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Franco CM, Giovanella L, de Almeida PF, Fausto MCR. Working practices and integration of primary health care doctors in remote rural areas in Brazil: a qualitative study. BMC PRIMARY CARE 2024; 25:319. [PMID: 39215232 PMCID: PMC11363646 DOI: 10.1186/s12875-024-02553-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 07/30/2024] [Indexed: 09/04/2024]
Abstract
Health care challenges in remote rural municipalities (RRMs) emphasize the importance of primary health care (PHC) and require an expanded scope of practice. Doctors are key actors in this context. The aim of this study was to explore the level of integration of doctors in RRMs and working practices. We conducted a qualitative study involving semi-structured interviews with 46 PHC doctors working in 27 RRMs in Brazil. Content analysis was performed, resulting in the identification of categories of analysis grouped under three core dimensions: doctor training and experience; comprehensive care and timely access; and the community-based approach. Doctors working in RRMs were mainly recent graduates with limited experience who had undertaken their degree outside Brazil, and care was focused on the individual. The findings also revealed weak sociocultural adaptation and a harsh working environment and issues related to social status that reinforced prejudice against rurality and poverty. Practice was limited in scope and care tended to be oriented towards acute problems, disease-centered and focused on the biomedical model of medicine. Barriers to the delivery of comprehensive care include both structural constraints, such as poor facilities and centralization of services in administrative centers, and the lack of professional competencies necessary for PHC in these areas. The findings point to the need to promote an expanded scope of practice in PHC delivery in RRMs, with major public investment in the promotion of training and strengthening career pathways in these areas.
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Affiliation(s)
- Cassiano Mendes Franco
- Faculty of Medicine, Federal University of Rio de Janeiro, R. Laura de Araújo, 36, Rio de Janeiro, 20211-170, Brasil.
| | - Lígia Giovanella
- Sergio Arouca National School of Public Health, Oswaldo Cruz Foundation, R. Leopoldo Bulhões, 1480, Rio de Janeiro, 21041-210, Brasil
| | - Patty Fidelis de Almeida
- Collective Health Institute, Fluminense Federal University, R. Marquês do Paraná, 303, Niterói, 24070-035, Brasil
| | - Márcia Cristina Rodrigues Fausto
- Sergio Arouca National School of Public Health, Oswaldo Cruz Foundation, R. Leopoldo Bulhões, 1480, Rio de Janeiro, 21041-210, Brasil
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Truche PR, Naus AE, Botelho F, Ferreira J, Bowder A, Caddell L, Zimmerman K, de Freitas Faria IM, Lopes BC, Costa EC, Dantas FLL, Cavalcante AJSA, Carvalho CALB, Abib S, Mooney DP, Alonso N. Delivery of essential pediatric congenital surgical care within Brazil's universal health coverage system: a national survey of pediatric surgeons. WORLD JOURNAL OF PEDIATRIC SURGERY 2023; 6:e000534. [PMID: 39286360 PMCID: PMC11403139 DOI: 10.1136/wjps-2022-000534] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 05/10/2023] [Indexed: 09/19/2024] Open
Abstract
Objective In this study, we assess the delivery of congenital pediatric surgical care under Brazil's system of universal health coverage and evaluate differences in delivery between public and private sectors. Methods A cross-sectional national survey of pediatric surgeons in Brazil was conducted. Participants were asked which of 23 interventions identified through the Disease Control Priorities 3 (Surgical Interventions for Congenital Anomalies) they perform and to report barriers faced while providing surgical care. Responses were weighted by state and stratified by sector (public vs private). Results A sample of 352 responses was obtained and weighted to represent 1378 practicing pediatric surgeons registered in Brazil during the survey time. 73% spend the majority of their time working in the public sector ('Sistema Único de Saúde' and Foundation hospitals), and most of them also work in the private sector. Generally, Brazilian pediatric surgeons have the expertise to provide thoracic, abdominal, and urologic procedures. Surgeons working mostly in the public sector were more likely to report a lack of access to essential medications (25% vs 9%, p<0.01) and a lack of access to hospital beds for surgical patients (52% vs 32%, p<0.01). Conclusions Brazilian pediatric surgeons routinely perform thoracic, abdominal, and urologic surgery. Those working in government-financed hospitals face barriers related to infrastructure, which may impact Brazilians who rely on Brazil's universal health coverage system. Policies that support pediatric surgeons working in the public sector may promote the workforce available to provide congenital pediatric surgical care.
