Evaluation of the Impacts of the “Avançar” Health Program on the Provision of Primary Health Care in the State of Rio Grande do Sul

Avaliação dos Impactos do Programa Avançar na Oferta de Cuidados Básicos em Saúde no Estado do Rio Grande do Sul

Abstract

In response to the twin challenge of restoring fiscal balance and enhancing social welfare, the Government of Rio Grande do Sul launched the Avançar Program in 2021, committing roughly R$ 6.3 billion in public investment. Organized around three strategic pillars - Growth (economic support, tax relief, logistics and mobility), People (public security, social assistance, culture, health and education), and Sustainability (innovation, technology and the environment) - the program earmarked R$ 542.5 million for the health sector. This study assesses the impact of the share allocated to upgrading the physical infrastructure of Primary Health Care Units (UBSs) on supply-side indicators of services delivered at these facilities, employing difference-in-differences econometric models. The evidence indicates that renovations and expansions of UBSs increased the volume of dental consultations, general procedures, and maternal care - manifested in a direct rise in prenatal visits - thereby suggesting that Avançar investments are strengthening Primary Health Care in Rio Grande do Sul.

Keywords:
Avançar Program; Public Health; Impact Assessment; Allocative Efficiency

Resumo

Diante da necessidade de conciliar equilíbrio fiscal e bem-estar social, o Governo do Rio Grande do Sul lançou, em 2021, o Programa Avançar, com investimento de R$ 6,3 bilhões. Estruturado em três eixos, Crescimento (apoio econômico, desoneração, logística e mobilidade), Pessoas (segurança, assistência social, cultura, saúde e educação) e Sustentabilidade (inovação, tecnologia e meio ambiente), o programa destinou R$ 542,5 milhões à saúde. Este estudo avalia o impacto de parcelas voltadas à infraestrutura das Unidades Básicas de Saúde (UBS) sobre indicadores de oferta de serviços, utilizando modelos econométricos de diferenças-em-diferenças. Os resultados indicam que reformas e ampliações das UBS elevaram atendimentos odontológicos, procedimentos gerais e a assistência a gestantes, com efeitos sobre consultas de pré-natal. Conclui-se que os investimentos do Avançar fortaleceram a Atenção Primária à Saúde no Rio Grande do Sul, sugerindo ganhos de acesso e capacidade instalada, e evidências de efetividade na alocação de recursos públicos.

Palavras-chave:
Programa Avançar; Saúde Pública; Avaliação de impacto; Eficiência Alocativa

1 Introduction

In recent years, there has been a significant increase in the debate surrounding the expansion of the welfare state, particularly within the Brazilian context where efforts are underway to promote development in this direction. This debate primarily focuses on the formulation and implementation of public policies aimed at stimulating specific sectors, considering both fiscal efficiency and the resulting social benefits. Given the delicate balance between fiscal conditions and the promotion of social welfare, it becomes crucial to conduct impact evaluations of these public policies to determine the benefits generated for society relative to the public resources invested.

According to the document "Evaluation of Public Policies: Practical Guide for ex post Analysis," published by the General Comptroller's Office (IPEA, 2018), the evaluation of public policy requires a detailed analysis and comprehensive diagnosis. This involves examining how the policy is being implemented, its intended and unintended effects, the key stakeholders involved, and how public resources are being utilized. Formal methods are necessary for this evaluation because, unlike individual analysis where subjective aspects can be easily ranked, it is challenging in the realm of public policies to synthesize subjective benefits for the entire society.

In this context, the "Avançar" program emerges/was born, launched by the State Government of Rio Grande do Sul in 2021 as an initiative to boost development across three main thematic axes: Growth, People, and Sustainability. This program received a significant investment of approximately R$6.3 billion to cover these three axes, aiming to enhance the state's welfare. Given the complexity and scope of these axes, it is prudent to address the program's effects in a segmented manner. Focusing on the investment in the health sector - which received the largest allocation of resources - this study aims to investigate the impacts of the program on indicators of primary health service provision in the state of Rio Grande do Sul.

