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  • br Acknowledgements This work was supported by the Bill and

    2018-10-26


    Acknowledgements This work was supported by the Bill and Melinda Gates Foundation [OPP10327313]; Eunice Shriver Kennedy National Institute of Child Health and Development [R01 HD070993]; and Grand Challenges Canada [Grant 0072-03]. The data used in this study come from Young Lives, an international study of childhood poverty, following the lives of 12,000 children in four countries – Ethiopia, India, Peru and Vietnam – over 15 years (www.younglives.org.uk). Young Lives is core-funded by UK aid from the Department for International Development (DFID) and co-funded from 2010–2014 by the Netherlands Ministry of Foreign Affairs, and by Irish Aid from 2014 to 2015. Findings and conclusions in this article are those of the authors and do not necessarily reflect positions or policies of the Bill and Melinda Gates Foundation, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Grand Challenges Canada, Young Lives, DFID or other funders. The funders had no involvement in the study design, in the collection, analysis, and interpretation of data, in the writing of this study, and in the decision to submit it continine for publication.
    Introduction Neonatal health continues to be a primary concern for policy makers in low- and middle income countries, with the millennium development goal maternal mortality targets being missed in many countries (Walker, Yenokyan, Friberg, & Bryce, 2013), and close to 3 million neonatal deaths every year (Bhutta et al., 2014; Oestergaard et al., 2011). One increasingly considered strategy to reduce neonatal mortality is community-based home visiting programs, which have been shown to lead to reductions in infant mortality of up to 40% (Baqui et al., 2009; Bhutta et al., 2011; Lassi, Haider, & Bhutta, 2010). Relatively little is known regarding the effectiveness of community-based home-visiting programs outside of South-East Asia, and in particular in settings where access to health services is common and affordable for poor populations as it is generally the case in urban areas of middle income countries. Brazil’s current transition from a center to a home based primary care system offers an ideal setting to directly assess the effectiveness of community-based models. First proposed in 1991 and created in 1994, Brazil’s Family Health Strategy (FHS) (programa de saúde da família) was initially deployed in small municipalities and became one of the primary health care strategies pursued by the Ministry of Health in 2000 (Sampaio, Mendonça, & Lermen, 2012). The FHS is intensive from a human resource and financial perspective. Under the FHS, areas comprising populations of 3000–4500 people are assigned to and supported by a family health team. Each family health team consists of six community health workers (CHWs), one nurse, two nurse assistants and one general practitioner. Households under the FHS receive a monthly visit by a CHW, who refers members to local health centers whenever needed. During their visits, CHWs are charged with monitoring a range of health conditions including pregnancy, hypertension, diabetes, and communicable diseases such as dengue, tuberculosis and leprosy. For pregnant women, CHWs monitor and encourage pre-natal care attendance, and visit mothers at home within the first few days after their hospital release post-delivery (Aquino, de Oliveira, & Barreto, 2009). This is different from the model traditionally used in Brazil, which primarily relies on patient initiative and offers targeted programs only to special populations based on epidemiological patterns of disease, vulnerability or risk (Morosini & Corbo, 2007). Both under the FHS and the traditional model, a wide range of services are available at primary health care centers and public hospitals. Each primary health care zone (primary health care unit coverage area) provides basic services for a population of 20,000–40,000 individuals. Under the FHS, each zone is divided into multiple FHS teams, with each community agent responsible for approximately 150 households (Macinko & Harris, 2015). Brazil’s traditional public health care model also offers comprehensive pediatric services, with appointments routinely scheduled one week after birth, and then at 1, 2, 4, 6, 9 and 12 months of age (Ministério da Saúde, 2008). The main difference of the FHS model is that it allows for home-based detection of health problems, as well as home-based support and promotion of access to publicly available services that are often not used due to lack of awareness, lack of time or lack of resources (Bassani, Surkan, & Olinto, 2009; Goldbaum, Gianini, Novaes, & Cesar, 2005), with large resulting differences in birth outcomes across socioeconomic groups (Macinko, de Fátima Marinho de Souza, Guanais, & da Silva Simões, 2007; Vettore, Gama, Lamarca, Schilithz, & Leal, 2010). Due to large social inequities and the high concentration of specialized health services, scaling up of the FHS model has been slow in São Paulo as well as other (and in particular urban) part of Brazil, resulting in a highly heterogeneous primary care systems within relatively close and highly similar geographic and socioeconomic strata (d׳Avila Viana, Rocha, Elias, Ibanez, & Bousquat, 2008). At the national level, partial FHS coverage has been achieved in over 95% of all municipalities, with an estimated 62% of the total population covered by the program in 2014 (Departamento de Atenção Básica, 2015; Macinko & Harris, 2015).