The analyses presented here suggest that PHC coverage through the “Home Health” programme is associated with improvements of some health outcomes over time in Bogota. The results have confirmed through a multivariate analysis the findings of the descriptive assessment conducted in 2008 [19], which found that health outcomes were better in those localities with high coverage of the “Home Health” programme.
Our results are also consistent with evidence from other contexts [15–18, 24–30] where an increase in PHC coverage has been related to improvements in child health.
In the Latin American region, this association has been widely evidenced. For example, an analysis of 22 countries identified a general decrease in IMR and under-5 mortality rates related to increasing PHC coverage between 1990 and 1998 [25]. Similarly, a study from Costa Rica in 2004 reported that for every 5 years of the reform that introduced PHC to its health system, the IMR was reduced by 13% [18].
Moreover, a comparative analysis between regions with different levels of PHC development in Brazil showed a greater reduction in IMR in those regions where the “Family Health” programme had been well implemented [15, 16]. During the period 1990–2002, Brazil reported that an increase of 10% in the coverage of the “Family Health” programme was associated with a reduction of 4.6% in IMR, while controlling for other socioeconomic variables [15]. Subsequently, in the period 1999–2004 this finding was confirmed reporting an attributable reduction of 13% in the IMR, 16% in the post-neonatal mortality and 44% in infant mortality rate due to ADD [16]. Similarly, a Bolivian study found lower IMR (35.1%) and under-5 mortality rates (74.3%) in PHC intervention areas when compared with non-intervention areas; and a decrease in the mortality rates by more than half (52%) in the intervention areas 5 years after the PHC implementation [17].
In other low and middle income countries in Africa and Asia reductions in the IMR have also been described ranging from 20% to 65% as a result of the strengthening of PHC interventions [12]. A research study in five East African countries concluded that three quarters of the risk to IMR could be decreased with the enhancement of PHC, including interventions such as antenatal care, immunisation and the provision of potable drinking water [26].
Studies from South Africa have reported decreases between 10% and 32% of acute malnutrition in children under 5 years of age [13, 27], and comparisons made in Bolivia suggested a lower risk of mortality due to acute malnutrition in areas where PHC has been better developed [17]. As regards the increase in vaccination coverage, different studies in developing countries have shown significant correlations between increases in PHC coverage and availability of immunisation [13, 16, 17, 28]. An association between PHC coverage and increases in the prevalence of exclusive breastfeeding has also been supported by different reports, suggesting that access to preventive programmes for maternal and child care is enhanced by PHC interventions. In this respect, programmes based on PHC could strengthen important components of preventive health activities and may be easier and faster than other approaches in achieving a higher prevalence of exclusive breastfeeding [29, 30].
The results of our study differ from those reported in the Brazilian studies regarding infant mortality rates due to ADD and pneumonia. Brazil reported statistically significant decreases in infant and post-neonatal mortality rates due to ADD and non-significant reductions in mortality from acute respiratory infections [15, 16]. In our case, it was the opposite.
Contextual factors emerge as possible explanations for the Bogota findings. The significant reduction in mortality as a result of pneumonia could be due to the introduction of “Acute Respiratory Disease rooms” (“Salas ERA” in Spanish) as part of the PHC strategy [19]. However, this intervention could not be considered in this analysis because of the lack of available information. The reasons for a higher risk of mortality due to ADD in high coverage localities, although not statistically significant, are not clear. It might be that the government has developed more intensively in low PHCI localities certain social interventions related to diarrheal diseases such as improving water and sanitation, increase of sewerage coverage and implementation of programmes that provide food subsidies.
Moreover, it is important to note that the magnitude of the effect in this study was lower than that observed in other contexts. This could be because in the present analysis only data for the third year after the implementation of PHC were included and a longer period of time would have been required to demonstrate a greater effect. Another possible explanation suggested in one of the first assessments of the Brazilian programme [15] is that IMR and under-5 mortality rates had already experienced a significant decline years before the PHC implementation as function of a wide range of social interventions that could affect health outcomes, and that the scale of future declines would be less sensitive to the interventions associated with PHC reforms.
Study limitations
The limited scope of the ecological design does not provide conclusive evidence of causality. Likewise, the unavailability of information on a disaggregated level lower than localities (e.g. micro-territories, families or individuals) does not permit us to determine with certainty whether the reductions or increases in health outcomes occurred in the targeted population.
In addition, the lack of information about population size in each strata before 2009 led us to carry out retro-projections that are only an estimate of the population size. This could under- or overestimate the variables that make up the PHCI and therefore could affect the measurement of the coverage intensity and the classification of groups.
Another important limitation is the periodicity and availability of socioeconomic information, which is collected only every four years; this could have affected our estimations of the relationship between the PHC coverage and the improvement of health conditions.
Finally, the complexity and influence of many social determinants on the health outcomes studied ideally requires a multi-level analysis that takes into account latent unmeasured variables that could be confounding the apparent relationship between PHC and health outcomes. Further research should include representative data on individual “Home Health” users and non-users and additional variables that allow a disaggregation of the evolution of macro and micro social indicators. Such research could improve efforts to disentangle which factors of the PHC reforms are contributing to improvements in health outcomes.
