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      Evolution of the quality of prenatal care in the primary network of Brazil from 2012 to 2018: What can (and should) improve?

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          Abstract

          The article describes the temporal evolution of prenatal quality indicators in the primary health care network in Brazil and investigates regional differences. This study used data from the external evaluation of Brazil’s National Program for Improving Primary Care Access and Quality (PMAQ) with health teams participating in Cycles I, II and III of the Program, carried out respectively in 2012, 2013/14 and 2017/18. The number of visits, physical examination procedures, guidelines and request for laboratory tests were investigated. There was a positive evolution for tests—HIV, syphilis, blood glucose and ultrasound, and for all tests, guidance on feeding and weight gain of the baby and examination of the oral cavity. The indicators that performed the worst were: performance of tetanus vaccine, six or more visits, receiving guidance on exclusive breastfeeding and care for the newborn, and the procedures—all, measurement of uterine height, gynecological exam and cervix cancer prevention. These changes had a varied behavior between the regions of the country.

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          The quality of care. How can it be assessed?

          Before assessment can begin we must decide how quality is to be defined and that depends on whether one assesses only the performance of practitioners or also the contributions of patients and of the health care system; on how broadly health and responsibility for health are defined; on whether the maximally effective or optimally effective care is sought; and on whether individual or social preferences define the optimum. We also need detailed information about the causal linkages among the structural attributes of the settings in which care occurs, the processes of care, and the outcomes of care. Specifying the components or outcomes of care to be sampled, formulating the appropriate criteria and standards, and obtaining the necessary information are the steps that follow. Though we know much about assessing quality, much remains to be known.
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            The Brazilian health system at crossroads: progress, crisis and resilience

            The Unified Health System (Sistema Único de Saúde (SUS)) has enabled substantial progress towards Universal Health Coverage (UHC) in Brazil. However, structural weakness, economic and political crises and austerity policies that have capped public expenditure growth are threatening its sustainability and outcomes. This paper analyses the Brazilian health system progress since 2000 and the current and potential effects of the coalescing economic and political crises and the subsequent austerity policies. We use literature review, policy analysis and secondary data from governmental sources in 2000–2017 to examine changes in political and economic context, health financing, health resources and healthcare service coverage in SUS. We find that, despite a favourable context, which enabled expansion of UHC from 2003 to 2014, structural problems persist in SUS, including gaps in organisation and governance, low public funding and suboptimal resource allocation. Consequently, large regional disparities exist in access to healthcare services and health outcomes, with poorer regions and lower socioeconomic population groups disadvantaged the most. These structural problems and disparities will likely worsen with the austerity measures introduced by the current government, and risk reversing the achievements of SUS in improving population health outcomes. The speed at which adverse effects of the current and political crises are manifested in the Brazilian health system underscores the importance of enhancing health system resilience to counteract external shocks (such as economic and political crises) and internal shocks (such as sector-specific austerity policies and rapid ageing leading to rise in disease burden) to protect hard-achieved progress towards UHC.
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              Child morbidity and mortality associated with alternative policy responses to the economic crisis in Brazil: A nationwide microsimulation study

              Background Since 2015, a major economic crisis in Brazil has led to increasing poverty and the implementation of long-term fiscal austerity measures that will substantially reduce expenditure on social welfare programmes as a percentage of the country’s GDP over the next 20 years. The Bolsa Família Programme (BFP)—one of the largest conditional cash transfer programmes in the world—and the nationwide primary healthcare strategy (Estratégia Saúde da Família [ESF]) are affected by fiscal austerity, despite being among the policy interventions with the strongest estimated impact on child mortality in the country. We investigated how reduced coverage of the BFP and ESF—compared to an alternative scenario where the level of social protection under these programmes is maintained—may affect the under-five mortality rate (U5MR) and socioeconomic inequalities in child health in the country until 2030, the end date of the Sustainable Development Goals. Methods and findings We developed and validated a microsimulation model, creating a synthetic cohort of all 5,507 Brazilian municipalities for the period 2017–2030. This model was based on the longitudinal dataset and effect estimates from a previously published study that evaluated the effects of poverty, the BFP, and the ESF on child health. We forecast the economic crisis and the effect of reductions in BFP and ESF coverage due to current fiscal austerity on the U5MR, and compared this scenario with a scenario where these programmes maintain the levels of social protection by increasing or decreasing with the size of Brazil’s vulnerable populations (policy response scenarios). We used fixed effects multivariate regression models including BFP and ESF coverage and accounting for secular trends, demographic and socioeconomic changes, and programme duration effects. With the maintenance of the levels of social protection provided by the BFP and ESF, in the most likely economic crisis scenario the U5MR is expected to be 8.57% (95% CI: 6.88%–10.24%) lower in 2030 than under fiscal austerity—a cumulative 19,732 (95% CI: 10,207–29,285) averted under-five deaths between 2017 and 2030. U5MRs from diarrhoea, malnutrition, and lower respiratory tract infections are projected to be 39.3% (95% CI: 36.9%–41.8%), 35.8% (95% CI: 31.5%–39.9%), and 8.5% (95% CI: 4.1%–12.0%) lower, respectively, in 2030 under the maintenance of BFP and ESF coverage, with 123,549 fewer under-five hospitalisations from all causes over the study period. Reduced coverage of the BFP and ESF will also disproportionately affect U5MR in the most vulnerable areas, with the U5MR in the poorest quintile of municipalities expected to be 11.0% (95% CI: 8.0%–13.8%) lower in 2030 under the maintenance of BFP and ESF levels of social protection than under fiscal austerity, compared to no difference in the richest quintile. Declines in health inequalities over the last decade will also stop under a fiscal austerity scenario: the U5MR concentration index is expected to remain stable over the period 2017–2030, compared to a 13.3% (95% CI: 5.6%–21.8%) reduction under the maintenance of BFP and ESF levels of protection. Limitations of our analysis are the ecological nature of the study, uncertainty around future macroeconomic scenarios, and potential changes in other factors affecting child health. A wide range of sensitivity analyses were conducted to minimise these limitations. Conclusions The implementation of fiscal austerity measures in Brazil can be responsible for substantively higher childhood morbidity and mortality than expected under maintenance of social protection—threatening attainment of Sustainable Development Goals for child health and reducing inequality.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Formal analysisRole: MethodologyRole: Project administrationRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Formal analysisRole: MethodologyRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Formal analysisRole: MethodologyRole: Writing – original draftRole: Writing – review & editing
                Role: Formal analysisRole: MethodologyRole: Writing – original draftRole: Writing – review & editing
                Role: Formal analysisRole: MethodologyRole: Writing – original draftRole: Writing – review & editing
                Role: Formal analysisRole: MethodologyRole: Writing – original draftRole: Writing – review & editing
                Role: Formal analysisRole: MethodologyRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Formal analysisRole: MethodologyRole: Project administrationRole: Writing – original draftRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS One
                plos
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                18 January 2022
                2022
                : 17
                : 1
                : e0262217
                Affiliations
                [1 ] Department of Social Medicine–Universidade Federal de Pelotas, Pelotas, Brazil
                [2 ] Postgraduate Programme in Epidemiology, Universidade Federal de Pelotas, Pelotas, Brazil
                [3 ] Postgraduate Programme in Family Health (PROFSAÚDE), Universidade Federal de Pelotas, Pelotas, Brazil
                [4 ] Faculty of Medicine, Universidade Federal de Pelotas, Pelotas, Brazil
                [5 ] State Department of Health, Rio Grande do Sul, Brazil
                [6 ] Postgraduate Programme in Nursing, Universidade Federal de Pelotas, Pelotas, Brazil
                University of Cape Town, SOUTH AFRICA
                Author notes

