Evolução, resultados e eficiência da atenção primária à saúde no Brasil.

Abstract

The study aimed to evaluate the evolution, results and efficiency of Primary Health Care in Brazil. The analysis of evolution considered elements of organization and structure, provision of services and results of primary care in Brazilian municipalities between 2002 and 2019. Negative binomial regressions of panel data with a fixed effect were used to investigate the effect of the population size of the municipalities on the said elements. It was found that municipalities with a smaller population size had higher per capita expenditure, coverage and provision of services. Municipalities with a larger population size had lower morbidity and mortality due to conditions sensitive to primary care. Based on these results, the association of socioeconomic, demographic factors and the structure of municipal health systems with morbidity and mortality due to PHC-sensitive conditions in Brazil was investigated. To this end, negative binomial regressions of fixed-effect panel data were performed. The results indicated that users who lived in municipalities with worse socioeconomic conditions had a higher risk of dying and especially of being hospitalized for conditions sensitive to primary care. Greater access to computed tomography and ultrasound examinations also contributed to reducing the risk of death or hospitalization for the same conditions. Still on the health results of users and the population, the impact of elements of the organization, structure and provision of Primary care services with morbidity and mortality due to conditions sensitive to primary care. To this end, negative binomial regressions of fixed-effect panel data were also carried out, controlled by socioeconomic factors, population size and the structure of municipal health systems. Users who lived in municipalities with greater coverage or provision of services had a lower risk of death and hospitalization for conditions sensitive to primary attention. Per capita expenditure was not associated with mortality, but acted to reduce the risk of hospitalizations. The effect of organization, structure and provision of services was stronger on hospitalizations than on mortality. Finally, the efficiency of primary care processes and results in Brazilian municipalities was evaluated between 2008 and 2019 using the Data Envelopment Analysis technique based on slacks, with product orientation and variable returns to scale. To analyze the environmental and non-discretionary factors that were related to efficiency, second-stage data envelopment analysis was performed using a truncated bootstrap regression. The average efficiency of the municipalities was 66% and 50% for processes and results respectively. In other words, with the same levels of per capita expenditure and number of teams per 3,450 inhabitants, it would be possible to expand the provision of services and reduce deaths and hospitalizations, by reducing the inefficiency of primary care. Municipalities with a smaller population size were more efficient in processes, demonstrating on average greater productivity per team in the period studied. Municipalities with worse socioeconomic conditions were more efficient in processes and less efficient in results. The presence of CT scanners, ultrasound devices and a greater number of specialized medical care visits per inhabitant contributed to increasing the efficiency of results. Greater financial investment in health with municipalities' own resources was also associated with increased efficiency of results. The findings of this thesis reinforce the hypothesis that the context in which each municipality is located impacts its efficiency, therefore the actors involved with the organization and planning of primary care must take these aspects into account, strengthening equity in decision-making, seeking Finally, reduce the inefficiency of primary health care in Brazilian municipalities.