Brazil is well known as a country with large social and economic inequalities (Solt, 2016). But in recent years, Brazil has made considerable strides in extending a range of social protections including achieving nearly universal health coverage, expanding community-based primary care through the Family Health Strategy (FHS), and providing a robust conditional cash transfer program (Atun et al., 2015; Guanais, 2015).
This special edition of The Journal of Ambulatory Care Management (JACM) presents a series of articles on Brazil's National Program to Improve Primary Care Access and Quality (PMAQ). The PMAQ, initiated in 2010, is intended to accelerate access to primary care through the FHS while providing resources and pay-for-performance incentives to enhance health care infrastructure and the quality of care provided. The articles contained in the issue vary considerably in their methods and approach, but all make use of data generated as part of the PMAQ's first and second rounds of performance assessment conducted in 2011-2012 and 2013-2014.
The first article, “Diabetes Care in Brazil: Program for Improving Primary Care Access and Quality—PMAQ,” by Tomasi et al. (2017) uses data on 8118 health care users with diabetes from the first PMAQ cycle. In it, the authors identify a series of markers for good-quality diabetes care and determine, using these criteria, that less than one-sixth of diabetic patients interviewed fulfill the criteria for having received high-quality care for their condition. However, in health centers with a complete inventory of inputs and other structure-related items, the prevalence of high-quality diabetes care nearly doubled. The odds of receiving high-quality care were 13% higher when the teams' work process and management were deemed adequate and 14% higher when the teams' clinical practice was deemed adequate, thus illustrating the need to attend to structural reforms and process improvement methods to enhance the quality of care for diabetes.
In “Primary Health Care and Cervical Cancer Mortality Rates in Brazil: A Longitudinal Ecological Study,” Rocha et al. (2017) examined the relationship between preventive actions conducted by the Family Health Teams and trends in cervical cancer mortality rates among Brazilian states over a 10-year period (2002-2012). The authors find that in adjusted models, higher household income, greater population size (a proxy for urbanicity), higher primary health care financing, and the ability to perform colposcopy directly within primary care were all associated with lower than expected rates of cervical cancer mortality. These findings emphasize the potential of the PMAQ in further expanding the availability of technology (such as colposcopy) at the primary care level and in ensuring adequate primary care financing.
“Primary Care Dentistry in Brazil: From Prevention to Comprehensive Care,” by Neves et al. (2017), focuses on another innovative aspect of Brazilian primary care: incorporation of oral health care teams within the primary care facility. The article assesses the association between sociodemographic characteristics, health care indicators, work process characteristics, and the performance of preventive dental procedures by more than 10 000 oral health care teams assessed during the first phase of PMAQ. The authors found that slightly less than one-third of the teams were able to provide all recommended oral health services. Service provision was positively associated with the overall geographic and socioeconomic contexts of the municipality, structural characteristics of the health center as well as specific actions of the health care teams, suggesting a clustering of high-quality care and a synergistic association between better primary care processes and better oral health care.
In their article, Matta-Machado et al. (2017) ask, “Is the Use of Information and Communication Technology Associated With Certain Aspects of Women's Primary Health Care in Brazil? An Exploratory Approach.” The study analyzed incorporation of information and communication technologies (ICTs) including infrastructure, equipment, connectivity, and the use of these technologies in management and health care provision in the primary care teams participating in the second PMAQ cycle (2013-2014). They then assessed the relationship between the presence and use of such technologies and indicators of women's health care, finding a positive association between greater ICT use and higher quality of care in terms of breast and cervical cancer screening and prenatal and postnatal care. They emphasize the relative unevenness of the presence and use of ICTs in Brazilian primary care and advocate for its enhanced adoption in light of its positive benefits for the aspects of women's health examined in the study.
In “Evaluation of Brazilian Primary Health Care From the Perspective of the Users: Accessible, Continuous, and Acceptable?” Fausto et al. (2017) examine the experience of nearly 110 000 primary care users in Brazil in terms of their health care provider's accessibility, continuity, and acceptability using the second round of the PMAQ (2013-2014). Results show that structural aspects of primary care were associated with better indicators of accessibility (especially for oral health care and access to medicines) and continuity of care (patient navigation in the health system). However, the authors did not find an association between structural aspects of primary care centers and indicators of acceptability of care, suggesting an area that requires additional improvement.
