EVIDENCE BASED PUBLIC HEALTH POLICY AND PRACTICE

Evaluation of the impact of the Family Health Program on infant mortality in Brazil, 1990–2002

James Macinko¹, Frederico C Guanais² and Maria de Fátima Marinho de Souza³

¹ Department of Nutrition, Food Studies, and Public Health, New York University, USA
² Robert F Wagner Graduate School of Public Service, New York University
³ Faculty of Medicine, University of São Paulo and University of Cuiabá; Secretariat of Health Surveillance, Ministry of Health of Brazil

Correspondence to:
Correspondence to:
Professor J Macinko
Department of Nutrition, Food Studies, and Public Health, New York University, 35 West 4th Street, 12th Floor, New York, NY 10012-1172 USA; james.macinko{at}nyu.edu

Objective: To use publicly available secondary data to assess the impact of Brazil’s Family Health Program on state level infant mortality rates (IMR) during the 1990s.

Design: Longitudinal ecological analysis using panel data from secondary sources. Analyses controlled for state level measures of access to clean water and sanitation, average income, women’s literacy and fertility, physicians and nurses per 10 000 population, and hospital beds per 1000 population. Additional analyses controlled for immunisation coverage and tested interactions between Family Health Program and proportionate mortality from diarrhoea and acute respiratory infections.

Setting: 13 years (1990–2002) of data from 27 Brazilian states.

Main results: From 1990 to 2002 IMR declined from 49.7 to 28.9 per 1000 live births. During the same period average Family Health Program coverage increased from 0% to 36%. A 10% increase in Family Health Program coverage was associated with a 4.5% decrease in IMR, controlling for all other health determinants (p<0.01). Access to clean water and hospital beds per 1000 were negatively associated with IMR, while female illiteracy, fertility rates, and mean income were positively associated with IMR. Examination of interactions between Family Health Program coverage and diarrhoea deaths suggests the programme may reduce IMR at least partly through reductions in diarrhoea deaths. Interactions with deaths from acute respiratory infections were ambiguous.

Conclusions: The Family Health Program is associated with reduced IMR, suggesting it is an important, although not unique, contributor to declining infant mortality in Brazil. Existing secondary datasets provide an important tool for evaluation of the effectiveness of health services in Brazil.

Abbreviations: IMR, infant mortality rate; PSF, Programa Saúde da Família; ARI, acute respiratory infections; VIF, variance inflation factor

Keywords: primary health care; Family Health Program; Brazil; health services evaluation; health care reform; infant mortality

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