The investment in the health sector by the Avançar program was directed toward four main segments: Rede Bem Cuidar RS (Quality Care Network RS), Farmácia Cuidar + (Better Pharmacy Care), Infrastructure of State Department of Health (Secretaria Estadual de Saúde - SES), and the Hospital Network. These investments were distributed over four stages, with a total estimated value of R$542.5 million.

Focusing on the Rede Bem Cuidar RS, the program aims to renovate and expand Basic Health Units (UBS) in 76 municipalities. These actions are distributed across various regions of the state, aiming to improve the capacity to offer basic health services to the population.

Considering this scenario, it is essential to evaluate the effects of the Avançar RS Program on the provision of health services, with special interest in primary health care in the state of Rio Grande do Sul. This is particularly relevant for the effective management of public policies aimed at the well-being of the population of Rio Grande do Sul, providing insights that enable public managers to reassess the cost-benefit of investments and adjust the program's actions as necessary.

This article is structured into five sections for comprehensive understanding. Section 2 discusses studies related to health economics and their impact on the target audience. Section 3 describes the database and methodology utilized. Section 4 presents and discusses the results of the analyses performed. Finally, Section 5 offers the study's concluding remarks.

2 The Avançar RS Program and Studies Related to Health Economics

2.1 The Avançar RS Program

Launched in June 2021, the Avançar RS Program aims to stimulate economic growth and enhance the quality of services offered to the population of Rio Grande do Sul. Divided into three main thematic axes - Avançar with Sustainability, Avançar for the People, and Avançar in Growth - the program encompasses sixteen distinct sub-areas. These sub-areas include the Works Plan, Paving, Iconic Projects, Culture, Health, Innovation, Education, Security, Sports, Penal and Socio-Educational System, Agriculture and Rural Development, Sustainability, Works and Housing, Tourism, Economic Development, and Communication.

With a special focus on the health sector, the health Avançar - with- its first stage launched on September 13, 2021 - aims to invest R$249.7 million by the end of 2022. This investment is primarily directed toward the acquisition of construction and equipment intended to improve the hospital network (R$177.5 million), pharmaceutical assistance (R$21 million), basic health units (R$31.4 million), and support for the infrastructure of municipal health secretariats (R$19.8 million).

A second stage of the program, announced on January 4, 2022, totaling R$99.4 million, will enhance the quality of care provided by the Unified Health System (SUS) in hospitals (R$66.6 million), basic health units (R$12.8 million), and pharmaceutical assistance (R$20 million). A third stage, throughout 2022, allocated an additional R$120 million in public resources, especially for hospital infrastructure (R$100 million) and basic health units (R$20 million). Finally, a fourth stage of the program, also presented in 2022 and amounting to R$73.4 million, is underway, divided between the Rede Bem Cuidar (R$21.4 million) and the hospital network (R$52 million). The sum of these four stages will total R$542.5 million, representing the largest investment ever made in the health sector in the last 20 years in the state of Rio Grande do Sul.

Thus, the Avançar in the Health Program seeks to improve infrastructure conditions and broaden the reach of primary care by financing the expansion of the hospital network and strengthening Basic Health Units (UBSs).

2.2 Studies Related to Health Programs in Brazil

Evaluating health-system performance is a multifaceted undertaking driven by the need to optimize the allocation of public resources and ensure managerial transparency, particularly in settings characterized by tight budget constraints and rising demand for equitable, high-quality services. The specialized literature on Brazil’s Unified Health System (SUS) stresses that robust methodologies are indispensable for untangling the factors that shape efficiency, effectiveness, and equity, as well as for monitoring inequalities in access to and quality of care across population groups (Viacava et al., 2004). Against this backdrop, the appraisal of public investments - such as those channeled through government programs - is crucial for determining whether the funds deployed translate into tangible performance gains, thereby supporting the continuous improvement of health policy.

Within the multidimensional performance framework, the access dimension is paramount when the analytical focus is on investments aimed at expanding service provision. The Health-System Performance Assessment Project (Projeto de Avaliação do Desempenho do Sistema de Saúde - PROADESS) defines access as the system’s capacity to provide the necessary care at the right place and time (PROADESS, n.d.). Although a comprehensive evaluation must also address effectiveness, efficiency, appropriateness, and respect for users’ rights, concentrating on access allows researchers to test whether additional resources effectively increase the availability and utilization of services by the target population. Accordingly, assessments of initiatives such as the Avançar in the Health Program may legitimately prioritize access when measuring the direct effects of funding on the ability of Basic Health Units (UBSs) to meet community needs.