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Affiliation(s)
- Paul R Truche
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Abbie E Naus
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Fabio Botelho
- Department of Pediatric Surgery, McGill University, Montreal, Québec, Canada
| | - Julia Ferreira
- Department of Pediatric Surgery, McGill University, Montreal, Québec, Canada
| | - Alexis Bowder
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Luke Caddell
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Kathrin Zimmerman
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | | | - Bellisa Caldas Lopes
- Department of Pediatric Surgery, Instituto de Medicina Integral Professor Fernando Figueira, Recife, Brazil
| | - Eduardo Corrêa Costa
- Department of Pediatric Surgery, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | | | | | | | - Simone Abib
- Department of Pediatric Surgery, UNIFESP, Sao Paulo, Brazil
| | - David P Mooney
- Department of Pediatric Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Nivaldo Alonso
- Department of Plastic Surgery, University of São Paulo Institute of Biomedical Sciences, Sao Paulo, Brazil
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Galvao TF, Baldin Tiguman GM, Antonio BVR, de Alencar RRFR, Garcia LP, Silva MT. Perceived discrimination in health services and associated factors in Manaus Metropolitan Region, Brazil: a cross-sectional population-based study. ETHNICITY & HEALTH 2022; 27:847-857. [PMID: 32909824 DOI: 10.1080/13557858.2020.1817341] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 08/23/2020] [Indexed: 06/11/2023]
Abstract
Objectives: Discrimination is the differentiated treatment of individuals due to prejudgments. Discriminatory practices in health care result in negative effects on patients' health. In Brazil, skin color represents the main form of racial discrimination, which may have an impact on the accessibility and quality of health care. The Brazilian Amazon lacks investigations on this topic at the population level. This study aims to estimate the prevalence of perceived discrimination in health services and associated factors in the Manaus Metropolitan Region, state of Amazonas, Brazil.Design: A population-based cross-sectional study was conducted with a probabilistic sample of adults interviewed in 2015. The associated factors were investigated by calculating the prevalence ratio (PR) using Poisson regression with robust variance.Results: A total of 4,001 participants were included. The overall prevalence of perceived discrimination was 12.9% (95% confidence interval [CI]: 11.8-13.9%). When compared to the reference categories, women (PR = 1.43; 95%CI: 1.20-1.70), individuals with brown skin color (Brazilian mixed race; PR = 1.33; 95%CI: 1.04-1.71), people who suffer from hypertension (PR = 1.27;95%CI: 1.03-1.57), and people who frequently used health services (p≤0.03) experienced more discrimination from health professionals.Conclusions: The prevalence of perceived discrimination in health services in Manaus Metropolitan Region is frequent and is associated with ethnic, social and health-related factors. Investments in inclusive public health policies and a better quality of health assistance are required to tackle this problem.
