Impact of Rapid Expansion of the Estrategia de Saude da Familia in Rio de Janeiro: Mixed Methods Evaluation

The United Nations has recently set a target for countries to provide comprehensive healthcare at low cost to all citizens. While this is a welcome development, there are concerns that strengthening Primary Health Care (PHC) is not prioritised enough within national and international plans to achieve this. These concerns are grounded in knowledge that health systems with stronger PHC tend to have greater population reach, can respond better to local health needs, and provide a comprehensive set of benefits at lower cost. One potential reason for the lack of priority given to PHC is that most previous research in this area has been conducted in North America and Europe.

Brazil has invested in PHC over the last 20 years through the Estrategia Saude da Familia (ESF). The focus of the ESF is to re-orientate the Brazilian health system to PHC through the delivery of community based health care by multidisciplinary teams. The ESF is much less developed in large cities than rural areas, with poor populations living in favelas (urban slums) being especially underserved. ESF coverage was low (7% in 2008) in Rio de Janeiro until recently, but this has increased substantially since 2011(to 50% in June 2016) reflectings political ambition to achieve universal coverage in the city. The impact of ESF expansion in Rio de Janeiro on health outcomes and costs has important implications for how health systems in large cities in Brazil and internationally should be developed.

Our project will be conducted by a multi-disciplinary team of researchers and policy makers from Brazil, UK and USA, including doctors, health planners, mathematical modellers, and social scientists. It involves quantitative analyses of a unique database that has linked information from patients' medical records (both primary care and hospitalisation records), data on eligibility for state welfare benefits, and deaths in the city. This component of the project will examine whether public investment in ESF in Rio de Janeiro has produced better health outcomes, including a lower likelihood of being admitted to hospital for chronic conditions and a lower risk of death during infancy. It will examine whether individuals dually enrolled in the ESF and a major conditional cash transfer programme derive health benefits above those obtained from each programme in isolation. The project will also explore whether certain groups of patients, including from different race/ethnic groups, benefit more from the ESF than others. We will observe practices in health clinics and undertake interviews with health managers, clinicians, and patients to understand success in the implementation process and barriers to programme expansion. We will undertake mathematical modelling to estimate the potential benefits from further expansion of the programme in the city and whether comparable benefits may accrue if the ESF is expanded in other major Brazilian cities.

Our project aims to influence the development of PHC in Rio de Janeiro, other large cities in Brazil, and internationally by generating and actively disseminating timely evidence to policy-makers especially in a period of economical crisis. We will achieve this by including policy-makers and programme implementers from Rio de Janeiro in our research team. We will jointly host dissemination events with the Pan American Health Association in Rio de Janeiro and Brasilia with policy-makers from cities across Brazil to share the findings in order to inform policy development in the country and internationally. Our evaluation will provide important information to other countries seeking to achieve UHC in major urban areas and large cities, such as Colombia and India. By fostering links between academics and policy makers from Brazil, UK, and USA with extensive experience in analysing linked datasets, microsimulation modelling and qualitative research, we will build research skills and research translation capacity among all team members.

Primary health care strengthening has been insufficiently prioritised in Universal Health Coverage proposals. This may be partly due to lack of evidence from middle-income countries. This project will use mixed methods to evaluate the impact of recent expansion of the Estratégia de Saúde da Familia (ESF) in Rio de Janeiro (RJ). The project has three interlinked work packages:

WP1 An individual-level dataset linking PHC, hospital, mortality and welfare recipient data will be created. We will examine impacts of the ESF on a variety of outcome indicators and whether ESF benefits are similar across key patient characteristics (race/ethnicity, socio-economic status, literacy). We will explore potential synergistic health benefits from ESF and enrolment in a national conditional cash transfer programme (Bolsa Familia). Analytic approaches of the longitudinal dataset will include difference-in-difference analyses with propensity score matching, in addition to individual-level multi-level regression modelling.

WP2 Micro-simulation modelling will exploit the large amount of estimates and parameters obtained from WP1 to model the effectiveness and cost-effectiveness of a variety of ESF coverage scenarios in RJ, and additionally in 16 Brazilian cities with more than 1 million population (where ESF coverage is low and 45 million (22%) of the population live).

WP3: Our qualitative research component will focus on understanding patient and provider perspectives on the introduction of ESF, PHC processes (including comprehensiveness, coordination, and continuity), and health outcomes. Special attention will be given to potential barriers and facilitators to the implementation of the new care model. Data will be collected through three mutually complimentary methods: i) participant observation in family clinics, ii) semi-structured interviews with patients and health care workers iii) focus group interviews of community health workers.

The inclusion of a target to achieve Universal Health Coverage (UHC) in the Sustainable Development Goals (SDGs) is welcome. However, the importance of primary healthcare (PHC) strengthening in achieving UHC is absent from the SDG document. This reflects concerns that PHC is being insufficiently prioritised within UHC proposals at both national and international levels. Our project has the potential to provide important and timely evidence - in much greater detail than currently - to influence health care planning for UHC at local, national and international levels.
In Brazil, understanding the implementation challenges and impacts of the ESF in large cities is vital - as much needed progress in achieving UHC in urban Brazil is threatened by constraints in public expenditure precipitated by economic crisis. Policy-makers in Brazil need confidence in programmes they fund and implement, including detailed understanding of the impact on populations' health and potential un-intended consequences. The political commitment to achieving UHC in Rio de Janeiro (RJ) is an exemplar for studying ESF impacts in urban Brazil and other countries where UHC progress lags in urban areas. Our study aims to contribute to the Brazilian and international PHC evidence through: i) understanding the implementation pathways to rapid PHC expansion in an urban and politically challenging environment; ii) providing in-depth estimates of the impact of the program on a wide range of health outcomes and sub-groups at greater detail than previous studies and using robust methods with casual inference (through the exploitation of individual-level PHC records); iii) supplementing quantitative analyses with qualitative understanding of ESF from patient and health professional perspectives, explaining and validating our findings; and iv) forecasting potential PHC policy scenarios in RJ and other Brazilian cities to highlight the potential impact on health from further expansion and inform policy direction.
The outcomes from this research study not only have the potential to influence global understanding of PHC programmes, but also establish a strong model for policy-maker and researcher relationships. This integrated research package will ensure policy-maker and implementers focus specific research questions to maximum relevance, whilst results can be quickly disseminated and inform implementation actions on the ground. There will be capacity building through joint management and sharing of different data sources, collaborative efforts towards a joint research goal, and improvements in the interface of the research translation pathway. By fostering links with departments with strong experience in micro-simulation and primary care hospital linked datasets, the project will expand local research capacity in Brazil and within partner institutions in the UK and US.
The project will create a novel dataset that links welfare benefit, health care, and mortality data, establishing a leading example of robust impact evaluations. This has been enabled by the investment in electronic medical records (EMRs) within the ESF expansion programme in RJ. The dataset is not only unique in Brazilian context but internationally - i.e. the UK's Clinical Practice Research Dataset has only recently linked PHC records to hospital admissions and mortality data, but has no data on welfare receipt status. The project therefore adds considerable value by creating a legacy dataset that will be available for ongoing policy evaluation and analyses. For example, the dataset will enable Brazil to participate in cross-national benchmarking of health system performance which increasingly involves comparisons of middle and high income countries. The planned application of quasi-experimental experimental designs using routine datasets in the project will be unique to Brazil. This will set an important new benchmark for conducting high quality policy evaluation using routine data sources in MICs.