At the state level, the broader Avançar-RS package - launched in September 2021 - has not yet undergone impact evaluation regarding its influence on access indicators, particularly those related to primary care. This gap justifies empirical inquiry. Evidence from other interventions aimed at improving access can, however, provide useful benchmarks.

Studies focusing on adults show that Brazil’s Family Health Strategy (Estratégia Saúde da Família - ESF) has enhanced beneficiaries’ access to and follow-up within the health system. Using 2008 PNAD microdata, Macinko and Lima-Costa (2012) find that ESF enrollment is associated with a higher probability of having a consistent source of care, more medical consultations, and better access to prescribed medicines, along with greater user satisfaction. Analyzing the 2013 National Health Survey, Dourado, Medina, and Aquino (2016) report that ESF registration is positively correlated with having a usual/consistent source of care, especially among individuals with longer program exposure in the North, Northeast, and Center-West regions.

Carrets, Teixeira, and Balbinotto Neto (2022), using ELSI-Brasil data, confirm that the ESF improves perceived access to services, particularly among socioeconomically vulnerable groups. Likewise, Kashiwakura et al. (2021) show that higher per capita municipal health spending from 2016 to 2019 correlates with better UBS physical infrastructure - more consultation rooms/offices, equipment, and service diversification.

Assessing 2014-2016 data, Lins and Menezes (2021) find that greater federal primary-care funding raises the probability of hospital utilization, suggesting that basic care has not fully assumed a preventive role yet nonetheless expands overall access to hospital services. Soares (2007), studying federal capital investments in 1995-2001, documents increase in hospital admissions and outpatient visits but no commensurate rise in installed capacity (e.g., beds), indicating limited infrastructure expansion.

Internationally, the integration of oral-health and prenatal services has been emphasized. A systematic review and meta-analysis by Le et al. (2021) show that periodontitis is significantly associated with a higher risk of pre-eclampsia in low- and middle-income countries, underscoring the importance of policies that link dental and maternal care. Stenberg et al. (2019) estimate that scaling up primary-health-care investment in 67 countries could avert up to 60 million deaths by 2030 and raise average life expectancy by 3.7 years at a cost of only 3.3 percent of their collective GDP - a highly favorable cost-effectiveness profile.

Investments such as the ESF generate spillovers beyond access. Numerous studies show sizeable reductions in infant mortality (Macinko et al., 2007; Aquino et al., 2009; Rocha & Soares, 2010; Guanais, 2013; Bhalotra et al., 2019), especially in the North and Northeast (Reis, 2014; Santos & Jacinto, 2018). Important complementarities with social programs like Bolsa Família (Guanais, 2013) and Primeira Infância Melhor (Ribeiro et al., 2018; 2021) amplify these outcomes, and cost-effectiveness analyses highlight the broad societal returns of the ESF (Rocha & Soares, 2010). Positive impacts also extend to reproductive health - higher contraceptive use and lower teen motherhood in poorer areas (Hellwig et al., 2021) - and to education, where evidence shows improved school participation and retention (Rocha & Soares, 2010; Costa, 2018; Funtowicz et al., 2018), though one study notes a potential trade-off with average learning (Costa, 2018).

Despite predominantly favorable findings, Silva and Becker (2022) detect no significant ESF effect on quality-of-life metrics, suggesting either sample-selection issues or the need for more sensitive indicators. Heterogeneous effects are also salient: benefits are stronger in municipalities with longer program duration and in the country’s most socioeconomically vulnerable regions (Rocha & Soares, 2010).

Taken together, this body of evidence implies that the Avançar in the Health Program is likely to enhance service quality and, consequently, population health in Rio Grande do Sul - if the funds are effectively deployed. Health-economics research indicates that private funding often yields larger health gains than public spending in contexts of weak institutions (Fujii, 2018), yet there is broad agreement that health expenditures, overall, improve population-health indicators (Gani, 2009).

