2008年-世界发展银行全球_Brazil_-_Innovative_Approaches_to_Extending_Family_Health_Services_4页_612kb

Summary of the Family Health Extension Project (FHEP) in Brazil

Core Content

The Family Health Extension Project (FHEP), completed in 2002, aimed to enhance the Family Health Program (PSF) in Brazil, which was established in 1994 to shift the health care system from curative to preventive and community-based. The project focused on improving the utilization and quality of publicly-financed health services, especially for the poor, through a combination of innovative financing, training, and management reforms.

Main Views and Key Information

Inequities in Health Outcomes

• In 2000/2001, 45% of Brazil's population lived in poverty, with 23% (35 million) in extreme poverty.
• Poor urban children had better vaccination rates and treatment access for common diseases, but higher disease prevalence.
• The urban poor had worse health outcomes than the rural poor at similar income levels.
• Poor families had 25% lower utilization of health services than non-poor families.
• Child mortality, teenage fertility, and maternal mortality were significantly higher among the poor.

The Family Health Program (PSF) and Its Challenges

• The PSF was built on the Programa de Agentes Comunitarios (PACS), which used community health agents.
• PSF teams included doctors, nurses, and other health professionals, and were responsible for 600–1,000 families.
• The program aimed to expand coverage from 25% (38 million people) to 50% of the population.
• Challenges included:
  • Patchy implementation in urban areas.
  • Lack of clear prioritization criteria for interventions.
  • Inadequate referral systems.
  • Uneven service quality due to shortages of supplies and training.
  • Human resource bottlenecks, including reliance on temporary staff.

Results of the FHEP

• The first phase of FHEP expanded PSF coverage to 187 municipalities, reaching 34.4% of the population.
• Health service indicators improved significantly in municipalities with higher PSF coverage:
  • Prenatal visits increased by 12% in areas with over 60% PSF coverage.
  • Tetanus vaccination coverage increased up to three times in high-coverage areas.
  • Hospital admissions for ARI and diarrhea decreased by 15% and 7%, respectively, in high-coverage areas.
• Training improvements were substantial: from 48% to 86% of PSF staff had relevant training in management, planning, and service delivery.

Innovative Approaches

• Pooled Funding: FHEP pooled IBRD (World Bank) and government funds, reducing transaction costs and ensuring efficient use.
• Performance-Based Financing:
  • A bonus was given to 35 municipalities that met three criteria: fund execution, coverage extension, and accounting transparency.
  • A performance prize was awarded to 12 municipalities based on coverage and financial compliance, with R$6 million in additional transfers.
• Monitoring and Evaluation (M&E) Systems:
  • The project supported the development of M&E systems for PSF.
  • It introduced quality certification systems, referral networks, and performance agreements.

Lessons Learned

• Pooled funding reduced transaction costs and improved program coordination and delivery outcomes.
• Technical assistance is critical, especially for municipalities with low institutional capacity.
• Customized interventions based on capacity assessments are necessary to address local needs.
• Stability and sustainability of health teams require stronger training and employment policies.
• Decentralization demands effective coordination between federal, state, and municipal levels.
• Integration of primary care with specialized services and logistical systems is essential for improving service quality and patient outcomes.

Conclusions

• The PSF has contributed to significant health improvements in Brazil, including a 47% reduction in infant mortality over 14 years.
• However, health disparities persist across regions, income groups, and urban/rural areas.
• The health system remains hospital-centered, limiting affordability and sustainability.
• Non-communicable diseases (NCDs) are now the main cause of death, requiring greater system integration and primary care focus.

Key Takeaways

• The FHEP successfully expanded the PSF to 50% coverage.
• Performance-based financing and pooled funding were innovative tools for improving service delivery and institutional capacity.
• Monitoring and training were essential for ensuring quality and sustainability.
• Community-based health delivery remains a key strategy for reducing health inequities in Brazil.