Araujo, EdsonCavalini, LucianaGirardi, SabadoIreland, MeganLindelow, Magnus2014-12-162014-12-162014-09https://hdl.handle.net/10986/20728This study presents two case studies, each on a current initiative of contracting for primary health services in Brazil, one for the state of Bahia, the other for the city of Rio de Janeiro. The two initiatives are not linked and their implementation has independently sprung from a search for more effective ways of delivering public primary health care. The two models differ considerably in context, needs, modalities, and outcomes. This paper identifies their strengths and weaknesses, initially by providing a background to universal primary health care in Brazil, paying particular attention to the family health strategy, the driver of the basic health care model. It then outlines the history of contracting for health care within Brazil, before analyzing the two studies. The state of Bahia sought to expand coverage of the family health strategy and increase the quality of services, but had difficulty in attracting and retaining qualified health professionals. Rigidities in the process of public hiring led to a number of isolated contracting initiatives at the municipal level and diverse, often unstable employment contracts. The state and municipalities decided to centralize the hiring of health professionals in order to offer stable positions with career plans and mobility within the state, and chose to create a state foundation, acting under private law to manage and oversee this process. Results have been mixed as lower than expected municipal involvement resulted in relatively high administrative costs and consequent default on municipal financial contributions. The state foundation is undergoing a governance reform and has now diversified beyond hiring for primary care. The municipality of Rio de Janeiro, which until recently relied on an expansive hospital network for health care delivery, sought in particular to expand primary health services. The public health networks suffered from inefficiency and poor quality, and it was therefore decided to contract privately owned and managed, not-for-profit, social organizations to provide primary care services. The move has succeeded in attracting considerable increases in funding for primary health and coverage has increased significantly. Performance initiatives, however, still need fine-tuning and reliable information systems must be implanted in order to evaluate the system.en-USCC BY 3.0 IGOADMINISTRATIVE COSTSADMINISTRATIVE RULESAGEDAMBULATORY SERVICESANTENATAL CAREBASIC HEALTH CAREBIRTH CONTROLBLOCK GRANTSBULLETINCARE PERFORMANCECHRONIC DISEASECITIESCIVIL SOCIETY ORGANIZATIONSCLINICSCOMMUNITY HEALTHCOMPLICATIONSCONTRACTUAL ARRANGEMENTSDEATHSDECENTRALIZATIONDELIVERY OF HEALTH SERVICESDEVELOPING COUNTRIESDIABETESDISEASESDRUGSECONOMIC INEQUALITYECONOMIC POLICYECONOMICSECONOMIES OF SCALEEMERGENCY CAREEMERGENCY ROOMSEMPLOYMENTEQUIPMENTESSENTIAL MEDICINESFAMILIESFAMILY HEALTHFINANCIAL CONTRIBUTIONSFINANCIAL INCENTIVESFINANCIAL RESOURCESGOVERNMENT CAPACITYHEALTH AFFAIRSHEALTH CARE DELIVERYHEALTH CARE FACILITIESHEALTH CARE NEEDSHEALTH CARE PROVISIONHEALTH CARE WORKERSHEALTH CLINICSHEALTH COVERAGEHEALTH EDUCATIONHEALTH FACILITIESHEALTH INDICATORSHEALTH INEQUALITIESHEALTH INFORMATIONHEALTH INFORMATION SYSTEMHEALTH INFORMATION SYSTEMSHEALTH INFRASTRUCTUREHEALTH ORGANIZATIONHEALTH PLANNINGHEALTH POLICYHEALTH PROFESSIONALSHEALTH PROFESSIONSHEALTH PROMOTIONHEALTH PROVIDERSHEALTH RISKSHEALTH SECTORHEALTH SERVICEHEALTH SERVICE DELIVERYHEALTH SERVICESHEALTH SPENDINGHEALTH STRATEGYHEALTH SYSTEMHEALTH SYSTEM PERFORMANCEHEALTH SYSTEM REFORMHEALTH SYSTEMSHEALTH WORKERSHEALTHY LIFEHOME CAREHOSPITALHOSPITAL MANAGEMENTHOSPITAL SECTORHOSPITAL SERVICESHOSPITAL SYSTEMHOSPITALSHUMAN RESOURCE MANAGEMENTHUMAN RESOURCESHUMAN RIGHTHYPERTENSIONILLNESSINCOMEINCOME COUNTRIESINCOME INEQUALITYINFANTINFANT MORTALITYINFORMATION ASYMMETRYINTEGRATIONINTERNATIONAL ORGANIZATIONSIUDLABOR MARKETLABORATORIESLARGE POPULATIONSLAWSLEPROSYLIFE EXPECTANCYLIFE EXPECTANCY AT BIRTHLIVE BIRTHSLOCAL GOVERNMENTSLOW BIRTH WEIGHTMANAGEMENT OF HEALTHMANAGEMENT OF PATIENTSMATERNAL MORTALITYMATERNAL MORTALITY RATIOMEDICAL CAREMEDICAL DOCTORSMEDICAL EDUCATIONMEDICAL PROCEDURESMEDICAL RESIDENTSMEDICAL SCHOOLMEDICAL STAFFMEDICINESMILLENNIUM DEVELOPMENT GOALMINISTRY OF HEALTHMORBIDITYMORTALITYNATIONAL LEVELNONGOVERNMENTAL ORGANIZATIONSNURSENURSESNUTRITIONORAL HEALTHOUTREACH ACTIVITIESPATIENTPATIENTSPHYSICIANPOCKET PAYMENTSPOLICY DECISIONSPOLICY MAKERSPOLITICAL DECISIONPOOR QUALITY CAREPOPULATION DENSITYPREGNANCYPREGNANT WOMENPRENATAL CAREPRIMARY CAREPRIMARY HEALTH CAREPRIMARY HEALTH CARE FACILITIESPRIMARY HEALTH CARE SERVICESPRIMARY HEALTH FACILITIESPRIMARY HEALTH SERVICESPRIMARY HEALTH SYSTEMPRIVATE SECTORPROGRESSPROVISION OF CAREPROVISION OF HEALTH SERVICESPUBLIC ADMINISTRATIONPUBLIC CONTRACTPUBLIC HEALTHPUBLIC HEALTH SYSTEMPUBLIC POLICYPUBLIC SECTORPUBLIC SERVICESQUALITY IMPROVEMENTQUALITY OF CAREQUALITY OF SERVICESRESPECTSCHOOL HEALTHSECRETARY OF HEALTHSERVICE PROVIDERSSERVICE PROVISIONSOCIAL ACTIONSOCIAL PARTICIPATIONSOCIAL SECURITYSOCIAL SECURITY BENEFITSSOCIAL SERVICESSOCIOECONOMIC DEVELOPMENTSTATE POLICYSTATE UNIVERSITYSTRATEGIC PRIORITIESSUSTAINABLE DEVELOPMENTTUBERCULOSISUNIVERSAL ACCESSUNIVERSITIESURBAN AREASVACCINATIONWOMANWORKERSWORKFORCEWORLD HEALTH ORGANIZATION10.1596/20728