Investment in primary care reduces racial inequality in Brazil

Photo credit: CCS/Fiocruz/Peter Ilicciev

Extracted from Cidacs/Fiocruz. Original portuguese version here.

Nearly 130 after the abolition of slavery in Brazil, racial inequality remains structurally rooted in the country. Over the period 2000-2013, the mortality rate due to conditions sensitive to primary care (avoidable deaths) was between 17% and 23% higher in Brazilians who declared themselves black or brown. However, the expansion of primary care plays an important role in reducing social inequalities in health and can help reverse these numbers.

These are some of the results pointed out in the study "Association between expansion of primary healthcare and racial inequalities in mortality amenable to primary care in Brazil: the national longitudinal analysis", published on 30th May, in an influential open-access journal PLoS Medicine.

When analysing the impact of the expansion of the Family Health Strategy program over the period 2000 to 2013, the researchers identified a twofold reduction in avoidable mortality in black or brown self-reported populations when compared to white populations. Although the expansion of ESF was associated with a 6.8% reduction in mortality due to primary care sensitivity conditions among white people, the reduction among black/pardo was 15.4%.

Researchers from Imperial College London, Thomas Hone and Christopher Millet carried out the work in collaboration with researchers from the Center for Data Integration and Knowledge for Health (Cidacs/Fiocruz), Davide Rasella and Mauricio Barreto. To reach these conclusions, the study used statistical modelling based on data from 1,622 Brazilian municipalities, selected according to adequate reporting of vital statistics.

The study highlights the poorly studied relationship, especially in low and middle-income countries, between the expansion of the primary health care network and health inequalities, including racial inequalities. The evidence also reinforces previous studies demonstrating an association between the expansion of primary care and a reduction in avoidable mortality.

The authors argue that the Family Health Strategy should continue to be prioritised. Expansion and consolidation should continue in areas with vulnerable populations, such as rural areas and urban peripheries, in order to further reduce inequalities in health and ensure progress towards the 10th Sustainable Development Goal (SDG).

"The possibility of reducing spending on health and social policies can have harmful effects and reverse the consistent trends of improving the health standards of our population" says the coordinator of Cidacs and one of the collaborators of the study, Mauricio Barreto.


Racial inequality is widespread in Brazil: black and brown populations have the highest rates of illiteracy, have lower income, and use health services less. In relation to health, they have lower life expectancy, are more affected by infectious diseases (tuberculosis, leprosy, and leishmaniosis, among others), malnutrition, anaemia and have higher mortality rates due to external causes, such as drug overdose and homicide.

In addition, this racial group has lower access to health services and higher rates of forgone health care. The findings from this study suggest the Family Health Strategy may have facilitated access to health care for these populations, especially due to the proactive approach of the agents of health.


The Family Health Strategy is a Brazilian community-based primary health care program that has been expanding since the 1990s and is the main platform for achieving Universal Health Coverage in the country.

In addition to decreasing social inequality, the expansion of the Family Health Strategy has already been associated with the reduction of infant mortality, avoidable hospitalizations and deaths from cardiovascular and respiratory diseases.


Access other publications of the authors in partnership with UNDP RIO+ Centre:

Davide Rasella, Rosana Aquino, Carlos A T Santos, Rômulo Paes-Sousa, Mauricio L Barreto. Effect of a conditional cash transfer programme on childhoodmortality: a nationwide analysis of Brazilian municipalities.

Davide Rasella (Federal University of Bahia) and Romulo Paes (RIO+ Centre). Combining Conditional Cash Transfers and Primary Health Care to Reduce Childhood Mortality in Brazil.

David Rasella, Daniel Villela, Romulo Paes Souza, Delia Boccia, Ana Wieczorek Torrens, Mauro Sanchez, Draulio Barreira, Sanjay BasuMobilizing Big Data and Microsimulation for SDGs: Forecasting the Impact of a Conditional Cash Transfer Programme on Tuberculosis in Brazil.