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Affiliation(s)
- Tais Freire Galvao
- Faculty of Pharmaceutical Sciences, University of Campinas, Campinas, Brazil
| | | | | | | | - Leila Posenato Garcia
- Board Directory of Studies and Social Policies, Institute of Applied Economic Research, Brasília, Brazil
| | - Marcus Tolentino Silva
- Post-Graduate Program of Pharmaceutical Sciences, Universidade de Sorocaba, Sorocaba, Brazil
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Figueiredo AM, McKinley DW, Massuda A, Azevedo GD. Evaluating medical education regulation changes in Brazil: workforce impact. HUMAN RESOURCES FOR HEALTH 2021; 19:33. [PMID: 33726741 PMCID: PMC7967964 DOI: 10.1186/s12960-021-00580-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 03/03/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND Shortages and inequitable distribution of physicians is an obstacle to move towards Universal Health Coverage, especially in low-income and middle-income countries. In Brazil, expansion of medical school enrollment, curricula changes and recruitment programs were established to increase the number of physicians in underserved areas. This study seeks to analyze the impact of these measures in reduce inequities in access to medical education and physicians' distribution. METHODS This is an observational study that analyzes changes in the number of undergraduate medical places and number of physicians per inhabitants in different areas in Brazil between the years 2010 and 2018. Data regarding the number of undergraduate medical places, number and the practice location of physicians were obtained in public databases. Municipalities with less than 20,000 inhabitants were considered underserved areas. Data regarding access to antenatal visits were analyzed as a proxy for impact in access to healthcare. RESULTS From 2010 to 2018, 19,519 new medical undergraduate places were created which represents an increase of 120.2%. The increase in the number of physicians engaged in the workforce throughout the period was 113,702 physicians, 74,771 of these physicians in the Unified Health System. The greatest increase in the physicians per 1000 inhabitants ratio in the municipalities with the smallest population, the lowest Gross Domestic Product per capita and in those located in the states with the lowest concentration of physicians occurred in the 2013-2015 period. Increase in physician supply improved access to antenatal care. CONCLUSIONS There was an expansion in the number of undergraduate medical places and medical workforce in all groups of municipalities assessed in Brazil. Medical undergraduate places expansion in the federal public schools was more efficient to reduce regional inequities in access to medical education than private sector expansion. The recruitment component of More Doctors for Brazil Program demonstrated effectiveness to increase the number of physicians in underserved areas. Our results indicate the importance of public policies to face inequities in access to medical education and physician shortages and the necessity of continuous assessment during the period of implementation, especially in the context of political and economic changes.
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Affiliation(s)
- Alexandre Medeiros Figueiredo
- Health Sciences Postgraduate Program, Universidade Federal do Rio Grande do Norte, Natal, Brazil.
- Department of Health Promotion, Federal University of Paraíba, Campus I, Jardim Universitário, S/N, Castelo Branco, João Pessoa, PB, Brazil.
| | | | - Adriano Massuda
- School of Business Administration, Fundação Getulio Vargas (FGV EAESP), Av. 9 de julho, 2029, Bela Vista, São Paulo, SP, 01313-902, Brazil
| | - George Dantas Azevedo
- Multicampi School of Medical Sciences, Federal University of Rio Grande do Norte, Av. Cel. Martiniano, 541, Caicó, RN, 59300-000, Brazil
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Cavalcante DDFB, Domingues CV, Meloni DR, Almeida FMD, Probst LF, Cavalcanti YW, Meneghim MDC, Pereira AC. Financial impact of the change in the vulnerability profile of More Doctors Program. Rev Saude Publica 2020; 54:148. [PMID: 33331491 PMCID: PMC7726938 DOI: 10.11606/s1518-8787.2020054002156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 03/31/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To estimate the flow of professionals and the financial impact of the Programa Mais Médicos para o Brasil (PMMB - More Doctors for Brazil Program) within the More Doctors Program (MDP) for the Brazilian Ministry of Health and the participating municipalities of the state of São Paulo, from January 2019 to March 2022. METHODS A financial impact study was conducted in the state of São Paulo based on public secondary databases. The number of PMMB vacancies per municipality, of physicians and vulnerability profiles were described to measure the loss of replacement of professionals in the period. RESULTS In the specified period, the number of PMMB physicians in participating cities will decrease from 2,533 to 320, and the number of participating municipalities from 373 to 86. The municipalities that will need to replace the physicians will have a financial impact of R$ 929,487,904.77 (with sensitivity analysis, ranging from R$ 650,641,533.34 to R$ 1,208,334,276.20). CONCLUSION The change of vulnerability methodology adopted for the PMMB will represent serious consequences, that is, less population assistance and high financial impact for the municipalities of the state of São Paulo in a scenario of budget limitations.