                Competing Interests: The authors have declared that no competing interest exist.

                Author information
                https://orcid.org/0000-0001-7328-6044
                https://orcid.org/0000-0001-9742-5774
                https://orcid.org/0000-0001-6798-9130
                https://orcid.org/0000-0002-6088-3904
                Article
                PONE-D-21-11493
                10.1371/journal.pone.0262217
                8765636
                35041716
                86119993-eaa6-49b2-8290-f2a20b6bc377
                © 2022 Tomasi 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.

                History
                : 7 April 2021
                : 20 December 2021
                Page count
                Figures: 0, Tables: 3, Pages: 13
                Funding
                Funded by: Ministry of Health
                Funded by: Federal University of Pelotas and the Delfim Mendes da Silveira Foundation
                Funded by: University Support Foundation
                The data from this study were produced within the scope of an external evaluation process of the Program for Improving Access and Quality of Primary Care (PMAQ-AB). This program was fully funded by the Ministry of Health, which transferred resources to several federal universities for them to conduct fieldwork in 2012, 2013/2014 and 2017/2018. Resources were decentralized to Universities and managed by supporting foundations. In our case, the Federal University of Pelotas and the Delfim Mendes da Silveira Foundation (FDMS) and the University Support Foundation (FAU). The resources were mainly applied in tickets and daily rates for interviewers, acquisition of tablets and accessories, and research grants. Research grants were not a salary, they were a temporary incentive for researchers to dedicate themselves to the project's activities. Data are available in open access to the entire population. Our research group – and others across the country – has been producing several scientific articles, published in Brazil and abroad, since 2013. In total, the amount transferred to our institution, responsible for 20% of data collection throughout Brazil, was $3,386,415.The Ministry of Health only guided the development and standardization of data collection instruments, so that the information collected by the universities could also be used in the teams' certification process. This certification defined the values of transfers to municipalities. Funders did not participate in data analysis, decision to publish or preparation of the manuscript.
                Categories
                Research Article
                People and places
                Geographical locations
                South America
                Brazil
                Medicine and Health Sciences
                Women's Health
                Maternal Health
                Pregnancy
                Medicine and Health Sciences
                Women's Health
                Obstetrics and Gynecology
                Pregnancy
                Medicine and Health Sciences
                Medical Conditions
                Infectious Diseases
                Bacterial Diseases
                Tetanus
                Medicine and Health Sciences
                Medical Conditions
                Infectious Diseases
                Infectious Disease Control
                Vaccines
                Physical Sciences
                Chemistry
                Chemical Compounds
                Salts
                Sulfates
                Medicine and Health Sciences
                Oncology
                Cancer Prevention
                Medicine and Health Sciences
                Medical Conditions
                Infectious Diseases
                Bacterial Diseases
                Caries
                Medicine and Health Sciences
                Women's Health
                Maternal Health
                Breast Feeding
                Medicine and Health Sciences
                Pediatrics
                Neonatology
                Breast Feeding
                Custom metadata
                The original data are held in a public webpage http://aps.saude.gov.br/ape/pmaq and can be located using the search terms 'cycle 1 PMAQ microdata', 'cycle 2 PMAQ microdata' and 'cycle 3 PMAQ microdata'.

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