Impact Evaluation Note BRAZIL Maria Francisca Carvalho!Cintia Albuquerque!Mirja Sjoblom

H E A LT H R E S U LT S I N N O VAT I O N T R U S T F U N D

1. Background (Brazil)

•  Large reduction in IMR, U5MR and MMR in the past 2 decades o  U5MR decreased by 57.6 percent between 1990 and 2008 o  MMR dropped from 140 to 75 per 100,000 live births 1990 and 2008, although

MMR remains high relative to many middle-income country (MIC) peers

•  MDG 4&5 will be achieved but regional differences and inequalities still exist o  poor children *2 as likely to die compared to those in the highest economic quintile

•  Growing problem of chronic and non-communicable diseases

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1. Background (Pernambuco)

•  Pernambuco has long lagged behind the rest of the country in terms of economic development and health outcomes; but in recent years the economy has been growing rapidly

•  In 2010 IMR and U5MR were of 16.7 and 18.8 deaths per 1,000 births respectively. Pernambuco ranked number 19 of Brazil’s 26 states on both indicators.

•  There are large variations in IMR; o  Best performing municipalities : 13 and 15 deaths per 1,000 births. o  Worst performing municipalities: 44 and 45 deaths per 1000 births.

•  The main causes of deaths in the state were: circulatory disease (30 percent), external causes (14 percent), cancers (13 percent), and chronic respiratory disease (10 percent).

•  To improve its indicators, the State is developing new strategies for primary care, seeking to strengthen the Family Health Strategy.

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2. Description of Intervention

•  Performance-based contracts will be signed between FHTs and municipalities/SES. These contracts will regulate the requirements for FHTs to receive results-based payments;

•  Indicators linked to the payment will be on Mother and Child Health and Chronic Diseases, which are currently the main issues that the state is trying to solve in Primary Care;

•  Performance-based payments will be calculated based on a target-based formula which also takes into account public health priorities;

•  Performance payments will be targeted at FHTs. The individual bonuses will be similar for all cadres (physicians, nurses, community agents) and paid on an semiannual /annual basis;

•  Verification of results will be carried out by an independent auditor and visits will be unannounced.

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3. Results Chain

4. Primary Research Questions

•  The research questions are: •  (1) Does the RBF program improve the coverage and

quality of priority health services related to MCH and chronic diseases?

•  (2) Does enhanced supervision and results-reporting alone improve the coverage and quality of priority health services related to MCH and chronic diseases?

•  (3) What is the relative cost-effectiveness of the RBF program vis-à-vis enhanced supervision and results-reporting alone vis-à-vis status quo in terms of the coverage and quality of priority health services related to MCH and chronic diseases.

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4. Primary Research Questions The evaluation will use a mixed-method approach. Some of the

key questions that will be answered through qualitative data collection include:

•  Why are certain teams performing better than others under the two interventions? What factors influence performance?

•  How are the different interventions perceived by the patients and other stakeholders in the health system? What is working well and what is not working well? How can the program be more impactful when/if scaled-up?

5. Outcome Indicators

Indicators: •  Quality of care for diabetes/hypertension patients (e.g.

patients registered, control of blood pressure/sugar levels) •  Pap smear coverage for women •  Quality of prenatal visits (timing [1st semester] blood

pressure/sugar levels for pregnant women) •  Coverage of baby-well visits, vaccination (triplice viral and

pentavelente) and exclusive breastfeeding

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6. Identification Strategy/ Method

•  One macro-region of the State has been chosen to implement the Pilot Project, which has 35 municipalities and 214 teams;

•  Stratified-by-municipality, matched triplet cluster randomized design;

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T1:P4P T2:Enhanced supervision C:Status quo

7. Sample and Data

•  PSF Clinic based data o  Clinic Assessment o  Interviews with providers/members of FHTs    o  Review of medical records o  Patient Exit Interviews

•  Household based data o  Household survey

Qualitative data collection – to be defined which instruments that will be used.

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8. Time Frame / Work Plan

•  Baseline - June 2014 •  Start of intervention – June 2014 •  Follow up survey- Dec 2015 •  Results- First quarter of 2016

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