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Effectiveness of primary health care evaluated by a longitudinal ecological approach
  1. Airton T Stein1,
  2. Erno Harzheim2
  1. 1Collective Health Department—Fundação Faculdade Federal de Ciências Médicas de Porto Alegre and Universidade Luterana do Brasil and Gerência de Ensino e Pesquisa do Grupo Hospitalar Conceição, Brasil
  2. 2Post-Graduation Program in Epidemiology, Departamento de Medicina Social, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Brasil
  1. Correspondence to:
 Dr E Harzheim, Rua Álvaro Guterres
 335/504 CEP: 91920-010, Porto Alegre, RS, Brazil; ernoharz{at}

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The expansion of primary health care in Brazil is shaping the agenda for health care policy in the Latin American region.

Brazil is the country with the third worst income distribution in the world and, as a consequence of the unequal distribution of its main determining factors—income, education, living conditions, sanitation, and health service1—the health indicators also present broad inequalities by regions and social classes. Child health, because of greater vulnerability to risks and also to health protective factors, is a clear example of this iniquitous situation in Brazil. In 1999, the child mortality rate in the north eastern region of Brazil was 52.4/1000, while in the southern region it was 17.2/1000 live births.2 A population based investigation performed in 1990–1991, in two cities in the north east3 found 40% of avoidable deaths among the absolute total of children who died aged less than 1 year. One of the strategies of the Ministry of Health to develop the National Health System (SUS), bringing together effectiveness and equity, has been to extend the primary health care network through the Family Health Program (PSF, Programa Saúde da Família). The PSF intends to increase access to health care services, contributing to universalise care, in a context of limited resources. The social groups targeted by this strategy were initially those with greater socioeconomic vulnerability, so as to contribute to reducing the inequities in health.4 Today the PSF is the way into the SUS for over 60 million inhabitants, and is one of the largest primary care programmes in the world.5 Thus, a study like that of Macinko et al,6 which performed a longitudinal evaluation, at a national level, of a broad primary health care strategy, is important to consolidate this model of care in Brazil and also internationally, to contribute scientific evidence on the effectiveness of primary care, more than 25 years after Alma-Atta.

The use of secondary data is quite a useful tool for the analysis of contribution of primary health care. This paper evaluated primary health care in Brazil using an aggregate risk study. Brazilian states were classified by the general level of exposure to the Family Health Program in their environment. It is important to bear in mind that an aggregate risk study is rarely definitive. The main problem is a potential methodological bias (ecological fallacy). Otherwise, its longitudinal ecological approach, controlling for confounding factors, showed the important contribution of the Family Health Program to decreasing infant mortality in Brazil. The PSF should be acknowledged as a collective strategy to optimise health. In this sense, the ecological approach presents advantages to identify the collective effects of this strategy that should not be reduced to a purely individual health action (the “individualistic fallacy”).7

From the perspective of public policies, the study by Macinko et al provides important evidence for managers, professionals, and population on a health action—the PSF—that has occupied an outstanding position in the field of public policies in Brazil. The development of creative strategies to evaluate national public policies in health is important to defend the use of public resources to improve the health conditions of the population and to seek equity, especially in areas with great inequalities such as in Brazil.

Macinko et al show the importance of performing studies using secondary data, and they emphasise that an accessible, comprehensive, coordinated, and longitudinal health care model based on promotion and protection, on early diagnosis, on the return to health of individuals and family, is essential to improve the health indicators. This study also contributes to identifying strategies to monitor the effectiveness of a national programme. Strategies that seek to qualify the public health policies by using scientific evidence, such as The Observatory on Public Policies and Health for Latin America, which is under the leadership of the University of Alicante, value this type of investigation to help managers in decision making.

This paper will certainly help further organisational models for health care in developing countries. It is important to recognise that the current status of each country is unique, but the expansion of primary health care is shaping the agenda for health care policy in the Latin American region.

The expansion of primary health care in Brazil is shaping the agenda for health care policy in the Latin American region.


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