The Combined Effects of the Expansion of Primary Health Care and Conditional Cash Transfers on Infant Mortality in Brazil, 1998–2010

摘要

Objectives. I examined the combined effects of access to primary care through the Family Health Program (FHP) and conditional cash transfers from the Bolsa Familia Program (BFP) on postneonatal infant mortality (PNIM) in Brazil. Methods. I employed longitudinal ecological analysis using panel data from 4583 Brazilian municipalities from 1998 to 2010, totaling 54?253 observations. I estimated fixed-effects ordinary least squares regressions models with PNIM rate as the dependent variable and FHP, BFP, and their interactions as the main independent variables of interest. Results. The association of higher FHP coverage with lower PNIM became stronger as BFP coverage increased. At the means of all other variables, when BFP coverage was 25%, predicted PNIM was 5.24 (95% confidence interval [CI]?=?4.95, 5.53) for FHP coverage?=?0% and 3.54 (95% CI?=?2.77, 4.31) for FHP coverage?=?100%. When BFP coverage was 60%, predicted PNIM was 4.65 (95% CI?=?4.36, 4.94) when FHP coverage?=?0% and 1.38 (95% CI?=?0.88, 1.89) when FHP coverage?=?100%. Conclusions. The effect of the FHP depends on the expansion of the BFP. For impoverished, underserved populations, combining supply- and demand-side interventions may be necessary to improve health outcomes. Income inequality in Brazil is among the highest in the world, and major inequalities of health status across socioeconomic levels are pervasive despite improvements associated with an expansion in health and social programs since the late 1990s. 1,2 In 1988, a newly drafted federal constitution mandated universal access to health care, leading to the creation of the Unified Health System. The main driver of the early implementation of the Unified Health System was expansion of primary health care, mainly through the Family Health Program (FHP) introduced in 1994. Currently, the FHP has 109.3 million registered users (57.3% of the Brazilian population). The program finances primary care services by teams of health professionals composed of physicians, nurses, technicians, and community health agents serving specific catchment areas. Previous studies have found evidence that, between 1990 and 2004, the FHP reduced levels of infant mortality, ambulatory care–sensitive hospitalization, and adult mortality. 3–8 In 2001, the federal government introduced conditional cash transfer (CCT) programs, which provide cash to poor families if they comply with regular school attendance and growth monitoring. In 2003 CCT programs were overhauled, and the Bolsa Familia Program (BFP) was created. Unlike its predecessors, the BFP included a specific health services utilization component: the program required younger children and their mothers to use preventive care services. The expansion of BFP coverage was very rapid; it included 11 million families by 2006 and peaked at 13 million in 2010. Currently, families enrolled in the BFP receive a monthly cash transfer, averaging US$75.25, and 92% of registered beneficiaries are women. The requirement for participation is uniform across the country and depends on household income per capita and the number and ages of family members. The maximum family income per capita for eligibility is US$70.25 per month. Studies have associated the expansion of the BFP with reduction in poverty and income inequality, positive nutritional outcomes in children, and improvements in school attendance. 9,10 In other countries, similar programs are associated with the increased use of preventive services and improved anthropometric and nutritional outcomes. 11–13 Previous studies argue that the association between primary health care services on the supply side and CCT programs on the demand side should improve health outcomes. 13,14 Low-income families are likely to experience stronger barriers to access to health care services; however, providing cash and requiring families to use preventive care will probably not improve health status if services are unavailable. Despite theoretical expectations, the relationship between the supply- and demand-side aspects of primary health care has not been sufficiently tested in the literature. Important decreases in infant mortality in Brazil and expansions of both the FHP and the BFP occurred between 1998 and 2010 (a figure illustrating this trend is available as a supplement to the online version of this article at http://www.ajph.org ), but, to my knowledge, no study has examined whether these events are related. Recent official data state that infant mortality fell from 29.7 deaths per 1000 live births in 2000 to 15.6 deaths per 1000 live births in 2010. Most of this reduction is associated with improvements in postneonatal infant mortality (PNIM) rates (infants dying between ages 28 and 364 days), which is likely associated with primary care services. 15 Infant mortality is an interesting indicator because of the intrinsic importance of the concept it captures and because it correlates with medical care and socioeconomic devel