43721 REACHING THE POOR 2008 WITH HEALTH SERVICES Brazil Reaching the Poor with Health Care--Filling the Cracks in Universal Coverage National Universal Programs in Health Alongside government efforts, non-profit initiatives have also tried to reach the poor. An example of this is the Pas- Universal health care programs are typically created with the torate of the Child--a program launched in 1983 by the objective of improving access to care among the poor and Catholic Church targeting undernourished children and the addressing persistent inequalities. The experience of Brazil poorest children. described here suggests it is possible to conclude that achiev- ing equality in health outcomes requires complementing uni- versal coverage care with other strategies geared at improv- Universal Care but not Reaching Majority ing utilization of available services by the poor. of the Poorest Brazil is among the 12 countries in the world with the Brazil's National Immunization Program, established in 1973 greatest income inequality. Inequality in health outcomes has is a universal program for the entire population to eradicate been recognized as a leading health problem in the Americas. vaccine preventable diseases, e.g., polio, measles, BCG and Brazil has undertaken a number of health initiatives geared at DPT. Services were delivered through the primary care pre- improving access to care among the poorest members of the ventive services at health facilities. To amplify program pen- society. These include: universal primary health care pro- etration, national immunization campaigns were carried out grams, targeting of specific health programs to the poor; pro- to increase awareness of the importance of vaccines in pre- grams that provided cash incentives /rewards to municipalities venting diseases. In addition, availability of services was also who provide care to the poorest families; and cash incentives enhanced through expanding delivery sites to include places to the poorest families of municipalities for the proper utiliza- that the poor usual visit or congregate--such as supermar- tion of available heath and education public services. kets, malls and community centers. Brazil's National Immunization Program was established Results of Brazil's immunization efforts showed that while in 1973 as a universal health services program delivered there were significant increases in vaccine coverage in the through the primary care preventive services at public health 1994­2000 period, the prevalence of incomplete immuniza- centers and polyclinics. The Antenatal Care Program is one tions had its highest concentration in children living in house- of the most traditional of health care services delivered holds in the poorest 20% (or lowest quintile) of the popula- through Brazil's primary care. The PSF family health pro- tion. In Sergipe, a city in northeastern Brazil, a study gram was created in 1994 in an effort to reorganize the pri- conducted in 2000 found that children living in the poorest mary care services. It was proactive in nature, and service 20% of households in the population received the least ben- was to be provided through a team of health care providers. efit from the services provided, as opposed to children in the In 1998 the creation of the Sistema Unico de Saude (SUS-- highest 20% of households--reflecting inequality in cover- United Health System) under the constitution, provided uni- age. Table 1 illustrates the consistency in inequality for the versal health care--health as a right for all regardless of poorest households with national data from 1996 and the income. This effort was meant to address inequality that Sergipe study. resulted from inability to pay for services. www.worldbank.org/wbi/healthandaids The long-established National Antenatal Care Program Table 1. Prevalence of incomplete immunization among also comes up short with respect to reaching the poorest children 12 months and older, by asset quintiles and concentration indexes for DHS/Brazil (1996) and Sergipe women in Brazil. National utilization of antenatal care serv- Study (2000) ices is high, with more than 90% of women having at least one check up and on average, the number of consultations per Wealth DHS (1996) Sergipe (2000) quintiles n = 3827 n = 1436 person is more than six. Whilst the overall coverage of the antenatal care program is good, mothers living in households 1 33.4 28.0 of the least poor seemed to have benefited more from the serv- 2 16.4 20.4 ices provided--reflecting inequality in coverage. The greatest 3 14.2 20.6 concentration of women receiving inadequate antenatal were from families in the poorest quintile--reflecting poor focus 4 11.9 15.5 (Table 2). Both the pro-poor focus and level of coverage of the 5 15.3 17.8 antenatal care program were found to be less than that of the All 19.3 20.5 immunization program. p < 0.001 p = 0.176 Despite achieving major improvements in the nation's ability to address the issues associated with incomplete CI = ­21.8 CI = ­10.8 immunization and inadequate antenatal care, inequality per- DHS Demographic and Health Survey ; CI Concentration indexes. sisted. The families in the poorest 20% of the population Sources: BEMFAM, DHS/Brazil 1996 and J.A. Cesar, Sergipe Study 2000. were consistently among those who did not receive services at all or the services received were incomplete or inadequate in comparison to families in higher income groups. Table 2. Proportion of mothers receiving inadequate The Pastorate of the Child is an example of a non-govern- antenatal care by asset quintiles and concentration indexes for two studies. mental initiative targeted specifically to the poorest children. Launched in 1983 by the Catholic Church, this program is Wealth DHS Sergipe built on volunteer leaders, mainly women, recruited from the quintiles (1996) (2000) local community who