Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Project Name Region Task Team Leader Sector Project ID Number Borrower Brazil-Family Health Project Latin America and the Caribbean Gerard La Forgia Report No. PID10183 Other Population, Health & Nutrition BRPE57665 Government of Brazil Implementing Agency Ministry of Health - Secretaria de Saude Ms. Patricia Leal Task Team Leader Project Coordinator Ministry of Health Bloco G, Ed. Sede, 8 andar Suit 823 Brasilia DF70058-900 Brazil Phone: 55-61-315-2046 Fax: 202-522-0050 Email: Patricia.raupp@saude.gov.br Environmental Category Date this PID Prepared November 8, 2001 Appraisal Date November 12-16, 2001 Project Board Date January 31, 2002 1. Country and Sector Background Main Sector Issues C Brazil's Poor Have Poor Health Outcomes. The most recent poverty assessment for the country estimates that 23 percent (35 million) of the population lives in extreme poverty and 45 percent lives in poverty. Approximately half of the poor live in urban areas. The health status of the Brazilian poor is significantly worse than that of the non-poor. Children of poor families have three times higher risk of dying before the age of 5 than children from the wealthiest segments of the population. While poor urban children have better vaccination rates and are more likely to be treated for diarrhea and ARI than their rural counterparts, the prevalence of these childhood illnesses (diarrhea and ARI) among the urban poor is higher. Although the urban poor have better access to health services during childhood than the rural poor, the higher urban infant mortality raise questions about the timeliness, continuity and quality of care received, and/or the severity of the underlying illness. Improving Performance Through Decentralization Depends on Improved Management Capacity at the Municipal Level. Brazil has taken an incremental approach to decentralization and health system reform. Initiated with the constitutional reforms of 1988 and supported by laws, decrees, and regulations spanning the 1990s, decentralization has transformed SUS from a centralized
system to one in which municipalities, and to a lesser extent states, are the main players in the organization and delivery of public health services. Although there is no hard evidence demonstrating the effect of decentralization on health status, service quality or system efficiency and equity, the MS as well as outside observers have noted a number of shortcomings in the decentralization process that may threaten future system performance and PSF expansion: (i) mismatch between delegated responsibilities and existing institutional capacity of many municipalities; (ii) unclear division of responsibilities between states and municipalities particularly in terms of planning, supervision and financial and information flows; (iii) weak municipal capacity to organize and manage health service delivery, in part due to a dearth of trained management professionals; (iv) absence of systematic monitoring and evaluation; (v) tendency of municipal managers to focus on inputs rather than results and outputs; and (vi) inability of many states and municipalities to implement functional referral systems. Reforms in Financing of Health Services are Advancing but Remain Incomplete. Recent reforms in health financing gave a strong impulse to the decentralization of basic care, strengthened the resource base available for health and demonstrated the government's strategy of gradual improvement of the health financing system. In 1998 the federal Government replaced fee-for-service reimbursements for basic interventions by a system of per-capita transfers for primary care (PAB -- Piso Assistencial Basico). The amount capitated is augmented to municipalities that adopt priority programs promoted by the government, such as the PSF. After years of struggling with temporary measures, in 2000 Congress approved Constitutional Amendment 29 (EC 29), mandating an increase in the funding levels for the health sector by the federal government (linking growth in health sector financing to GDP growth), and earmarking 12 percent of state revenues and 15 percent of municipal revenues to the health sector. Despite vigorous federal action to increase financing for health care and introduce alternative payment systems, with the intention of creating an equitable and rationalized system, virtually all observers agree that the reform agenda is far from complete. Currently, the Brazilian health system continues to be characterized by: (a) insufficient linkage between financial mechanisms and health priorities; (b) poor incentives for managers of primary care units (mostly municipal) and hospitals (mostly private) to use public resources efficiently; (c) management weaknesses at the municipal level, particularly in managing the PAB and applying these resources to purchase effective service delivery, in using information for monitoring and evaluating performance, and for taking strategic corrective actions; and (d) absence of rigorous analyses of resource use. The Family Health Program Has Major Potential, but Faces Obstacles to Future Expansion. PSF was launched in 1994 building on the strengths of its 1991 predecessor, the PAC (Programa de Atencao Comunitaria). PSF was conceived as a lynchpin in the transformation of the mainly curative and hospital-centered health care system toward one that is oriented toward prevention, promotion and basic care. The program seeks to develop high-quality primary care services that serve vulnerable populations in a proactive manner; eventually these services are expected to serve as an entry point to higher level services. PSF organized community agents into teams, which typically include a general practice or family health physician, a nurse, one or two auxiliary nurses and more recently a part-time dentist and/or dental technician. The PSF built upon the PAC by providing the teams with equipment (medical, transport, and basic information technology), -2 -