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Affiliation(s)
- Denise de Fátima Barros Cavalcante
- Universidade Estadual de Campinas. Faculdade de Odontologia de Piracicaba. Pós-Doutoranda em Odontologia em Saúde Coletiva. Piracicaba, SP, Brasil
| | - Carolina Vitti Domingues
- Universidade Estadual de Campinas. Faculdade de Odontologia de Piracicaba. Programa de Pós-Graduação em Odontologia. Piracicaba, SP, Brasil
| | - Diego Roberto Meloni
- Universidade de São Paulo. Faculdade de Medicina de Ribeirão Preto. Programa de Pós-Graduação em Saúde Pública. Ribeirão Preto, SP, Brasil
| | | | - Livia Fernandes Probst
- Universidade Federal de Mato Grosso do Sul. Faculdade de Odontologia de Campo Grande. Departamento de Saúde Coletiva. Campo Grande, MS, Brasil
| | - Yuri Wanderley Cavalcanti
- Universidade Federal da Paraíba. Centro de Ciências da Saúde. Departamento de Odontologia Social. Joao Pessoa, PB, Brasil
| | - Marcelo de Castro Meneghim
- Universidade Estadual de Campinas. Faculdade de Odontologia de Piracicaba. Departamento de Odontologia Social. Piracicaba, SP, Brasil
| | - Antonio Carlos Pereira
- Universidade Estadual de Campinas. Faculdade de Odontologia de Piracicaba. Departamento de Odontologia Social. Piracicaba, SP, Brasil
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Özçelik EA, Massuda A, McConnell M, Castro MC. Impact of Brazil's More Doctors Program on hospitalizations for primary care sensitive cardiovascular conditions. SSM Popul Health 2020; 12:100695. [PMID: 33319027 PMCID: PMC7725939 DOI: 10.1016/j.ssmph.2020.100695] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 11/11/2020] [Accepted: 11/12/2020] [Indexed: 11/18/2022] Open
Abstract
Globally, cardiovascular diseases are the leading cause of disease burden and death. Timely and appropriate provision of primary care may lead to sizeable reductions in hospitalizations for a range of chronic and acute health conditions. In this paper, we study the impact of Brazil's More Doctors Program (MDP) on hospitalizations due to cerebrovascular disease and hypertension. We exploit the geographic variation in the uptake of the MPD and combine coarsened exact matching and difference-in-difference methods to construct valid counterfactual estimates. We use data from the Hospital Information System in Unified Health System, the MDP administrative records, the Brazilian Regulatory Agency, the Ministry of Health, and the Brazilian Institute of Geography and Statistics, covering the years from 2009 to 2017. Our analysis resulted in estimated coefficients of -1.47 (95%CI: -4.04,1.10) for hospitalizations for cerebrovascular disease and -1.20 (95%CI: -5.50,3.11) for hypertension, suggesting an inverse relationship between the MDP and hospitalizations. For cerebrovascular disease, the estimated MDP coefficient was -0.50 (95%CI: -2.94,1.95) in the year of program introduction, -5.21 (95%CI: -9.43,-0.99) and -8.21 (95%CI: -13.68,-2.75) in its third and fourth year of implementation, respectively. Our results further suggest that the beneficial impact of MDP on hospitalizations due to cerebrovascular disease became discernable in urban municipalities starting from the fourth year of implementation. We found no evidence that the MDP led to reductions in hospitalizations due to hypertension. Our results highlight that increased investment in resources devoted to primary care led to improvements in hospitalizations for selected cardiovascular conditions. However, it took time for the beneficial effects of the MDP to become discernable and the Program did not guarantee declines in hospitalizations for all cardiovascular conditions, suggesting that further improvements may be needed to enhance the beneficial impact of the MDP on the level and distribution of population health in Brazil.
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Affiliation(s)
- Ece A. Özçelik
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, 02115, USA
| | - Adriano Massuda
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, 02115, USA
- São Paulo School of Business Administration, Fundação Getulio Vargas, São Paulo, Brazil
| | - Margaret McConnell
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, 02115, USA
| | - Marcia C. Castro
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, 02115, USA
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Benevides PM, Melo Neto AJD, Silva ICBD, Tenório MEC, Soares GB, Soares RDS, Sampaio J. Satisfação dos médicos do Programa Mais Médicos na Paraíba, Brasil: avaliação por modelagem de equações estruturais. CAD SAUDE PUBLICA 2020; 36:e00197319. [DOI: 10.1590/0102-311x00197319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 02/27/2020] [Indexed: 11/22/2022] Open
Abstract
O objetivo deste trabalho foi construir um modelo de avaliação da qualidade do trabalho no Programa Mais Médicos (PMM), baseado na satisfação do médico participante, utilizando a abordagem da modelagem de equações estruturais. Para isso, foi usado o banco de dados de respostas de um questionário desenvolvido por um grupo de supervisores do programa no Estado da Paraíba, Brasil, e aplicado aos médicos do estado entre dezembro de 2015 e setembro de 2016. Foi realizada análise fatorial exploratória para extrair os atributos significativos e formar as dimensões finais e, após, a análise fatorial confirmatória para avaliar a relação entre as variáveis. O modelo de satisfação proposto inicialmente sofreu algumas modificações com base nas análises, e o modelo final foi composto por 49 variáveis indicadoras agrupadas em seis dimensões: medicamentos, estrutura, aspectos do PMM, apoio, impressos e equipamentos. Medicamentos e estrutura foram os construtos com maior efeito direto na satisfação do médico (0,53 e 0,39), seguidos pelos aspectos do PMM e apoio (ambos com 0,29). Acredita-se que o instrumento proposto neste artigo possibilita uma visão ampla sobre os aspectos envolvidos na satisfação do trabalho do médico, sintetizando um ponto de partida para análises e validações posteriores sobre a qualidade do trabalho na atenção básica.
