Health Systems Research at Imperial College London

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1 Health Systems Research at Imperial College London CONFAP/MRC Workshop Brasília Dr Thomas Hone Research Fellow Department of Primary Care and Public Health

2 About us Department of Primary Care and Public Health (PCPH) Chronic disease management within health systems; Financial risk protection; Impact of smoke-free legislation; Healthcare quality and service performance; Impact of health systems on health outcomes Primary care and Universal Health Coverage (UHC); The Estratégia Saúde da Família; Quantitative research econometrics and biostatistics;

3 Current HSR in Brazil Collaborators at Fiocruz, UFBA, UFRJ, UERJ, and USP; MRC-funded mixed-methods evaluation on the Estratégia Saúde da Família in Rio de Janeiro Data linkage of ~2 million individuals in CadUnico Health and death records Impact evaluations of primary care services New areas of interest: Mais Médicos programme; Private v Public system interactions; healthcare quality; and O Programa Farmácia Popular

4 Global Health OPEN ACCESS Citation: Hone T, Rasella D, Barreto ML, Majeed A, Millett C (2017) Association between expansion of primary healthcare and racial inequalities in mortality amenable to primary care in Brazil: A national longitudinal analysis. PLoS Med 14(5): e pmed Academic Editor: Alexander C. Tsai, Massachusetts General Hospital, UNITED STATES Received: December 19, 2016 Accepted: April 13, 2017 Published: May 30, 2017 Copyright: 2017 Hone et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: All data used in the analyses are available from public websites hosted by Brazilian government agencies. Municipal-level datasets were extracted and downloaded. Data on mortality were obtained from index.php?area=0205&id=6937. Data on health services and health system resources were obtained from DATASUS/index.php?area=0204. Data on health expenditure were obtained from RESEARCH ARTICLE Association between expansion of primary healthcare and racial inequalities in mortality amenable to primary care in Brazil: A national longitudinal analysis Thomas Hone 1 *, Davide Rasella 2,3, Mauricio L. Barreto 2,3, Azeem Majeed 1, Christopher Millett 1,4,5 1 Public Health Policy Evaluation Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, United Kingdom, 2 Centre for Data and Knowledge Integration for Health (CIDACS), Instituto Fonçalo Muniz, Fundação Oswaldo Cruz, Salvador, Brazil, 3 Instituto de Saúde Coletiva, Universidade Federal da Bahia, Salvador, Brazil, 4 Center for Epidemiological Studies in Health and Nutrition, University of São Paulo, São Paulo, Brazil, 5 Department of Epidemiology, Institute of Social Medicine, Rio de Janeiro State University, Rio de Janeiro, Brazil * thomas.hone12@imperial.ac.uk Abstract Background Universal health coverage (UHC) can play an important role in achieving Sustainable Development Goal (SDG) 10, which addresses reducing inequalities, but little supporting evidence is available from low- and middle-income countries. Brazil s Estratégia de Saúde da Família (ESF) (family health strategy) is a community-based primary healthcare (PHC) programme that has been expanding since the 1990s and is the main platform for delivering UHC in the country. We evaluated whether expansion of the ESF was associated with differential reductions in mortality amenable to PHC between racial groups. Methods and findings Municipality-level longitudinal fixed-effects panel regressions were used to examine associations between ESF coverage and mortality from ambulatory-care-sensitive conditions (ACSCs) in black/pardo (mixed race) and white individuals over the period Models were adjusted for socio-economic development and wider health system variables. Over the period , there were 281,877 and 318,030 ACSC deaths (after age standardisation) in the black/pardo and white groups, respectively, in the 1,622 municipalities studied. Age-standardised ACSC mortality fell from 93.3 to 57.9 per 100,000 population in the black/pardo group and from 75.7 to 49.2 per 100,000 population in the white group. ESF expansion (from 0% to 100%) was associated with a 15.4% (rate ratio [RR]: 0.846; 95% CI: ) reduction in ACSC mortality in the black/pardo group compared with a 6.8% (RR: 0.932; 95% CI: ) reduction in the white group (coefficients significantly different, p = 0.012). These differential benefits were driven by greater reductions in mortality from infectious diseases, nutritional deficiencies and anaemia, By Thomas Hone, Davide Rasella, Mauricio Barreto, Rifat Atun, Azeem Majeed, and Christopher Millett Large Reductions In Amenable Mortality Associated With Brazil s Primary Care Expansion And Strong Health Governance ABSTRACT Strong health governance is key to universal health coverage. However, the relationship between governance and health system performance is underexplored. We investigated whether