The need for additional health investment is evident: projections point to growing resource demands in regions/countries such as Brazil (Rocha, Furtado, & Spinola, 2021). Since Rio Grande do Sul’s population is aging faster than the national average, target investments in health care are imperative. State initiatives that finance rigorous impact evaluations of their own health programs signal a strong commitment to evidence-based policymaking and delivery of high-quality services to citizens.

3. Methodology and Empirical Strategy

3.1 Empirical Strategy

To investigate the impacts of the Program on indicators of health service provision, panel data of Basic Health Units (UBS) from 2018 to 2023 will be constructed, based on two main groups of information: (1) identification of UBS benefited by the Avançar program, and (2) health sector data.

Regarding the first group of information, data from the State Department of Health of Rio Grande do Sul will be used to identify the municipalities covered by the Program. Additionally, these data allow for verification of the specificity of the resources allocated to each municipality, detailing whether they were designated to the Rede Bem Cuidar RS, and the purpose of the aid.

Health sector data will be obtained from the Basic Health Information System for Primary Care (Sistema de Informação em Saúde para a Atenção Básica - SISAB), organized into a UBS panel with information on the provision of health services in primary care. These data were organized monthly per UBS.

3.1.1 Difference-in-Differences Model

The study utilized an empirical strategy based on the difference-in-differences model, incorporating fixed effects controls and unit-specific trends for each UBS. This approach is justified by the availability of information over time for distinct groups of health units - both those benefited by the Avançar in the Health program and those that did not receive the resources. The main challenge in impact evaluations using econometric models is constructing adequate counterfactual to establish causal relationships, as the researcher typically only has access to the factual data.

Ideally, it would be necessary to simultaneously observe both the factual and the counterfactual to compare the performance of the dependent variables in scenarios with and without intervention. In the context of this study, this would mean comparing the performance in terms of health service provision of the units covered by the program with the hypothetical scenario in which these same units were not affected by the intervention.

The difference-in-differences method is presented as a robust alternative to capture the average effect of the program, assuming that, in the absence of the intervention, the trajectories of the variables in the treated units would follow patterns identical to those of the untreated units. Thus, any external shocks would affect both groups similarly. Therefore, the deviations observed in the trajectories of the variables of interest between the two groups after the intervention can be attributed to the effect of the program on the directly affected units, allowing for the establishment of valid causal relationships¹.

Consequently, for the case of UBS, in this study, the following equation will be estimated:

$Y_{it}=\alpha +\beta .AVANÇA{R}_{it}+{\theta }_i+{\mu }_t+{\epsilon }_{it}$ (1)

where $Y_{it}$ represents the variables of health service supply in unit i (UBS), such as the number of individual consultations, number of dental consultations, number of procedures performed, number of PICS procedures performed, number of collective activities and prenatal indicators, at time t. The term $AVANÇA{R}_{it}$ denotes a dummy variable that assumes a value equal to 1 if unit i at time t was benefited by the program. On the other hand, ${\theta }_i$ is a fixed effect of the health unit, which captures the unobserved and fixed features over time of unit i that influence the dependent variables, ${\mu }_i$ captures temporal effects common to all observational units, ${\epsilon }_{it}$ is a random error term and $\beta$ is the parameter of interest, which from 2023/01 onwards, should capture the effect of the intervention on the unit treated.

3.1.2 Robustness Check

To test the validity of the results, temporal falsification tests will be applied, as described in Rocha and Soares (2010), in which the occurrence of the program for periods prior to what was observed for the treatment units (UBS) is simulated. This strategy allows verifying the central hypothesis of previous parallel trends between the treated and control groups, a condition of the difference-in-differences method, so that it is expected that there will be no significant differences between the treated and control groups in the simulated periods prior to the actual period of exposure to the program.

3.2 Databases

In the initial attempt to estimate the impact of the Avançar Program on Basic Health Units (UBS), a subproject of the Rede Bem Cuidar focused on funds allocated for the renovation and expansion of the targeted UBS was evaluated. The choice of this subproject is due to the potential significant impact of the resources, with each UBS receiving an average of R$ 289,000. Of the 127 UBS that received funds, only 30 were completed and operational by January 2023. Other subjects, such as incentives for the implementation of the Rede Bem Cuidar (RBC) and the acquisition of dental equipment, have a lesser impact on production indicators, as they are intended for funding daily activities.

