University of Sao Paulo, Brazil.
University of Sao Paulo, Brazil.
Public Health. 2019 Jan;166:108-120. doi: 10.1016/j.puhe.2018.10.005. Epub 2018 Nov 23.
The aim of this study was to investigate the effects of primary healthcare decentralization on type 2 diabetes mellitus mortality and morbidity in different municipalities of a developing country.
This was a retrospective study based on a panel of annual data from 5560 Brazilian municipalities from 2000 to 2011.
The investigation used the staggered municipal adoption of a federal health information program as a quasi-experiment to identify the treatment effects of health decentralization on diabetes indicators. Using Difference-in-Differences models and instrumental variables, we analyzed the effects of primary healthcare decentralization on diabetes rates (i.e. diabetes deaths and hospitalizations by the number of people with a diabetes diagnosis and by population).
Evidence suggests improvements in universal access to primary health care and progress in the average health outcomes related to diabetes mortality (reduction of 30%) and hospitalization (reduction of 2.3%) due to decentralization. Effects are further pronounced in developed regions with higher incomes, while the poorest and less developed regions showed virtually no effect.
These results demonstrate that there are particular preconditions for successful primary health decentralization, especially related to returns of scale (big health facilities are associated with low cost per treatment), lack of human and physical capital, and government coordination problems.
本研究旨在探讨发展中国家不同城市基层医疗去中心化对 2 型糖尿病死亡率和发病率的影响。
这是一项基于 2000 年至 2011 年来自巴西 5560 个城市的年度面板数据的回顾性研究。
该研究利用联邦卫生信息计划在各城市交错采用作为准实验，以确定卫生去中心化对糖尿病指标的治疗效果。采用双重差分模型和工具变量法，分析了基层医疗去中心化对糖尿病率（即糖尿病死亡人数和按糖尿病诊断人数和人口计算的住院人数）的影响。
证据表明，由于去中心化，全民获得初级卫生保健的机会得到了改善，与糖尿病死亡率（降低 30%）和住院率（降低 2.3%）相关的平均健康结果也有所进展。在收入较高的发达地区效果更为显著，而最贫困和欠发达地区几乎没有效果。
这些结果表明，基层卫生去中心化存在特定的成功前提条件，特别是与规模回报（大的卫生设施与每次治疗的低成本相关）、人力和物力资本的缺乏以及政府协调问题有关。
