Cardiovascular disease is the leading cause of mortality among non-communicable chronic diseases and is responsible for 30% of all global deaths, constituting a large and growing burden in middle and low income countries.1 2 3 Ischaemic heart disease and cerebrovascular disease are responsible for the majority of cardiovascular disease mortality, accounting for 7.6 million and 5.7 million of deaths annually, respectively,4 and are leading causes of disease burden as measured in disability adjusted life years lost.5 6
The control, management, and prevention of cardiovascular disease and other non-communicable diseases is fundamentally different from acute care, relying on several features for success typically found within a strong primary health care system, and an approach centred primary health care could represent a cost effective strategy to reduce the cardiovascular disease burden in low and middle income countries.7 8
In Brazil, the Ministry of Health has designated the Family Health Program (FHP), the main primary health care programme of the country, as the leading initiative in the national strategy for reduction of cardiovascular disease and other diseases.9 10 The FHP was launched in 1994 and has experienced a dramatic expansion within and across Brazil’s 5564 municipalities. Presently, FHP, has become the world’s largest community based primary health care programme, present in 95% of municipalities and covering 53% of the Brazilian population in 2011.11
The major expansion of primary health care in Brazil through the FHP has translated into improved population health outcomes,12 13 and FHP activities include health promotion, primary prevention and management of cardiovascular disease risk factors, as well as secondary prevention for high risk individuals (monitoring of hypertension and diabetes) and rehabilitation of patients with cardiovascular disease, orchestrated primarily through domiciliary visits and community interventions operated by community health workers.10 14 In 2009, a list of ambulatory care-sensitive conditions was created to monitor primary health care performance and evaluate its cost effectiveness.15 In the past decade in the country a decline of about 20% in the age standardised mortality rates for ischaemic heart and cerebrovascular diseases has been documented—reaching 69.2 and 70.7 deaths per 100 000 inhabitants respectively in 2009.16 17 However, the mechanisms causing this decline have not been examined or identified, and it is speculated to be consequence (among others) of successful implementation of health policies that led to the expansion of access to primary health care.18 Ambulatory care-sensitive conditions represented 40% of the mortality from cerebrovascular and ischaemic and other forms of heart disease, accounting for more than half a million deaths in the past decade.11
The aim of the present study is to evaluate the impact of the FHP on age standardised mortality rates from heart and cerebrovascular diseases included in the ambulatory care-sensitive conditions, as well as the impact on some potential intermediate mechanisms, such as health promotion activities and hospitalisations for cardiovascular disease, in the period 2000 to 2009 in Brazilian municipalities.
Article from BMJ. 2014; 349: g4014.
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