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

联合国最近为各国设定了一个目标，即以低成本为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，但人们担心，加强初级保健在国家和国际计划中没有得到足够的重视。这些关切是基于这样的认识，即初级保健能力较强的卫生系统往往覆盖更多的人口，能够更好地满足当地的卫生需求，并以较低的成本提供一整套福利。初级保健未得到优先重视的一个潜在原因是，这一领域以前的研究大多是在北美和欧洲进行的，巴西在过去20年中通过"Saude da Familia战略“对初级保健进行了投资。欧洲社会基金的重点是通过多学科小组提供以社区为基础的保健服务，将巴西保健系统重新定位于初级保健。大城市的ESF远不如农村地区发达，生活在贫民窟（城市贫民窟）的贫困人口尤其得不到充分的服务。直到最近，里约热内卢的ESF覆盖率很低（2008年为7%），但自2011年以来大幅增加（2016年6月达到50%），反映了实现城市全民覆盖的政治雄心。ESF在里约热内卢的扩展对健康结果和成本的影响对巴西和国际大城市的卫生系统的发展具有重要意义。我们的项目将由来自巴西，英国和美国的多学科研究人员和政策制定者组成的团队进行，包括医生，健康规划师，数学建模师和社会科学家。它涉及对一个独特的数据库进行定量分析，该数据库将患者的医疗记录（包括初级保健和住院记录）、国家福利资格数据和城市死亡数据联系起来。该项目的这一部分将审查里约热内卢对ESF的公共投资是否产生了更好的健康成果，包括降低因慢性病住院的可能性和降低婴儿期死亡的风险。它将审查同时参加ESF和一个主要的有条件现金转移计划的个人所获得的健康福利是否高于单独从每个计划中获得的福利。该项目还将探讨某些患者群体，包括来自不同种族/族裔群体的患者，是否比其他人从ESF中受益更多。我们将观察卫生诊所的做法，并与卫生管理人员，临床医生和患者进行访谈，以了解实施过程中的成功和计划扩展的障碍。我们将进行数学模型，以估计进一步扩大该计划在该市的潜在效益，以及如果ESF在巴西其他主要城市扩大，是否会产生类似的效益。我们的项目旨在影响里约热内卢，巴西其他大城市，特别是在经济危机时期，通过及时向政策制定者提供和积极传播证据，在国际上发挥了重要作用。我们将通过让里约热内卢的决策者和方案执行者参加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举办传播活动，巴西各城市的决策者将分享研究结果，以便为国家和国际政策制定提供信息。我们的评估将为哥伦比亚和印度等寻求在主要城市地区和大城市实现全民健康覆盖的其他国家提供重要信息。通过促进来自巴西，英国和美国的学者和政策制定者之间的联系，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的经验，我们将在所有团队成员中建立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.