Impact of Rapid Expansion of the Estrategia de Saude da Familia in Rio de Janeiro: Mixed Methods Evaluation

联合国最近为各国制定了一个目标，以低成本向所有公民提供全面的医疗保健。虽然这是一个值得欢迎的发展，但有人担心，加强初级卫生保健(PHC)在国家和国际计划中没有得到足够的优先考虑，以实现这一目标。这些担忧是基于这样一种认识，即具有更强的PHC的卫生系统往往具有更大的人口覆盖面，能够更好地响应当地的卫生需求，并以较低的成本提供一套全面的好处。没有优先考虑PHC的一个潜在原因是，以前在这一领域的大多数研究都是在北美和欧洲进行的。巴西在过去20年里通过Estrategia Saude da Familia(ESF)对PHC进行了投资。ESF的重点是通过由多学科团队提供以社区为基础的卫生保健，将巴西卫生系统重新定位为PHC。与农村地区相比，ESF在大城市的发展程度要低得多，居住在贫民窟(城市贫民窟)的贫困人口尤其得不到服务。直到最近，里约热内卢的ESF覆盖率还很低(2008年为7%)，但自2011年以来大幅增加(2016年6月达到50%)，反映了在该市实现全民覆盖的政治雄心。ESF在里约热内卢的扩张对健康结果和成本的影响对巴西和国际上大城市的卫生系统应该如何发展具有重要的影响。我们的项目将由一个由来自巴西、英国和美国的研究人员和政策制定者组成的多学科团队进行，其中包括医生、卫生规划师、数学建模人员和社会科学家。它涉及对一个独特的数据库进行量化分析，该数据库将患者的医疗记录(包括初级保健和住院记录)、是否有资格获得国家福利的数据以及该市的死亡人数联系起来。该项目的这一部分将审查对里约热内卢ESF的公共投资是否产生了更好的健康结果，包括降低了因慢性病入院的可能性，以及降低了婴儿死亡风险。它将审查同时参加ESF和一项主要的有条件现金转移计划的个人是否获得了比单独参加每个计划所获得的健康好处更多的好处。该项目还将探索某些群体的患者，包括来自不同种族/民族的患者，是否比其他群体从ESF中受益更多。我们将观察卫生诊所的做法，并与卫生经理、临床医生和患者进行面谈，以了解执行过程中的成功情况和扩大方案的障碍。我们将进行数学建模，以估计在该市进一步扩大该计划的潜在好处，以及如果ESF在巴西其他主要城市扩大，是否会产生类似的好处。我们的项目旨在通过产生和积极传播及时的证据给决策者，特别是在经济危机期间，影响里约热内卢、巴西其他大城市和国际上的PHC的发展。我们将通过将来自里约热内卢的政策制定者和方案执行者纳入我们的研究小组来实现这一目标。我们将与泛美卫生协会在里约热内卢和巴西利亚联合主办宣传活动，与来自巴西各地城市的政策制定者分享调查结果，以便为该国和国际上的政策制定提供信息。我们的评估将为其他寻求在主要城市地区和大城市实现UHC的国家提供重要信息，如哥伦比亚和印度。通过促进来自巴西、英国和美国的在分析关联数据集、微观模拟建模和定性研究方面拥有丰富经验的学者和政策制定者之间的联系，我们将在所有团队成员中培养研究技能和研究翻译能力。

The United Nations has recently set a target for countries to provide comprehensive healthcare at low cost to all citizens. While this is a welcome development, there are concerns that strengthening Primary Health Care (PHC) is not prioritised enough within national and international plans to achieve this. These concerns are grounded in knowledge that health systems with stronger PHC tend to have greater population reach, can respond better to local health needs, and provide a comprehensive set of benefits at lower cost. One potential reason for the lack of priority given to PHC is that most previous research in this area has been conducted in North America and Europe.Brazil has invested in PHC over the last 20 years through the Estrategia Saude da Familia (ESF). The focus of the ESF is to re-orientate the Brazilian health system to PHC through the delivery of community based health care by multidisciplinary teams. The ESF is much less developed in large cities than rural areas, with poor populations living in favelas (urban slums) being especially underserved. ESF coverage was low (7% in 2008) in Rio de Janeiro until recently, but this has increased substantially since 2011(to 50% in June 2016) reflectings political ambition to achieve universal coverage in the city. The impact of ESF expansion in Rio de Janeiro on health outcomes and costs has important implications for how health systems in large cities in Brazil and internationally should be developed.Our project will be conducted by a multi-disciplinary team of researchers and policy makers from Brazil, UK and USA, including doctors, health planners, mathematical modellers, and social scientists. It involves quantitative analyses of a unique database that has linked information from patients' medical records (both primary care and hospitalisation records), data on eligibility for state welfare benefits, and deaths in the city. This component of the project will examine whether public investment in ESF in Rio de Janeiro has produced better health outcomes, including a lower likelihood of being admitted to hospital for chronic conditions and a lower risk of death during infancy. It will examine whether individuals dually enrolled in the ESF and a major conditional cash transfer programme derive health benefits above those obtained from each programme in isolation. The project will also explore whether certain groups of patients, including from different race/ethnic groups, benefit more from the ESF than others. We will observe practices in health clinics and undertake interviews with health managers, clinicians, and patients to understand success in the implementation process and barriers to programme expansion. We will undertake mathematical modelling to estimate the potential benefits from further expansion of the programme in the city and whether comparable benefits may accrue if the ESF is expanded in other major Brazilian cities.Our project aims to influence the development of PHC in Rio de Janeiro, other large cities in Brazil, and internationally by generating and actively disseminating timely evidence to policy-makers especially in a period of economical crisis. We will achieve this by including policy-makers and programme implementers from Rio de Janeiro in our research team. We will jointly host dissemination events with the Pan American Health Association in Rio de Janeiro and Brasilia with policy-makers from cities across Brazil to share the findings in order to inform policy development in the country and internationally. Our evaluation will provide important information to other countries seeking to achieve UHC in major urban areas and large cities, such as Colombia and India. By fostering links between academics and policy makers from Brazil, UK, and USA with extensive experience in analysing linked datasets, microsimulation modelling and qualitative research, we will build research skills and research translation capacity among all team members.