In “Evaluation of Primary Health Care Units in Rio de Janeiro City According to the Results of PMAQ 2012,” de Mello et al. (2017) trace the evolution of the FHS in the municipality of Rio de Janeiro. The authors demonstrate the rapid scale-up of the FHS in the city and emphasize the clustering of poorer-quality health centers in some geographic areas.
Taken together, the articles in this edition not only paint a picture of progress made toward expanded primary care access but also identify a series of challenges facing the FHS as it strives to meet the needs of a large, diverse population with limited resources. The data from the PMAQ, one of the world's largest initiatives to improve primary care performance, are beginning to be used to understand the structural and operational constraints faced by frontline health workers. There is scope to develop research using the PMAQ data even further, particularly in terms of determining whether the incentives provided at the municipal level improve delivery, outcomes, and equity in health care in Brazil.
In closing, we wish to thank the Inter-American Development Bank for its support of this supplement, the Brazilian Ministry of Health's Primary Care Department for its collaboration and for making PMAQ data publicly available, the authors for their work and insights, and Dr Norbert Goldfield and the JACM team for their support.
—James Macinko, PhD
Departments of Health Policy and Management and Community Health Sciences
UCLA Fielding School of Public Health
Los Angeles, California
—Matthew J. Harris, DPhil, MBBS, MSc, FFPH
Department of Primary Care and Public Health and the Institute of Global Health Innovation
Imperial College London
London, United Kingdom
—Marcia Gomes Rocha, PhD
Inter-American Development Bank
Atun R., de Andrade L. O., Almeida G., Cotlear D., Dmytraczenko T., Frenz P., Wagstaff A. (2015). Health-system reform and universal health coverage in Latin America. The Lancet, 385(9974), 1230–1247. doi:http://dx.doi.org/10.1016/S0140-6736(14)61646-9
de Mello L. A. F., Tonini T., Sousa da Silva A., Dutt-Ross S., de Souza Velasque L. (2017). Evaluation of primary health care units in the Rio De Janeiro City according to the results of PMAQ 2012. The Journal of Ambulatory Care Management, 40(Suppl. 2), S71–S82.
Fausto M. C. R., Bousquat A., Lima J. G., Giovanella L., de Almeida P. F., de Mendonça M. H. M., da Silva A. T. C. (2017). Evaluation of Brazilian primary health care from the perspective of the users: Accessible, continuous, and acceptable? The Journal of Ambulatory Care Management, 40(Suppl. 2), S60–S70.
Guanais F. C. (2015). The combined effects of the expansion of primary health care and conditional cash transfers on infant mortality in Brazil, 1998-2010. American Journal of Public Health, 105(Suppl. 4), S593–S599.
Matta-Machado A. T., Lima Â., Abreu D., Araújo L., Sobrinho D. F., Lopes É., Santos A. (2017). Is the use of information and communication technology associated with certain aspects of women's primary health care in Brazil? An exploratory approach. The Journal of Ambulatory Care Management, 40(Suppl. 2), S49–S59.
Neves M., do Amaral Giordani J. M., Ferla A. A., Neves Hugo F. (2017). Primary care dentistry in Brazil: From prevention to comprehensive care. The Journal of Ambulatory Care Management, 40(Suppl. 2), S35–S48.
Rocha T. A. H., da Silva N. C., Thomaz E. B. A. F., de Sousa Queiroz R. C., de Souza M. R., Vissoci J. R. N., Staton C. (2017). Primary health care and cervical cancer mortality rates in Brazil: A longitudinal ecological study. The Journal of Ambulatory Care Management, 40(Suppl. 2), S24–S34.
Solt F. (2016). The Standardized World Income Inequality Database. Social Science Quarterly. doi:10.1111/ssqu.12295
Tomasi E., Cesar M. A. D. C., Neves R. G., Schmidt P. R. C., Thumé E., da Silveira D. S., Facchini L. A. (2017). Diabetes care in Brazil: Program for Improving Primary Care Access and Quality—PMAQ. The Journal of Ambulatory Care Management, 40(Suppl. 2), S12–S23.