The provision of primary healthcare is based on the delivery of basic care and the dissemination of prevention practices to the population. In Brazil, a typical developing country characterized by the double burden of disease (coexistence of communicable and non-communicable diseases, NCD), the quest to provide universal health care financed by the government and free for all individuals nowadays faces the challenges of the ongoing demographic transition and huge health inequalities at individual-social-regional levels. Thus, the focus on primary healthcare may be key to deal with the escalating prevalence of NCD in the Brazilian population, especially diabetes, a health problem usually associated with important comorbidities.
During the 1990s and particularly in the 2000s, there were significant advances in the decentralization process within the Brazilian health system, in order to improve and increase the access of the population to the public health system. Primary healthcare, which is currently based on household visits by teams of health professionals (Family Health Strategy, FHS), favors the preventive approach in the Brazilian health system.
The decentralization of public goods provision, e.g. primary healthcare, brings additional benefits by informing local governments on its population preferences. Moreover, there is evidence of health benefits derived from primary healthcare decentralization, including a decrease in rates of infant mortality and undernourished children in the country. However, there were few studies analyzing the effects of primary healthcare decentralization on NCD prevalence and its consequences.
To bridge this gap, we conducted a study to account for the effects of primary healthcare decentralization on diabetes mellitus indicators in Brazil. Approximately 10% of the Brazilian population has diabetes mellitus diagnosis, and its treatment and related complications costs consume around 25% of the national health system budget. In 2015, according to the International Medical Statistics (IMS), the share of expenditures on anti-diabetic medications was 7.6% of global healthcare expenditures worldwide, becoming the second largest category of medications in global sales.
According to our results, primary healthcare decentralization in Brazil had positive impacts on diabetes morbidity and mortality indicators; however, it is important to point out that the effects were heterogeneous according to region and income. The evidence reflects the high degree of inequality in the country: whilst more developed regions (Southeast and South) showed the highest improvement in diabetes indicators due to decentralization process, the poorest regions had lower or no positive impacts at all in diabetes indicators. In addition, the 25% richest municipalities showed huge improvements due to primary healthcare decentralization, while the 25% poorest municipalities showed no changes in indicators.
Diabetes may be positively affected by primary healthcare provision connected to prevention measures, including primary prevention (to minimize the exposition to risk factors by promotion of healthy lifestyles), secondary prevention (to identify complications due risk factors as diagnosis and education programs), and tertiary prevention (to avoid complications by means of rehabilitation and disease management). In this sense, which mechanisms could help explain the differences between richest and poorest areas, or between the high- and low-income municipalities in Brazil, even though efforts and funding were available to strengthen preventive healthcare at the local level through decentralization processes?
First, the Brazilian government usually faces difficulties in contracting and keeping physicians in public healthcare facilities located far from the states capitals and metropolitan areas. In general, the state capital is characterized by better infrastructure and higher socioeconomic development in comparison to other regions, which usually struggle to provide adequate medical assistance for the population. Second, there are incentives for municipalities to split into more cities due to certain rules regarding local government financing by the federal government in Brazil. That is, splitting one municipality in two may provide additional funding for the same population coverage. However, this also means that the municipality may be split into smaller and poorer new municipalities that do not have enough infrastructure to provide public goods for the population. Finally, Brazil has an excess of unspecialized labor supply and a shortage of physical capital, thus the wages are low and the capital rents are high, implying a shortage of diagnosis and healthcare equipment and hospital facilities in the poorest regions.
Therefore, we conclude that the benefits of primary healthcare decentralization concentrate in regions where there are certain minimum levels of infrastructure, especially referring to human and physical capital, in order to provide suitable healthcare for the population. The lack of structural pre-conditions may result in higher inequalities in primary healthcare access and utilization due to decentralization process.