give one day a month, delivering infor- 1 70.0 49.1 mation and advice on maternal and child health care-- 2 43.5 48.3 including immunization. The Pastorate of the Child targets 3 27.4 35.3 undernourished children and children from the poorest fam- ilies. Despite its mission, research has demonstrated that this 4 19.1 30.2 program had poor coverage overall and the greatest concen- 5 13.6 18.7 tration of children benefiting were not from the poorest All 38.4 35.7 households nor were they children that were the most under- nourished. This program operated outside the existing public p < 0.001 p < 0.001 primary care structured system, was built on a foundation of CI = ­31.7 CI = ­18.3 volunteerism, and selected volunteer leaders from within the DHS Demographic and Health Survey; SUS Unified Health System; communities being served. This approach puts communities CI Concentration indexes. with the least developed organizational capacity and infra- Sources: BEMFAM, Brazil/DHS 1996; NA Neumann; JA Cesar, Sergipe Study 2000. structure, usually poorer communities, at a disadvantage with respect to benefiting from the service offered. universal population and particularly, the poor. Two pro- poor features of the program are: Addressing Access Barriers Against this background, in 1994 the government of Brazil I. Location of Phased Expansion: As the program was created the PSF family health program in an effort to reor- implemented, it focused first on the poorest areas, as well ganize the primary care services and improve service to the as those that had never before received primary care serv- poor. The principal objectives of PSF were to reach out to the ice, and II. Outreach: PSF program services were provided by health The Sergipe program, in existence since 1996, had the high- teams, each tasked with overseeing the health of selected est concentration representation of families from the poorest households and families. Unlike traditional care giving quintile although participation by families from the highest where the patient/family would visit health facilities seek- income quintile also had increased considerably. ing services for specific problems, the teams reached out to While both cities had a pro-poor focus, the focus of the their clients through home visits as well as community Porto Alegre program was higher. Here, the poorest house- activities. holds were nine times more likely to benefit from the pro- gram than the least poor. In Sergipe, the benefit ratio in The teams were constructed so as to facilitate the identifi- favour of the poorest quintile was only 2.5 times greater. The cation of the factors that represent possible threats to health differences observed are likely due to the different stages of in the community. Interventions were designed to address implementation of the program in the two sites. At the begin- these threats as well as to educate community members ning, coverage is low and the pro-poor focus is high, as about how these health threats can be prevented. Team staff observed in Porto Alegre. Later on, with increased overall included a general practitioner, a registered nurse, a nurse coverage, pro-poor focus decreases, but coverage is still assistant and four community health workers. A monetary higher among the poor. reward was offered to municipalities, through the Ministry of Health, based on their ability to maintain 70 % coverage of Conclusion the population. The PSF program has been implemented in phases across Universal programs many times refer to the intention to make Brazil and in 1996 the national coverage was estimated to be services available to all and not necessarily the actual cover- between 49.8% in the Northeast Region and 26% in the age of all in a country. Brazil's universal programs for immu- South East Region. In Porto Alegre in 2003, where the PSF nization and antenatal care highlight the fact that reaching the program was newly implemented, the proportion of its facil- poor requires specific pro-poor actions to improve access to ities located in areas with families living in households from the poor and vulnerable. The PSF family health program pro- the poorest quintile was highest with minimal representation vides an excellent example of how to do this by improving from households at the highest income quintile (Figure 1). targeting of universal programs. Compared to the evaluated Figure 1. Distribution of wealth status for residents of areas covered by the family health program (PSF), Porto Alegre and Sergipe, and for PSF users, Porto Alegre 50 50 41.0 PSF users PSF residents 40 40 35.7 ntsiop PSF residents 30 e 28.0 26.4 ntsiop 30 e 27.3 24.1 23.8 ag 20.021.1 ag entc 20 entc 20 erp 12.3 10.0 erp 13.2 11.5 10 10 4.6 2.0 0 0 1 2 3 4 5 1 2 3 4 5 wealth quintiles--Porto Alegre wealth quintiles--Sergipe Source: Neumann and others 1999. immunization and antenatal government programs and the terns of usage may provide some insight into these issues and targeted Pastorate of the Child program, PSF reaches the poor help to foster the development of even better approaches at a higher rate than other groups. The evaluation of the PSF geared at improving service utilization in the poorest sector of program suggests that maintaining a focus on the poor, the population. increasing awareness through individual and community edu- cational efforts as well as increasing service reach through Brazil: Are health and nutrition programs reaching the neediest? In: home visits as well as well-placed service sites, can produce Gwatkin DR, Wagstaff A, and Yazbeck AS. Reaching the Poor with greater participation by the poor in the health system. Future Health, Nutrition, and Population Services: What Works, What doesn't and Why. Washington, DC: World Bank; 2005, 353p. studies geared at identifying factors that drive the various pat- www.worldbank.org/wbi/healthandaids