What is the impact of the Family Health Program on the infant mortality rate?

Responsible researcher: Viviane Pires Ribeiro

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

Article authors: James Macinko, Frederico C Guanais and Maria de Fátima Marinho de Souza

Location of intervention: Brazil

Sample size: 27 Brazilian Federative Units

Big topic: Health

Type of Intervention: Effects of the Family Health Program on the infant mortality rate

Variable of main interest: Infant Mortality

Evaluation method : Experimental Evaluation (RCT)

Assessment Context

The Brazilian Unified Health System (SUS) was created and structured on the principle of universal health coverage as a right for all citizens, with an emphasis on decentralization, equity, comprehensiveness, hierarchization, community participation and complementary participation of the private sector. Since 1990, Brazil has undergone considerable healthcare reforms to implement this vision. The decentralization process, in particular, advanced quickly in the scope of primary health care.

The Family Health Program (PSF) can be considered the most important structural change ever carried out in Brazilian public health. As of 2004, the program covered approximately 66 million people, almost 40% of the entire population, providing a wide range of services that are offered by a team composed of a doctor, a nurse, a nursing assistant and (usually ) four or more community health workers. In some locations, the team also includes professionals from the dental and social fields. Each team is assigned to a geographic area and is responsible for recording and monitoring the health status of the population living in that area, providing primary care services and referring, when necessary, to other levels of care. Each team is responsible for, on average, 3450 people. Doctors and nurses generally provide services in healthcare facilities located within the community, while health workers provide health promotion services during home visits.

Intervention Details

Macinko et al. (2006) used publicly available secondary data to evaluate the impact of the Family Health Program on the infant mortality rate (IMR) over time. The study was carried out through a longitudinal analysis, using panel data from all 27 Brazilian Federative Units (comprising the 26 states and the federal district, Brasília). The period 1990–2002 was chosen by the authors because it includes three distinct periods: prior to the PSF (1990–1994), during the development of the PSF (1995–1998), and the final expansion of the PSF (1999–2002).

Data on infant mortality, PSF coverage area (proportion of the state population served by the PSF program) and health resources were obtained from the Ministry of Health website. Data on other health determinants were based on annual population surveys , conducted by the Brazilian Institute of Geography and Statistics (IGBE) and developed for representation at the state level by the Institute of Applied Economic Research (IPEA).

Methodology Details

Macinko et al. (2006) used fixed effects regression models for the 27 Federative Units. With the infant mortality rate (expressed as the number of deaths of children under 1 year of age per 1,000 births in the same year) as the dependent variable. Infant mortality was used because improving child health is a program priority.

The independent variables included in the model due to their possible influence on the dependent variable were: socioeconomic indicators (proportion of the population with access to clean water supply and per capita income); women's development indicators (female illiteracy and fertility rates); and health service indicators (doctors and nurses per 10,000 inhabitants and hospital beds per 1,000 inhabitants). Additional analyzes were also performed to examine the relationship between program coverage and infant mortality caused by diarrhea and acute respiratory infections.

Results

The results found by Macinko et al. (2006) indicate that during the period from 1990 to 2002, the Infant Mortality Rate declined from 49.7 to 28.9 per 1,000 births. Over the same period, coverage of the Family Health Program increased from 0% to 36%. The 10% increase in program coverage was associated with a 4.5% reduction in IMR, controlling for all other health determinants. Access to clean water and hospital beds per 1,000 population were negatively associated with Infant Mortality Rate, while female illiteracy, fertility rates and average income were positively associated with IMR. Examining the relationship between program coverage and deaths from diarrhea, the results suggest that the program can reduce child mortality. The impact of the program on deaths from acute respiratory infections was ambiguous.

Public Policy Lessons

The Family Health Program is associated with a reduction in the infant mortality rate, suggesting that it is a significant, although not the only, contributor to decreasing infant mortality. In other words, the main determinants of infant mortality in Brazil include: primary care and availability of hospital beds, clean water, income, female literacy and fertility. Thus, existing secondary data provides an important tool for evaluating the effectiveness of health services.

The policy implication is that a comprehensive approach based on improving children's health, with primary health care, can have considerable improvements in outcomes. To inform better policy, future studies could evaluate the cost effectiveness of PSF expansion, its impact on health, and estimate impacts at other levels of analysis (e.g., municipal and individual levels).

References

MACINKO, James; GUANAIS, Frederico C.; DE SOUZA, Maria de Fátima Marinho. Evaluation of the impact of the Family Health Program on infant mortality in Brazil, 1990–2002. Journal of Epidemiology & Community Health , vol. 60, no. 1, p. 13-19, 2006.