STRONG LOCAL GOVERNANCE FOR HEALTH IS ASSOCIATED WITH MORE EFFECTIVE PRIMARY HEALTH CARE AND GREATER REDUCTIONS IN AMENABLE MORTALITY

Introduction and Objectives Local governments have a pivotal role in local health service provision – especially primary healthcare (PHC) and in large decentralised countries such as Brazil. Little is known about how the strength of local governance arrangements can affect the performance of PHC. Brazil’s substantial expansion of PHC through the Family Health Strategy (ESF) is a timely setting to understand the relationships between local governments (municipalities) and local ESF services. Methods Fixed-effects longitudinal regression was employed to examine the impact of ESF expansion on mortality amenable to healthcare at the municipal level (n=1,622) over the years 2000-2013. Municipality governance for health was assessed using indicators from public administration surveys and a World Bank framework of local governance. We examine the effectiveness of ESF services in reducing mortality by three groups of governance score. We control for year trend, and health system and socioeconomic parameters. Results and Conclusions There was a differential impact of ESF by strength of local governance. Municipalities with the highest scores of local governance had an 11.3% (95%CI: 16.0%-6.4%) reduction in amenable mortality from full expansion of ESF (from 0% to 100% coverage) compared to a 4.5% (95%CI: 7.6%-1.4%) reduction in municipalities with the lowest scores. Local governance is an important determinant of health service effectiveness. There is potential inequity from large decentralisation and heterogeneous provision of national PHC services. Global efforts for UHC and PHC strengthening must recognise the importance of and aim to improve local governance for health.