a standardized system of work and reporting requirements. Each team is assigned the responsibility of providing care to a defined set of 600-1,000 families with use of standardized protocols. Several evaluations and assessments of PSF have been conducted by the government and other agencies. The main benefits found by these studies can be summarized as follows: (a) Increased coverage of basic care in small size municipalities with high infant mortality rates; (b) High acceptance of the program by health professionals and users; (c) Successful vehicle for channeling other government programs to the community and enhancing multisectoral collaboration; and (d) Positive impact on performance and outcome indicators, including: increased production of and access to basic health services; reduced hospital admissions and hospital care; and reduced infant mortality. Despite these accomplishments, the government's PSF strategy faces significant challenges, including: Limited coverage in large urban areas Inconsistent targeting and priority-setting: Inadequate referral systems: Uneven quality of PSF services: Human resource supply bottlenecks in terms of quantity and quality: Unstable contractual arrangements: 2. Project Objectives: a. Increase access to and utilization of basic health care services among low-income populations in urban centers with populations of 100,000 or greater, through expansion of the PSF, development of a referral and counter-referral system, and improvement in the management and organization of basic health services; and b.improve the quality of family health service provision through developing and strengthening in-service and pre-service training of human resources in the PSF model; c. Improve the performance and effectiveness of basic care services through strengthening monitoring and evaluation, information management and accreditation systems. 3. Rationale for Bank's Involvement: Project Alternatives Considered and Reasons for Rejection No project alternative: As a result of recent government financial forms, the health sector will benefit from increased funding during the foreseeable future. Bank financial participation in PSF expansion is important but not a critical factor. GOB and Bank agreed, however, that the value added of the loan and Bank involvement would be to assist the MS: (i) introduce outputsand performance-based approach toward PSF implementation and expansion; (ii) transform primary care practices to a PSF model; (iii) insert PSF implementation into recently approved decentralization reforms (NOAS 01/01); - 3 -
and (iv) develop and implement strong monitoring and evaluation in support of PSF implementation. Standard investment operation: After considerable analysis, both the Borrower and the Bank agreed on utilizing the Adaptable Program Lending to support the proposed project given the following considerations: (I) the long term horizon for meeting the program's developmental objectives; (ii) the existence of a sound sector reform program developed by the government; and (iii) the GOB's decision to stage the PSF expansion and decentralization reforms because of the level of complexity of these activities and the need for piloting new arrangements not fully evaluated yet in the sector. The APL will support the GOB's incremental approach to PSF expansion and sector reform, while "locking in" long-term institutional and political commitment to the program. Focus on rural vs. urban areas: The project will focus on extending PSF to urban areas. There is already substantial coverage in rural areas as MS focused PSF expansion there during the first implementation stage (1997-2001). Coverage extension in rural areas also was relatively easy due to weak presence of municipal providers, population density and interest from political leaders. One of the goals of the FHP is to reach the poor and underserved. In this context, urban targeting is also justified because 38 percent of those in the poorest income quintile live in urban areas, and health indicators among the urban poor are as bad or worse than indicators among the rural poor. 4. APL Program Description The FHP supports the Government's efforts to expand its successful PSF to large municipalities, with the expectation that it will increase access to, utilization of, and health benefits from basic health services, organized around the work of family health teams. The FHP provides technical and financial resources for the creation and strengthening of family health teams in most of the country's large metropolitan areas; development of sustainable in-service, pre-service and specialty training programs for members of the family health team; and large-scale, long-term improvements in monitoring and evaluation of PSF performance across the country. The program will finance a variety of inputs, including small-scale remodeling of primary care units, medical and non-medical equipment, vehicles, training and consultancy services. Approximately 40 percent of the financing will be allocated through municipal subprojects; the remainder will be administered directly by the MS, and will fund activities that yield national benefits. The six-year APL has three two-year phases. The first, two-year phase will support extension of the PSF to large urban municipalities, expansion of training opportunities for PSF team members, and development of core systems to enhance quality and performance of PSF provision. The second, two-year phase will support continued roll-out of the PSF in urban municipalities, strengthen the quality of institutions providing PSF-related training, and implement systems to improve quality and performance of PSF provision. The final phase will continue to support the roll-out of the PSF urban municipalities, consolidate PSF expansion and conversion in urban municipalities, produce PSF trainees on a systematic basis, and institutionalize support systems for quality and performance. 5. Project Description -4-
