Contracting for Primary Health Care in Brazil : The Cases of Bahia and Rio de Janeiro
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World Bank Group, Washington, DC
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This study presents two case studies,
each on a current initiative of contracting for primary
health services in Brazil, one for the state of Bahia, the
other for the city of Rio de Janeiro. The two initiatives
are not linked and their implementation has independently
sprung from a search for more effective ways of delivering
public primary health care. The two models differ
considerably in context, needs, modalities, and outcomes.
This paper identifies their strengths and weaknesses,
initially by providing a background to universal primary
health care in Brazil, paying particular attention to the
family health strategy, the driver of the basic health care
model. It then outlines the history of contracting for
health care within Brazil, before analyzing the two studies.
The state of Bahia sought to expand coverage of the family
health strategy and increase the quality of services, but
had difficulty in attracting and retaining qualified health
professionals. Rigidities in the process of public hiring
led to a number of isolated contracting initiatives at the
municipal level and diverse, often unstable employment
contracts. The state and municipalities decided to
centralize the hiring of health professionals in order to
offer stable positions with career plans and mobility within
the state, and chose to create a state foundation, acting
under private law to manage and oversee this process.
Results have been mixed as lower than expected municipal
involvement resulted in relatively high administrative costs
and consequent default on municipal financial contributions.
The state foundation is undergoing a governance reform and
has now diversified beyond hiring for primary care. The
municipality of Rio de Janeiro, which until recently relied
on an expansive hospital network for health care delivery,
sought in particular to expand primary health services. The
public health networks suffered from inefficiency and poor
quality, and it was therefore decided to contract privately
owned and managed, not-for-profit, social organizations to
provide primary care services. The move has succeeded in
attracting considerable increases in funding for primary
health and coverage has increased significantly. Performance
initiatives, however, still need fine-tuning and reliable
information systems must be implanted in order to evaluate
the system.
Palabras clave
ADMINISTRATIVE COSTS, ADMINISTRATIVE RULES, AGED, AMBULATORY SERVICES, ANTENATAL CARE, BASIC HEALTH CARE, BIRTH CONTROL, BLOCK GRANTS, BULLETIN, CARE PERFORMANCE, CHRONIC DISEASE, CITIES, CIVIL SOCIETY ORGANIZATIONS, CLINICS, COMMUNITY HEALTH, COMPLICATIONS, CONTRACTUAL ARRANGEMENTS, DEATHS, DECENTRALIZATION, DELIVERY OF HEALTH SERVICES, DEVELOPING COUNTRIES, DIABETES, DISEASES, DRUGS, ECONOMIC INEQUALITY, ECONOMIC POLICY, ECONOMICS, ECONOMIES OF SCALE, EMERGENCY CARE, EMERGENCY ROOMS, EMPLOYMENT, EQUIPMENT, ESSENTIAL MEDICINES, FAMILIES, FAMILY HEALTH, FINANCIAL CONTRIBUTIONS, FINANCIAL INCENTIVES, FINANCIAL RESOURCES, GOVERNMENT CAPACITY, HEALTH AFFAIRS, HEALTH CARE DELIVERY, HEALTH CARE FACILITIES, HEALTH CARE NEEDS, HEALTH CARE PROVISION, HEALTH CARE WORKERS, HEALTH CLINICS, HEALTH COVERAGE, HEALTH EDUCATION, HEALTH FACILITIES, HEALTH INDICATORS, HEALTH INEQUALITIES, HEALTH INFORMATION, HEALTH INFORMATION SYSTEM, HEALTH INFORMATION SYSTEMS, HEALTH INFRASTRUCTURE, HEALTH ORGANIZATION, HEALTH PLANNING, HEALTH POLICY, HEALTH PROFESSIONALS, HEALTH PROFESSIONS, HEALTH PROMOTION, HEALTH PROVIDERS, HEALTH RISKS, HEALTH SECTOR, HEALTH SERVICE, HEALTH SERVICE DELIVERY, HEALTH SERVICES, HEALTH SPENDING, HEALTH STRATEGY, HEALTH SYSTEM, HEALTH SYSTEM PERFORMANCE, HEALTH SYSTEM REFORM, HEALTH SYSTEMS, HEALTH WORKERS, HEALTHY LIFE, HOME CARE, HOSPITAL, HOSPITAL MANAGEMENT, HOSPITAL SECTOR, HOSPITAL SERVICES, HOSPITAL SYSTEM, HOSPITALS, HUMAN RESOURCE MANAGEMENT, HUMAN RESOURCES, HUMAN RIGHT, HYPERTENSION, ILLNESS, INCOME, INCOME COUNTRIES, INCOME INEQUALITY, INFANT, INFANT MORTALITY, INFORMATION ASYMMETRY, INTEGRATION, INTERNATIONAL ORGANIZATIONS, IUD, LABOR MARKET, LABORATORIES, LARGE POPULATIONS, LAWS, LEPROSY, LIFE EXPECTANCY, LIFE EXPECTANCY AT BIRTH, LIVE BIRTHS, LOCAL GOVERNMENTS, LOW BIRTH WEIGHT, MANAGEMENT OF HEALTH, MANAGEMENT OF PATIENTS, MATERNAL MORTALITY, MATERNAL MORTALITY RATIO, MEDICAL CARE, MEDICAL DOCTORS, MEDICAL EDUCATION, MEDICAL PROCEDURES, MEDICAL RESIDENTS, MEDICAL SCHOOL, MEDICAL STAFF, MEDICINES, MILLENNIUM DEVELOPMENT GOAL, MINISTRY OF HEALTH, MORBIDITY, MORTALITY, NATIONAL LEVEL, NONGOVERNMENTAL ORGANIZATIONS, NURSE, NURSES, NUTRITION, ORAL HEALTH, OUTREACH ACTIVITIES, PATIENT, PATIENTS, PHYSICIAN, POCKET PAYMENTS, POLICY DECISIONS, POLICY MAKERS, POLITICAL DECISION, POOR QUALITY CARE, POPULATION DENSITY, PREGNANCY, PREGNANT WOMEN, PRENATAL CARE, PRIMARY CARE, PRIMARY HEALTH CARE, PRIMARY HEALTH CARE FACILITIES, PRIMARY HEALTH CARE SERVICES, PRIMARY HEALTH FACILITIES, PRIMARY HEALTH SERVICES, PRIMARY HEALTH SYSTEM, PRIVATE SECTOR, PROGRESS, PROVISION OF CARE, PROVISION OF HEALTH SERVICES, PUBLIC ADMINISTRATION, PUBLIC CONTRACT, PUBLIC HEALTH, PUBLIC HEALTH SYSTEM, PUBLIC POLICY, PUBLIC SECTOR, PUBLIC SERVICES, QUALITY IMPROVEMENT, QUALITY OF CARE, QUALITY OF SERVICES, RESPECT, SCHOOL HEALTH, SECRETARY OF HEALTH, SERVICE PROVIDERS, SERVICE PROVISION, SOCIAL ACTION, SOCIAL PARTICIPATION, SOCIAL SECURITY, SOCIAL SECURITY BENEFITS, SOCIAL SERVICES, SOCIOECONOMIC DEVELOPMENT, STATE POLICY, STATE UNIVERSITY, STRATEGIC PRIORITIES, SUSTAINABLE DEVELOPMENT, TUBERCULOSIS, UNIVERSAL ACCESS, UNIVERSITIES, URBAN AREAS, VACCINATION, WOMAN, WORKERS, WORKFORCE, WORLD HEALTH ORGANIZATION