Objectives
As middle-income countries strive to achieve the Sustainable Development Goals (SDGs), it remains unclear to what degree expanding primary care coverage can help achieve those goals and reduce within-country inequalities in mortality. Our objective was to estimate the potential impact of primary care expansion on cause-specific mortality in the 15 largest Brazilian cities.
Design
Microsimulation model
Setting
15 largest cities by population size in Brazil
Participants
Simulated populations
Interventions
We performed survival analysis to estimate hazard ratios of death by cause and by demographic group, from a national administrative database linked to the Estratégia de Saúde da Família (Family Health Strategy, FHS) electronic health and death records among 1.2 million residents of Rio de Janeiro (2010-2016). We incorporated the hazard ratios into a microsimulation to estimate the impact of changing primary care coverage in the 15 largest cities by population size in Brazil.
Primary and secondary outcome measures
Crude and age-standardized mortality by cause, infant mortality, and under-5 mortality.
Results
Increased FHS coverage would be expected to reduce inequalities in mortality among cities (from 2.8 to 2.4 deaths per 1,000 between the highest- and lowest-mortality city, given a 40-percentage point increase in coverage), between welfare recipients and non-recipients (from 1.3 to 1.0 deaths per 1,000), and among race/ethnic groups (between Black and White Brazilians from 1.0 to 0.8 deaths per 1,000). Even a 40-percentage point increase in coverage, however, would be insufficient to reach SDG targets alone, as it would be expected to reduce premature mortality from non-communicable diseases by 20% (versus the target of 33%), and communicable diseases by 15% (versus 100%).
Conclusions
FHS primary care coverage may be critically beneficial to reducing within-country health inequalities, but reaching SDG targets will likely require coordination between primary care and other sectors.