Expanding the primary health care workforce through contracting with nongovernmental entities: the cases of Bahia and Rio de Janeiro.

BACKGROUND: Brazil has experienced difficulties in attracting health professionals (especially doctors and nurses) to practice at the primary health care (PHC) level and in rural and remote areas. This study presents two case studies, each a current initiative in contracting for primary health services in Brazil: one for the state of Bahia and the other for the city of Rio de Janeiro. The two models differ considerably in context, needs, modalities, and outcomes. This article does not attempt to evaluate the initiatives but to identify their strengths and weaknesses. METHODS: Analysis was based on indicators produced by the Brazilian health care information systems, a review of literature and other documentation, and key informant interviews. RESULTS: In the case of Bahia, the state and municipalities decided to create a State Foundation, a new institutional public entity acting under private law that centralizes the hiring of health professionals in order to offer stable positions with career plans and mobility within the state. Results have been mixed as a lower than expected municipal involvement resulted in relatively high administrative costs and consequent default on municipal financial contributions. In the case of Rio de Janeiro, the municipality opted to contract not-for-profit Social Organizations as it made a push to expand access to primary health care in the city. The approach has been successful in expanding coverage, but evidence on cost and performance is weak. CONCLUSIONS: Both cases highlight that improvements in cost and performance data will be critical for meaningful comparative evaluation of delivery arrangements in primary care. Despite the different institutional and implementation arrangements of each model, which make comparison difficult, the analysis provides important lessons for contracting out health professionals for PHC within Brazil and elsewhere.

The equity of admissions to the University Hospital of Brasilia.

BACKGROUND: Brazil has a highly stratified population with large socioeconomic disparities, as evidenced by marked differentiation in health status and access to health services by the population. In addition, the fact that the universal national healthcare system and a liberalised private care model exist side by side leads to increasingly inequitable health outcomes. AIMS: This study aims to appraise the equity of access to the University Hospital in Brasilia, Brazil, in 2013. METHODS: This study was a quantitative analysis of hospital admissions data. The sample included all patients admitted over a six-month period in 2013. Patient data was crossed with socioeconomic data (income and private health insurance status). Frequency tabulations and chi-square calculations were used to describe the patient mix, observe trends and appraise equity of admissions. RESULTS: Analysis of the data showed that the number of patients from each neighbourhood relative to the neighbourhood population was equitable. However, when assessed on the basis of insurance status (i.e., deducting the population covered by private health insurance), a high level of inequity was detected (chi-square 71.828, df 3, p<0,0001) whereby patients from wealthier neighbourhoods were overrepresented compared to those from poorer neighbourhoods. CONCLUSION: This study has shown that access to the University Hospital in Brasilia is not equitable when individual access to private healthcare is accounted for. The results show that dual access to both public and private healthcare is likely to be common, increasing some of the population's access to healthcare while decreasing access for others, and therefore contributing to inequity of access to healthcare services.