The data for the analysis were obtained from two sources: (1) the State Department of Health of Rio Grande do Sul, which provided information on municipalities and UBS served, amounts, payment dates, and the status of the projects; (2) the Basic Care Health Information System (SISAB/SUS), which records various data from the UBS. From SISAB, monthly variables were collected for each UBS, including the number of individual consultations, dental services, procedures performed, integrative and complementary health practices (PICS), collective activities, and prenatal indicators.

To prevent the estimates from being influenced by scale effects, the variables were weighted by the number of registrations linked to each UBS, expressed as rates per 100 registered individuals. The treated units (which received resources from the Avançar program) were compared with control UBS that did not participate in the program, using establishments classified as Family Health Support Centers, Health Posts/Outpatient clinics, and Basic Health Units.

Thus, Table 1 presents the descriptive statistics for the variables of interest for the 30 UBS with completed renovation and expansion works, as well as for the 2,087 UBS that formed the control group. The variables are presented in levels.

Table 1:
UBS - Descriptive statistics

	Treated					Controls
Variables	Mean.	SD.	CV.	Min.	Max.	Mean.	SD.	CV.	Min.	Max.
Linked Cadaster	3411	1661	0.49	3	11244	3185	2547	0.8	0	54079
Individual Consultations	306	2914	9.52	0	50133	158	7162	45.3	0	894600
Dental Care	4	33	8.25	0	1133	16	464	29.0	0	41150
Procedures	39	24	0.62	0	200	246	10696	43.5	0	1112800
Collective activities	5	55	11.00	0	1267	0.96	25	26.0	0	3500
PICS Procedures	0.13	0.5	3.85	0	5	0.54	23	42.6	0	3600
First prenatal care 12 weeks	0.07	0.06	0.86	0	0.53	0.33	9	27.3	0	1000
Pregnant women prenatal care	0.11	0.1	0.91	0	1	0.64	19	29.7	0	2100
Pregnant women with 1 to 3 visits	0.06	0.06	1.00	0	0.73	0.38	11	28.9	0	1200
Pregnant women with 4 to 5 consultations	0.01	0.03	3.00	0	0.41	0.07	3	42.9	0	400
Pregnant women plus consultations	0.03	0.05	1.67	0	0.42	0.14	7	50.0	0	1400
Pregnant women up to 20 weeks	0.01	0.03	3.00	0	0.33	0.03	2	66.7	0	400

• Source: Prepared by the authors.

4. Results

4.2 Effect of the Avançar Program on UBS

To evaluate the impacts of the Avançar Program on health indicators of Basic Health Units (UBS), a specific line of the program was selected: the transfer of funds for the renovation and expansion of health facilities. Of the 127 UBS covered by this modality, only 30 had completed the works by January 2023, which is considered the start date of operation for the renovated units.

Two groups of variables were analyzed, all expressed as rates per 100 registered individuals. The first group pertains to the production of UBS, including the number of individual consultations, dental consultations, general procedures, procedures of Integrative and Complementary Health Practices (PICS), and collective activities (Table 2). The second group encompasses prenatal care indicators, such as the number of pregnant women receiving their first consultation up to the 12th week, total number of pregnant women receiving prenatal care, number of prenatal consultations per pregnant woman, and number of pregnant women with exams evaluated up to the 20th week (Table 3).

The results showed that, in the post-renovation period up to June 2023, the UBS that were included experienced a statistically significant increase in the number of dental consultations and general procedures performed. There were no significant effects on individual consultations, PICS procedures, and collective activities. The increase in dental consultations may be related to the adherence criteria of the Rede Bem Cuidar, which requires the designation or creation of an Oral Health team, and to investments in dental offices.

The improvement in procedures, without an increase in individual consultations, suggests an enhancement in the quality of services provided. This indicates that even with the same number of consultations, there was an increase in the number of procedures performed, possibly due to the expansion of UBS infrastructure. The absence of effects on individual consultations may be associated with the excess demand faced by the units, limiting the increase in the quantity of consultations but not preventing improvements in quality.

