Research and Development, Waymark, San Francisco, California, USA
Public Health Policy Evaluation Unit, Imperial College London, London, UK.
BMJ Open. 2022 Jan 11;12(1):e049251. doi: 10.1136/bmjopen-2021-049251.
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.
Microsimulation model.
15 largest cities by population size in Brazil.
Simulated populations.
We performed survival analysis to estimate HRs 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 HRs into a microsimulation to estimate the impact of changing primary care coverage in the 15 largest cities by population size in Brazil.
Crude and age-standardised mortality by cause, infant mortality and under-5 mortality.
Increased FHS coverage would be expected to reduce inequalities in mortality among cities (from 2.8 to 2.4 deaths per 1000 between the highest-mortality 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% (vs the target of 33%), and communicable diseases by 15% (vs 100%).
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.
随着中等收入国家努力实现可持续发展目标（SDGs），扩大初级保健覆盖范围在多大程度上有助于实现这些目标并减少国内死亡率方面的不平等仍不清楚。我们的目的是估计初级保健扩大对巴西 15 个最大城市特定原因死亡率的潜在影响。
微观模拟模型。
按人口规模排列的巴西 15 个最大城市。
模拟人群。
我们进行生存分析，以根据国家行政数据库中的死亡率和死因死亡率，以及来自里约热内卢 120 万居民的家庭健康战略（FHS）电子健康和死亡记录（2010-2016 年），按人口比例估算死亡的 HR。我们将 HR 纳入微观模拟中，以估算巴西人口 15 个最大城市中改变初级保健覆盖率的影响。
粗死亡率和年龄标准化死亡率、婴儿死亡率和 5 岁以下儿童死亡率。
预计增加 FHS 覆盖范围将有助于减少城市间的死亡率不平等（从死亡率最高的城市到死亡率最低的城市，每 1000 人减少 2.8 人死亡，覆盖率增加 40 个百分点），在福利接受者和非接受者之间（从每 1000 人 1.3 人死亡减少到 1.0 人死亡），以及在种族/族裔群体之间（从黑人到巴西白人，每 1000 人减少 1.0 人死亡）。然而，即使覆盖率增加 40 个百分点，也不足以单独实现可持续发展目标，因为预计将减少非传染性疾病的过早死亡率 20%（而目标为 33%），以及传染病减少 15%（而目标为 100%）。
FHS 初级保健覆盖范围可能对减少国内健康不平等至关重要，但实现可持续发展目标可能需要初级保健和其他部门之间的协调。