Component 1. PSF Municipal Expansion and Institutional Modernization (US$56.6 million) This component will directly support the expansion of the population covered under the PSF in approximately 50 municipalities with populations of over 100,000 inhabitants through the conversion of the organization and provision of basic health services from a traditional model to the prevention, outreach- and performance-oriented PSF model; and the strengthening of a decentralization regime, following the NOAS/01/01 regulatory framework. The specific objectives of the component are to: (a) expand access to and utilization of basic health services by populations at risk in urban areas, which currently are underserved, through the implementation of the PSF model and upgrading of the service network; (b) establish functional referral and counter-referral systems through establishment of integrated service networks; (c) strengthen the system of PSF management and organization; and (d) improve the performance of the municipal providers of basic health services through development of performance-based organizational and management models, and the introduction of new health care practices. Municipalities seeking support under the project will submit a Conversion Plan (Plano de Conversao), following selection criteria and guidelines established by the MS, and included in the project's Operational Manual. The guidelines will draw on PSF strategies, institutional requirements stipulated in NOAS 01/01 regulations (regarding regionalization, formation of networks and organization and management of health services) and analyses of successful experiences to transforming traditional primary care to the PSF model. It is expected that Conversion Plans will take into account local conditions, such as installed capacity, demand, facilitating and constraining factors, special health priorities and others. Simulating the APL modality, interested municipalities will be required to present a broad description of six-year conversion program including end-of-program performance targets as well as a detailed description of activities and performance indicators to be achieved during the two-year project. The Conversion Plans will form the basis for agreements (Convenios) between the participating municipalities and the MS. The Conversion Plan, will be evaluated by a Technical Committee organized by the MS. Once approved by the MS, each Conversion Plan will be implemented as an investment subproject by the selected municipalities, consisting of four parts, which correspond to the four subcomponents described below: (a) Institutional modernization: Through financing of consultancy services and training workshops, seminars and materials, activities will seek to strengthen municipal capacity to regulate, organize, manage and provide health services through developing and implementing performance-based management agreements, policies and regulations for contracting human resources and instruments for monitoring community participation. The subcomponent will also support the preparation of municipal investment plans, referral and counter-referral systems and family health practice protocols. (b) Upgrading of municipal health service provision: Activities under this component are intended to improve the service delivery capacity of municipal - 5-
primary care providers through supporting remodeling of health centers and polyclinics, procurement of medical and non-medical equipment, furniture, vehicles and operating costs. (c) Strengthening of municipal information systems: This subcomponent will support incorporation and use of information technologies for planning and monitoring and evaluating health system organization and performance. Financing will include consultancy services, computer equipment and software and training workshops and materials. (d) Training and supervision: Activities will include development and implementation of training courses in strategic areas and work processes in support of PSF expansion, the conversion process and strengthening of supervisory systems. The subcomponent will finance consultancy services and training, workshops, seminars, publications and materials. Component 2. PSF Human Resource Development (US$60.9 million) This component will support the implementation of a human resource policy that contributes to the expansion of the PSF model; strengthens the qualifications and performance of family health professionals and PSF teams; and introduces new contents and methods in the preparation of health professionals. This component will have a national focus and be managed through the Project Management Unit (PMU). The objectives of the component are to: (a) increase the number and quality of PSF human resources; (b) expand and strengthen pre-service and in-service training for PSF human resources; (c) expand and strengthen programs for professional training, including residencies in family health, specialty training for physicians, nurses and dental hygiene assistants; and (d) introduce special programs (such as training center consortiums and virtual networks to exchange information) and demonstration projects that support and strengthen the human resource development activities. Many of the activities financed under Component 2 will be implemented through the P6los de Capacita6ao, training centers that offer courses and training modules directed at professionals on the Family Health Team. In addition, there are approximately 100 institutions of higher learning-universities, faculties and medical and nursing schools-which together with the State and Municipal Health Secretariats will be able to participate in the Program. Activities for the para-professional members of the team, particularly in the case of dental technicians, will be implemented through Technical Health Schools (Escolas Tecnicas de Saude), which are linked to the State and Municipal Health Secretariats. Existing contracts with training institutions will be supported under this subcomponent, as well new contracts, selected on a competitive basis. Activities are grouped into three subcomponents: (a) In-service training of PSF professionals and para-professionals: This subcomponent aims to strengthen PSF service organization and provision by supporting in-service training for several types of service managers, health professionals (doctors and nurses) and para-professionals (community health agents). Through financing training (consultancy services and workshops) and training materials and publications, training programs will be developed and implemented in clinical practices, public health, health planning, and clinical and non-clinical management. - 6-
