The quality of alternative models of primary health care and morbidity and mortality in Brazil: a national longitudinal analysis

BACKGROUND: Evidence is limited on health benefits from quality improvement of primary healthcare (PHC) in low- and middle-income countries (LMICs). This study investigated whether increasing PHC quality in Brazil with highly-skilled health professionals and integrated community health workers (CHWs) was associated with reductions in hospitalizations and mortality beyond benefits derived from increasing access. METHODS: Annual municipal-level data for 5,411 municipalities between 2000 and 2014 were analysed using fixed effects panel regressions. PHC quality was measured as: i) the proportion of consultations provided by highly-skilled health professionals (doctors and nurses); and ii) the proportion of visits provided by CHWs from multidisciplinary PHC teams. Models assessed associations between PHC quality and hospitalization and mortality from diabetes, cardiovascular disease (CVD), tuberculosis, leprosy, perinatal and maternal causes, and adjusted for PHC access, utilisation, presence of secondary care services, and socioeconomic factors. FINDINGS: A one percentage point increase in the proportion of consultations provided by highly-skilled health professionals was associated with 0•019 fewer deaths from diabetes per 100,000 population (95%CI: -0•034, -0•003; p-value: 0.0167) and 0•029 fewer hospitalizations per 100,000 from leprosy (95%CI: -0•055, -0•002; p-value: 0.0321). A one percentage point increase in the proportion of care provided by CHWs from multidisciplinary PHC teams was associated with 0•025 fewer deaths from CVD per 100,000 (95%CI: -0•050, -0•001; p-value: 0.0442) and 0•148 fewer maternal hospital admissions per 100,000 (95%CI: -0•286, -0•010; p-value: 0.0356). No significant associations were found for the other twenty pairs of exposures and outcomes analysed. INTERPRETATION: Investing in higher-quality PHC models with highly-skilled health professionals and integrated CHWs can deliver reductions in mortality and hospitalizations in LMICs. FUNDING: None.