Brazil’s Family Health Program, implemented in 1996 with the intent of providing universal community-based primary care, coincided with a significant decline in the country’s infant mortality rate, according to a study by researchers at New York University and Brazil’s Ministry of Health. The findings appear in the latest issue of the Journal of Epidemiology and Community Health.
The research was conducted by James Macinko, assistant professor of public health in NYU’s Department of Nutritition, Food Studies, and Public Health; Frederico C. Guanais, a doctoral student at NYU’s Robert F. Wagner Graduate School of Public Service; and Maria de Fátima Marinho de Souza, director of the Epidemiologic Analysis Unit at Brazil’s Ministry of Health and a medical school faculty member at the universities of São Paulo and Cuiabá.
Brazil’s Family Health Program is the main government effort to improve primary health care by providing a comprehensive range of preventive and curative health care services delivered by a team composed of one physician, one nurse, a nurse assistant, and several community health workers. The team is responsible for the care of all families in a specific geographic area, usually consisting of about 3,500 people per team. The program’s ultimate aim is to achieve universal access to primary care for all citizens. To measure its impact, the researchers began collecting a variety of health data, from all 27 Brazilian states, beginning in 1990 and ending in 2002, the most recent period for which reliable data were available.
During this 13-year period, the country’s infant mortality rate (IMR) declined from 49.7 to 28.9 per 1,000 live births. During the same period, Family Health Program coverage increased from 0 to 40 percent of the population (about 70 million people). The analyses showed that a 10-percent increase in Family Health Program coverage was independently associated with a 4.5-percent decrease in IMR-in other words, for every 10 percent of the population with access to the program, the researchers found a 4.5-percent additional decline in IMR than was observed in areas without program coverage.
The researchers used a study design that measured, over time, changes in health data by state. They also employed fixed effects analyses to control for state-level characteristics (such as cultural practices and regional differences in infrastructure) that might influence study results. The impact of the family health program was found to be consistent even after controlling for other health determinants, such as socioeconomic conditions (access to adequate water supply, adequate sanitation, and per capita income), women’s development indicators (illiteracy, fertility rate), and health services indicators (the availability of physicians, nurses, and hospital beds).
In spite of the robust nature of the findings, the researchers cautioned against overstating the impact of Brazil’s Family Health Program, noting that it was an important, but not unique, contributor to reduced infant mortality rates in Brazil.
This is because they found other factors that influenced the country’s infant mortality rates: improving water access by 10 percent was associated with a 3 percent reduction in IMR and availability of hospital beds was associated with a much more modest 1.35 percent reduction. Notably, female illiteracy was the most important determinant of infant mortality: decreasing female illiteracy by 10 percent could reduce IMR by as much as 16 percent—a greater amount than all other variables combined.
The policy recommendations were that Brazil’s comprehensive, multi-sectorial approach to promoting child health, with the family health program at its center, was an effective means of improving child survival in Brazil.
The study was supported by the NYU’s Steinhardt School of Education, the Brazilian Ministry of Health, and the National Council for Research and Development of Brazil.