Ensaios sobre a equidade na Atenção Primária à Saúde: uma revisão de escopo e a análise da eficiência municipal e uma avaliação do programa Mais Médicos

Abstract

Primary Health Care (PHC), as a care model, represents the starting point in health systems. In the Brazilian context, the Unified Health System (SUS) is the structure that aims to ensure universal and free access to health services, based on the pillars of equity, comprehensiveness, and social participation. However, as with global health systems, SUS faces pressing challenges, with the limitation of financial and human resources being a significant obstacle that impacts its ability to provide effective and consistent care. One approach to improving equity in primary care involves the rational allocation of resources, seeking to maximize service provision while minimizing waste. This study presents three essays on equity in PHC, aiming to provide evidence to enhance SUS planning. The first essay consists of a scoping review of the literature on efficiency in PHC and its relationship with the concept of equity, covering 45 articles that used Data Envelopment Analysis (DEA). The review results highlight that human resources and infrastructure are the most frequently associated inputs in producing health actions and outcomes. Furthermore, most DEA models in the reviewed articles address equity solely in relation to “Health Access,” often using demographic and urbanization variables in a second stage to support efficiency scores. The second essay analyzes the efficiency of Primary Health Care in Brazil concerning the use and allocation of health resources to increase equity in municipal services. The methodology employed is the Dynamic Network Data Envelopment Analysis, with three divisions (Financial, Operational, and Outcome), covering the years 2019 to 2021, with municipalities as Decision-Making Units (DMUs) stratified by population size. The results indicated that the average efficiency of Brazilian municipalities slightly increased over the analyzed years, with the greatest efficiency gains in the Operational division and losses in the Financial division. Two profiles of efficient municipalities were identified: one in the North and Northeast regions of Brazil and the other in the Center-West, Southeast, and South regions. The analyses showed that municipalities with up to 25,000 inhabitants had the lowest percentage of efficient municipalities. In the second-stage analysis, a negative effect was identified on overall efficiency scores for municipalities classified as “Adjacent Rural”; social vulnerability also negatively affected these efficiency scores, while the population's educational level had a positive effect. The third essay evaluates the impact of the Mais Médicos Program on the allocation of physicians in the Family Health Strategy and its influence on health access equity for Brazil’s most vulnerable populations. Using a difference-in-differences model with multiple periods (2010-2019), a positive effect was observed in the provision of doctors, especially in 2016. However, this impact declined in subsequent years, being negatively affected by the interruption of the international cooperation agreement. The program benefited three of the eight priority profiles, reinforcing its importance in expanding equity in health access.