(b) Pre-service and specialty training of PSF professionals: Through financing consultancy services, scholarships, internships and training workshops, conferences, materials and publications, this subcomponent will provide pre-service training to professionals relevant to the organization and provision of services under the PSF model. This subcomponent will support the development and expansion of programs that prepare health managers, family health physician and nurse specialists, dental hygiene assistants and community health agents. (c) Demonstration activities to support training and education: This subcomponent seeks to improve the quality and quantity of training opportunities for current and future members of PSF teams. This will be accomplished through the creation of regional networks of training centers, creation and maintenance of web-based clearinghouse for training materials, and piloting of curriculum development programs in medical and nursing schools to develop new and improved educational methods and materials relevant to the family health discipline. The subcomponent will finance consultancy services, audio-visual equipment, training workshops, conferences, materials and publications. Project Component 3. Monitoring and Evaluation (US$ 14.0 million) Under this component, rigorous and coordinated monitoring and evaluation methodologies will be employed to assess the structure, processes, outputs and impact of the PSF. This will entail an effort to build on, improve and integrate several existing information systems in the health sector. In addition, evaluation methodologies, instruments, strategies and plans developed under other FHP components will be applied. The primary objectives of the component are to: (a) create systems for permanent, cost-effective monitoring and evaluation of the PSF and the training institutions' performance; and (b) develop and implement systems of accreditation of basic family health units and PSF training centers. The project will provide a central source of financing for four subcomponents, described below. Activities will be conducted on a national basis, and will be managed through the Project Management Unit (PMU) within the MS. As necessary, the MS may enter into subcontracts with universities and/or technical institutions for management of research. (a) Strengthening of monitoring systems: Activities will support the consolidation and standardization of monitoring systems and instruments for basic health care. It will strengthen PSF monitoring, incorporate performance measures into monitoring systems, expand and strengthen regional technical support centers (Centros Regionales de Capacitacion para o Monitoramento de Atencao Basica) responsible for collecting and synthesizing health system data and overseeing PSF performance, development of integrated data systems and introduction of new information technologies. Financing will support consultancy services, training, computer hardware and software, study tours and training workshops, materials and publications. (b) Evaluation of PSF implementation: This subcomponent will support the development of evaluation methodologies and instruments to measure the acquisition and application of skills by individuals trained in Family Health and the impact of training center networks, demonstration projects, curricular and pedagogic innovations supported in Component 2. It will also support impact evaluations of a sample of PSF teams and PSF training centers implemented between 1997 and 2001. The project will finance consultancy -7 -
services, publications, training workshops and materials, study tours and seminars. (c) Accreditation of the basic family health teams, facilities and training institutions: Through financing consultancy services, publications, training, workshops and seminars, this subcomponent will develop an accreditation regulatory framework and corresponding systems for: (I) family health teams and facilities; and (ii) PSF training centers (Polios de Capacitacao). (d) Research and Evaluation Fund: This subcomponent will support evaluations and operational research on topics related to the development and performance of the PSF and the related training institutions, the process of decentralization of the SUS, human resources in the health sector, efficiency and effectiveness of the PSF, and other strategic topics identified by the MS. Awards will be made on a competitive basis. The project will finance consultancy services, publications, workshops and international seminars. Component 4: Project Management (US$4 million) This component would support project management for all components, including the design and implementation of a monitoring information system to monitor and supervise project activities. This component would also support issue-specific studies related to seeking solutions to implementation problems, including qualitative as well as quantitative techniques. This component would finance annual audits for the whole project in a declining basis both Component. The component would finance consultant services, facilities and equipment for the maintenance of the PMU and per diem for supervision in the field. 6. Project Financing: Estimated total Project Costs: US$136 million 7. Project Implementation This is a two-year project, the first phase of a six-year APL. The planned effectiveness date is March 1, 2002 with a closing date of February 28, 2004 8. Project Sustainability Ownership: By design, the PSF is intricately woven into a well-established and extensive participatory process in the health sector. In addition to the high priority bestowed by the MS, the PSF has been discussed and strongly endorsed by stakeholders through consultative mechanisms, including state, municipal and local health councils (to secure client inputs) and the Intra-governmental Management Commissions (to secure inputs from federal, state, municipal health authorities and staff). Basic health priorities and corresponding indicators that buoy the PSF resulted from a series of consultations with state, municipal and local health councils during 2000, and published by the MS (Portaria no. 393/GM) in March, 2001. Also, one criterion for Conversion Plan approval is evidence of consultation with local stakeholders and of close correspondence between Plan objectives and agreements made between municipal authorities and health councils. 9. Lessons Learned from Past Operations in the Country/Sector - 8 -
