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Contracting for Primary Health Care in Brazil: The Cases of Bahia and Rio de Janeiro


  • Edson Araujo
  • Luciana Cavalini
  • Sabado Girardi
  • Megan Ireland
  • Magnus Lindelow


This study presents two case studies, each on a current initiative of contracting for primary health services in Brazil, one for the state of Bahia, the other for the city of Rio de Janeiro. The two initiatives are not linked and their implementation has independently sprung from a search for more effective ways of delivering public primary health care. The two models differ considerably in context, needs, modalities, and outcomes. This paper identifies their strengths and weaknesses, initially by providing a background to universal primary health care in Brazil, paying particular attention to the family health strategy, the driver of the basic health care model. It then outlines the history of contracting for health care within Brazil, before analyzing the two studies. The state of Bahia sought to expand coverage of the family health strategy and increase the quality of services, but had difficulty in attracting and retaining qualified health professionals. Rigidities in the process of public hiring led to a number of isolated contracting initiatives at the municipal level and diverse, often unstable employment contracts. The state and municipalities decided to centralize the hiring of health professionals in order to offer stable positions with career plans and mobility within the state, and chose to create a state foundation, acting under private law to manage and oversee this process. Results have been mixed as lower than expected municipal involvement resulted in relatively high administrative costs and consequent default on municipal financial contributions. The state foundation is undergoing a governance reform and has now diversified beyond hiring for primary care. The municipality of Rio de Janeiro, which until recently relied on an expansive hospital network for health care delivery, sought in particular to expand primary health services. The public health networks suffered from inefficiency and poor quality, and it was therefore decided to contract privately owned and managed, not-for-profit, social organizations to provide primary care services. The move has succeeded in attracting considerable increases in funding for primary health and coverage has increased significantly. Performance initiatives, however, still need fine-tuning and reliable information systems must be implanted in order to evaluate the system.

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  • Edson Araujo & Luciana Cavalini & Sabado Girardi & Megan Ireland & Magnus Lindelow, 2014. "Contracting for Primary Health Care in Brazil: The Cases of Bahia and Rio de Janeiro," Health, Nutrition and Population (HNP) Discussion Paper Series 91322, The World Bank.
  • Handle: RePEc:wbk:hnpdps:91322

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    References listed on IDEAS

    1. Liu, Xingzhu & Hotchkiss, David R. & Bose, Sujata, 2007. "The impact of contracting-out on health system performance: A conceptual framework," Health Policy, Elsevier, vol. 82(2), pages 200-211, July.
    2. Michele Gragnolati & Magnus Lindelow & Bernard Couttolenc, 2013. "Twenty Years of Health System Reform in Brazil : An Assessment of the Sistema Único de Saúde," World Bank Publications, The World Bank, number 15801, December.
    3. Timothy Besley & Maitreesh Ghatak, 2003. "Incentives, Choice, and Accountability in the Provision of Public Services," Oxford Review of Economic Policy, Oxford University Press, vol. 19(2), pages 235-249, Summer.
    4. Karen Eggleston & Richard Zeckhauser, 2002. "Government Contracting for Health Care," Discussion Papers Series, Department of Economics, Tufts University 0202, Department of Economics, Tufts University.
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