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Rasella D, Hone T, de Souza LE, Tasca R, Basu S, Millett C. Mortality associated with alternative primary healthcare policies: a nationwide microsimulation modelling study in Brazil. BMC Med 2019; 17:82. [PMID: 31023330 PMCID: PMC6485171 DOI: 10.1186/s12916-019-1316-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 03/27/2019] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Brazil's Estratégia Saúde da Família (ESF) is one of the largest and most robustly evaluated primary healthcare programmes of the world, but it could be affected by fiscal austerity measures and by the possible end of the Mais Médicos programme (MMP)-a major intervention to increase primary care doctors in underserved areas. We forecast the impact of alternative scenarios of ESF coverage changes on under-70 mortality from ambulatory care-sensitive conditions (ACSCs) until 2030, the date for achievement of the Sustainable Development Goals (SDGs). METHOD A synthetic cohort of 5507 Brazilian municipalities was created for the period 2017-2030. A municipal-level microsimulation model was developed and validated using longitudinal data and estimates from a previous retrospective study evaluating the effects of municipal ESF coverage on mortality rates. Reductions in ESF coverage, and its effects on ACSC mortality, were forecast based on two probable austerity scenarios, compared with the maintenance of the current coverage or the expansion to 100%. Fixed effects longitudinal regression models were employed to account for secular trends, demographic and socioeconomic changes, healthcare-related variables, and programme duration effects. RESULTS Under austerity scenarios of decreasing ESF coverage with and without the MMP termination, mean ACSC mortality rates would be 8.60% (95% CI 7.03-10.21%; 48,546 excess premature/under-70 deaths along 2017-2030) and 5.80% (95% CI 4.23-7.35%; 27,685 excess premature deaths) higher respectively in 2030 compared to maintaining the current ESF coverage. Comparing decreasing ESF coverage and MMP termination with achieving 100% ESF coverage (Universal Health Coverage scenario) in 2030, mortality rates would be 11.12% higher (95% CI 9.47-12.76%; 83,937 premature deaths). Reductions in ESF coverage would have stronger effects on mortality from infectious diseases and nutritional deficiencies and would disproportionately impact poorer municipalities, with the concentration index for ACSC mortality 11.77% higher (95% CI 0.31-22.32%) and also ending historical declines in racial health inequalities between white and black/pardo Brazilians. CONCLUSIONS Reductions in primary healthcare coverage due to austerity measures are likely to be responsible for many avoidable deaths and may preclude achievement of SDGs for health and inequality in Brazil and in other low- and middle-income countries.
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Affiliation(s)
- Davide Rasella
- Instituto de Saúde Coletiva, Universidade Federal da Bahia, Salvador, Bahia Brazil
- Public Health Policy Evaluation Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Thomas Hone
- Public Health Policy Evaluation Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | | | - Renato Tasca
- Pan-American Health Organization/World Health Organization Country Office for Brazil, Brasilia, Brazil
| | - Sanjay Basu
- Center for Population Health Sciences, School of Medicine, Stanford University, Stanford, California USA
- Center for Primary Care and Outcomes Research, School of Medicine, Stanford University, Stanford, California USA
- Center for Primary Care, Harvard Medical School, Boston, Massachusetts USA
| | - Christopher Millett
- Public Health Policy Evaluation Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
- Center for Epidemiological Studies in Health and Nutrition, University of São Paulo, São Paulo, Brazil
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