The design reflects lessons related to (a) the impact of the PSF in Brazil; (b) international experience with the implementation of primary care models; and (c) previous Bank work in health operations and evaluations. The main lessons and design responses are: The PSF has great potential to improve the coverage and quality of basic care, as well as health outcomes. Several assessments and formative evaluations have been carried out by the government and other institutions (including an assessment done by the World Bank) regarding the performance of the PSF program. The main benefits found by these studies are: (i) increased coverage of basic health care in small size municipalities with high infant mortality rates; (ii) high satisfaction with the program by users; (iii) positive impact on registered infant mortality rates, vaccination coverage, childhood nutrition, and hospitalization rates; and (iv) increased production of basic health services. The evaluation findings provide the rationale for supporting expansion of the PSF. At the same time, they point to the fact that the positive experiences of the PSF have occurred primarily in rural or small urban areas where basic care supply was irregular at best. Expansion to large urban areas may require a adaptation to a different set of supply and demand conditions. These adaptations can only be made on the basis of a thorough understanding of household and provider characteristics in the municipalities, and continuous, rigorous, program-relevant monitoring and evaluation. Design of activities under Component 3 of the project reflect an understanding of the importance of M&E to ensure that the PSF potential during the expansion period. Successful implementation of new primary care models depends on major changes in underlying incentives. Family health or similar (outreach) models of primary care can be found in other countries including the UK, Canada, Honduras (nutrition) and Cuba. Other countries in Latin America also are trying to develop new models of primary care, such as Mexico, Guatemala and Honduras (nutrition). Some of the implementation lessons obtained by these experiences include the following: (i) The most difficult part of the reform is to effectively change the culture of both the health providers and users. (ii) While there are numerous experiences of development of new primary care programs that have been successful in expanding access to the poor, the team found fewer examples of successfully linking these programs to higher levels of care; (iii) New programs tend to be developed in years of economic growth and fiscal expansion based on additional money. When the expansion of these programs is not accompanied by a simultaneous reform of the traditional programs, the new programs tend to be short-lived - when there is a fiscal contraction, the new programs are the first to be cut as the traditional programs tend to have stronger legal and political means to defend themselves. As a response to these lessons, the project strongly reinforced with financing and institutional reforms already under implementation. (iv) Developing a robust monitoring and evaluation system that provides continuous feedback on performance is a key element contributing to program success. Given the dynamic nature of the Brazilian health system, allow for flexibility - but within an agreed upon framework that emphasizes results. Implementation experiences of other World Bank projects, including the Second North East Basic Health Services (98), AIDS and STD Control (98), Amazon Basin Malaria Control (97), and Endemic Disease Control (97); MTR of the ongoing REFORSUS project (99), as well as broader health sector and country portfolio reviews, -9-
indicate that project success can depend on flexibility in the face of changing economic and political conditions, and ability to reorient when new knowledge becomes available. The instrument selected for the project - an APL - provides the benefits of a two-year planning horizon, permitting mid-course corrections. At the same time, its focus on showing results during each two-year interval, and maintaining an overall development framework, keeps "big picture" issues at the forefront. 10. Program of Targeted Interventions: Yes X No - 10. Environmental Aspects: (Rating:(C) The FHP foresees no large civil works activities, but has potential for generating both positive and negative environmental impacts. In the first stage of implementation of the FHP, there will be increased demand for specialized outpatient services, because the program will represent a new channel of access to medical services for that segment of the population that did not previously have access to such services. In this stage, the negative impacts of the process are concentrated mostly in increased generation of waste material at the health units, with the consequent need for more effective controls. For the most part, these measures involve implementation of a System of Waste Management that includes minimization of generation plus segregation of waste. At the same time, however, the FHP has great potential for producing positive impacts. Over the medium-term, there will be a reduction in demand for urgent and emergency services, as health services are improved, the number of hospitalizations due to avoidable causes also is expected to decline. In this case, positive impacts will result from a drop in the volume of waste generated, together with improved health conditions for the population. At the same time, the waste generated as a result of the current system of acquiring and utilizing medicine products is also expected to decline; it is anticipated that there will be a smaller volume of expired medicines and implementation of an effective System of Waste Management. 12. Contact Points Gerard La Forgia: Task Team Leader The World Bank Human and Social Development Group Mail Stop I 7-700 Washington, D.C. 20433 Phone: 202-458-9730 Fax: 202-522-0050 13. For information on other project related documents contact: The InfoShop The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 458-5454 Fax: (202) 522-1500 - 10 -
Web: http:// www.worldbank.org/infoshop Note: This is information on an evolving project. Certain components may not be necessarily included in the final project. This PID was processed by the InfoShop during the week ending November 16,2001-11 -