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标题：Impact of the Family Health Program on Infant Mortality in Brazilian Municipalities
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作者：Rosana Aquino ; Nelson F. de Oliveira ; Mauricio L. Barreto 等
期刊名称：American journal of public health
印刷版ISSN：0090-0036
出版年度：2009
卷号：99
期号：1
页码：87-93
DOI：10.2105/AJPH.2007.127480
语种：English
出版社：American Public Health Association
摘要：Objectives. We evaluated the effects of the Family Health Program (FHP), a strategy for reorganization of primary health care at a nationwide level in Brazil, on infant mortality at a municipality level. Methods. We collected data on FHP coverage and infant mortality rates for 771 of 5561 Brazilian municipalities from 1996 to 2004. We performed a multivariable regression analysis for panel data with a negative binomial response by using fixed-effects models that controlled for demographic, social, and economic variables. Results. We observed a statistically significant negative association between FHP coverage and infant mortality rate. After we controlled for potential confounders, the reduction in the infant mortality rate was 13.0%, 16.0%, and 22.0%, respectively for the 3 levels of FHP coverage. The effect of the FHP was greater in municipalities with a higher infant mortality rate and lower human development index at the beginning of the study period. Conclusions. The FHP had an important effect on reducing the infant mortality rate in Brazilian municipalities from 1996 to 2004. The FHP may also contribute toward reducing health inequalities. Despite stagnation in economic growth, civil wars, and the HIV/AIDS epidemic, with the exception of a few countries in Africa and Asia, infant mortality continued to decline throughout the 1990s in developing countries, although the rate of decline was less than in the 2 previous decades.¹ Although social and economic factors are still fundamental determinants of these trends, even in contexts of recession and economic crisis, the persistent reduction in infant mortality draws attention to other factors. Support is increasing for the idea that the decline in infant mortality is the result of a broad range of determinants, many of which result from social policies that were implemented during this period.^{2 – 4} However, although different actions by health systems affect infant mortality, few studies have evaluated the total impact of programs, such as primary health care ones, that combine a set of interventions aimed at various risk factors.⁵ In Brazil, infant mortality rates have shown important declines in recent decades but are still higher than expected when compared with other countries with similar economies.^{6 – 8} Concerning the principal determinants of the observed downward trends, studies have pointed to the importance of implementing public policies in basic sanitation and nutrition; the sharp drop in fertility, especially in the 1980s; and the expansion of primary care services, especially maternal and child health programs.^{6 , 9 – 11} Since 1994, the Family Health Program (FHP) has been an important pillar in the reorganization of the Unified National Health System, whose organizational principles include universality and equity. By 2004, the program had been implemented in 82% of Brazil's 5561 municipalities, covering some 40% of the total national population. The FHP is centered on a family and community approach in which multiprofessional teams (including physicians, nurses, community health agents, and oral health professionals) work under the principles of comprehensive care.¹² Each FHP team is responsible for permanent and systematic follow-up of a given number of families residing in a circumscribed area and for establishing ties of commitment and shared responsibility.¹² Priority actions in the FHP include promotion, prevention, and care for mothers and children, such as the promotion of breastfeeding, prenatal care, neonatal and under-5 care, immunization and other actions toward prevention, and management of infectious diseases such as diarrhea.¹² The year 2008 marks the 30th anniversary of the Alma–Ata Declaration, which advocated primary health care based on the principles of community participation and the use of appropriated technology in health promotion and disease prevention and control. Worldwide, primary health care principles have received great attention, and the need to renew and adapt these principles in different contexts has been stressed. Several international initiatives provide opportunities to discuss and evaluate countries’ efforts to provide health for all and produce recommendations about the role of primary health care given the complexity of today's health challenges.^{13 – 15} In our study, we evaluated the effect of the implementation of the FHP on infant mortality rates in Brazilian municipalities from 1996 to 2004. The FHP strategy in Brazil and the availability of nationwide data provide a unique opportunity for evaluating the impact of a comprehensive program, rather than merely isolated health measures.