expansion of the Brazilian Estratégia de Saúde da Família (ESF; family health strategy), a community-based primary care program, reduced amenable mortality (mortality avoidable with timely and effective health care) and whether this association varied by municipal health governance. Fixed-effects longitudinal regression models were used to identify the relationship between ESF coverage and amenable mortality rates in 1,622 municipalities in Brazil over the period Municipal health governance was measured using indicators from a public administration survey, and the resulting scores were used in interactions. Overall, increasing ESF coverage from 0 percent to 100 percent was associated with a reduction of 6.8 percent in rates of amenable mortality, compared with no increase in ESF coverage. The reductions were 11.0 percent for municipalities with the highest governance scores and 4.3 percent for those with the lowest scores. These findings suggest that strengthening local health governance may be vital for improving health services effectiveness and health outcomes in decentralized health systems. Universal health coverage is a priority for World Health Organization (WHO) member states 1 and a target of the United Nations Sustainable Development Goals. 2 However, the focus of policy makers and researchers concerned with extending universal health coverage has been on financing, benefit packages, and service coverage,with less emphasis on health systems governance. The WHO asserts that universal health coverage cannot deliver anticipated health benefits in the absence of good governance. 3 Governance can be defined as the combination of political, social, economic and institutional factors that affect the behavior of organizations and individuals and that influence their performance. 4 It includes the steering and rule-making related functions carried out by governments. 5 As a prerequisite for effective policy making, preserving local political commitment, and protecting the achievements of universal health coverage, strong health governance is essential for the implementation of universal health coverage. 6 Health governance is considered to be central to the relationship between spending and improvements in health. 7 Implementation of universal health coverage in many countries is decentralized to local agencies to promote the adaptation of services to local needs, increase accountability to citizens, and encourage the participation of local communities with the aim of increasing service quality and efficiency However, envisaged benefits are unlikely doi: /hlthaff HEALTH AFFAIRS 36, NO. 1 (2017): Project HOPE The People-to-People Health Foundation, Inc. Thomas Hone (thomas.hone12@imperial.ac.uk) is a PhD student in the Public Health Policy Evaluation Unit, Department of Primary Care and Public Health, School of Public Health, at Imperial College London, in England, and a visiting scholar at the Harvard T. H. Chan School of Public Health, in Boston, Massachusetts. Davide Rasella is a Wellcome Trust Research Fellow at the Centro de Pesquisas Gonçalo Muniz, Fundacão Oswaldo Cruz, in Salvador, Brazil. Mauricio L. Barreto is a senior investigator at the Instituto Gonçalo Muniz, Fundação Oswaldo Cruz, and a professor at the Instituto de Saúde Coletiva, Universidade Federal da Bahia, in Brazil. Rifat Atun is a professor of global health systems at Harvard University. Azeem Majeed is a professor of primary care in the Department of Primary Care and Public Health, Imperial College London, and a primary care physician in London. Christopher Millett is a professor of public health in the Department of Primary Care and Public Health, Imperial College London, and a visiting professor at the Center for Epidemiological Studies in Health and Nutrition, Universidade de São Paulo, and in the Department of Epidemiology, Institute of Social Medicine, at the Universidade do Estado do Rio de Janeiro, both in Brazil. Downloaded from by Health Affairs on January 12, 2017 by HW Team PLOS Medicine May 30, / 19 January :1 Health Affairs 149

5 Health Systems Research in Imperial College School of Public Health; Department of Primary Care and Public Health (PCPH). Department for Infectious Disease Epidemiology (DIDE). Institute of Global Health Innovation; Centre for Health Policy. Business School; Centre for Health Economics & Policy Innovation (CHEPI).

6 Opportunities for collaboration School of Public Health PCPH quantitatively-focused evaluations of health services and policies; DIDE health economics focus on health services for infectious disease; Institute of Global Health Innovation, Centre for Health Policy Healthcare innovations factors affecting the diffusion and uptake of health care innovation; Global health and Development Group - health technology assessment and evidence-based health policy; Business School, CHEPI Healthcare regulation, payment, and organisational change;