECD Reviews of Health Systems,

The expansion of PHC coverage contributed to�significant improvements in population health outcomes

Number of maternal deaths in women aged 10 to 54 years, with an uncertainty interval of 95%, Brazil, 1990-2019

Rev. Soc. Bras. Med. Trop. 55 (suppl 1) • 2022

IBGE, 2019.

Equity: PHC spending proportionally benefits the poorest

World Bank, 2017.

PHC

Hospital care (pub)

Hospital care (pri)

Private Vol Health Insurance

Efficiency: PHC, on average, more efficient than hospital care

PHC efficiency scores

Hospital care efficiency scores

World Bank, 2017.

The more efficient the PHC, the larger is the impact in the municipality’s health system

Relationship between efficiency in primary care and efficiency in medium and high complexity

World Bank, 2017.

The greater the FHT coverage, the more efficient PHC at municipal level

World Bank, 2017.

There are too few PHC physicians in Brazil: Municipalities are responsible for hiring health professionals for PHC, with wide variations across the country

The uneven distribution of medical doctors is a major concern in Brazil

Density of family and community medicine in Brazil per States, 2018

Health workers’ density and GDP per capita by state

World Bank, 2017.

OECD, 2021.

More recently, Brazil has embarked on a major PHC finance reform

• In 2020, a new PHC funding model – Previne Brasil

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• This new funding model substantially modifies the way the MoH transfers resources for PHC to the municipalities

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• The new financing model includes:
• A weighted capitation calculated according to the population registered with the FHTs

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• A Pay-for-performance (P4P)

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• Incentives for strategic actions and priority areas (target 16 programmes)

Parameter of registration by team - by the type of municipality

Weight per registered person – by socioeconomic vulnerability, demographic adjustment and distance adjustment criteria

PHC P4P: Targets and weights assigned for each performance indicator, 2020

The reform simplified the transfer mechanism and increase autonomy for local policy makers to manage resources

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Reforms aligned with the recommendations from the Lancet Commission on PHC financing

Lancet Glob Health 2022; 10: e715–72

The road towards a population-based payment model

Structural challenges remains…

• the Brazilian PHC system is still characterized by:
• relatively low population coverage (although improved 65%)
• large disparities in care quality across regions and poor/reach municipalities, and
• a weak referral system (fragmentation of care)
• FHTs provide a set of limited low-complexity procedures (not comprehensive enough to meet evolving patients’ needs)

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• Tackling these challenges requires:
• strengthening the gatekeeping function
• expand the range of services provided by FHTs
• Expand scope of practice of nurses and other cadres

Lessons from Brazil…

• Brazil has made rapid progress toward universal coverage of its population through its Unified Health System (SUS)

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• PHC, through the FHTs, has been the key strategy to expand health care coverage since the beginning of SUS

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• Remarkable success to improve key population health outcomes (infant mortality rates, maternal health, immunization, and avoidable hospitalization for chronic conditions

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• Balance between decentralization of service delivery and volume/scale of services and capacity to attract health personnel (particularly GPs)

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• Recent PHC financing reform aimed at improving quality and care integration (capitation + P4P)
• A step towards better integration with rest of the system

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Thank you