For the prenatal indicators, the program generated significant improvements. There was an increase in the number of first prenatal consultations up to the 12th week, in the total number of pregnant women receiving prenatal care, and in the number of pregnant women who had 1 to 5 prenatal consultations. No significant effects were observed in the number of pregnant women with more than five consultations or in the exams evaluated up to the 20th week. These results indicate that the program improved assistance to pregnant women, promoting healthier and safer pregnancies, which may reduce obstetric complications and maternal-infant mortality.

Despite the low number of UBS with completed works, the partial results suggest positive effects on production variables and prenatal indicators. The evidence indicates that the resources from the Avançar Program directed to the Rede Bem Cuidar contribute to policies promoting primary health care, strengthening programs such as the Family Health Strategy. This underscores the importance of investments in infrastructure to improve the quality of health services offered to the population.

Table 2
Effects of Avançar on production indicators of the UBS.

	Individual Consultations	Dental Care	Procedures	PICS Procedures	Collective Activities
Treatment	-148.8777	16.5399**	228.8928***	0.8229	-4.0975
	(309.4715)	(8.1784)	(81.5535)	(0.7799)	(5.0624)
Observations	125.616	102.730	125.353	34.509	112.226
R-squared	0.0006	0.0022	0.0006	0.0018	0.0024
Number of UBS	2,230	1,959	2,230	1,307	2,154
Year FE	YES	YES	YES	YES	YES
UBS FE	YES	YES	YES	YES	YES

• Source: Survey results. Robust standard error in parentheses and significance levels *** p<0.01, ** p<0.05, * p<0.1.

Table 3
Effects of Avançar on Prenatal Care Indicators at the UBS

	First prenatal care 12 weeks	Pregnant women prenatal care	Pregnant women with 1 to 3 visits	Pregnant women with 4 to 5 consultations	Pregnant women plus consultations	Exams up to 20 weeks
Treatment	0.4026***	0.8110***	0.515***	0.1125**	0.2353	0.0452
	(0.1509)	(0.2764)	(0.1610)	(0.0573)	(0.1501)	(0.0281)
Observations	81.973	79.441	81.973	81.973	81.973	81.973
R-squared	0.0020	0.0025	0.0021	0.0014	0.0009	0.0008
Number of UBS	2,154	2,154	2,154	2,154	2,154	2,154
Year FE	YES	YES	YES	YES	YES	YES
UBS FE	YES	YES	YES	YES	YES	YES

• Source: Survey results. Robust standard error in parentheses and significance levels *** p<0,01, ** p<0,05, * p<0,1.

4.2 Robustness check

To verify the robustness of the estimated results for the Basic Health Units (UBS), an event study strategy was adopted following Rocha and Soares (2010). The objective was to rule out the possibility that the effects attributed to the Avançar program were capturing pre-existing trends in UBS production and prenatal care services. To achieve this, dummy variables indicating periods prior to the completion of the renovation and expansion works (October, November, and December 2022) were added, limiting the analysis to the period from 2021 to 2023. This approach prevented factors associated with the COVID-19 pandemic or other public policies from influencing the results.

The analysis of the UBS production variables (Table 4) showed that in the three months preceding the completion of the works, there was no robust evidence of significant differences between the treatment and control groups. Most variables were not statistically significant or were significant in only one period, corroborating the robustness of the previous results.

For the prenatal care variables (Table 5), only the variable referring to 1 to 3 prenatal consultations showed significant prior differences, indicating that the estimated results for this variable may not be entirely robust. The other variables did not show significant effects or exhibited low statistical significance, supporting the evidence of improvement in prenatal care services at the UBS included in the program.

Table 4
Robustness check, previous trends, for production variables of the UBS

	Individual Consultations	Dental Care	Procedures	PICS Procedures	Collective Activities
Treatment	124,9995	3,5030***	173,3137**	0,9847	0,3347***
	(76,5771)	(1,0298)	(81,8291)	(0,9062)	(0,0965)
Treatment 2022/10	-96,3428	1,0580	-76,7000	-0,7071	-0,1176
	(128,7120)	(3,6101)	(152,2585)	(0,7856)	(0,1550)
Treatment 2022/11	26,3074	4,6101*	-63,4597	0,6757	0,1809**
	(93,6936)	(2,6597)	(252,8121)	(0,6281)	(0,0800)
Treatment 2022/12	117,8839	5,8853**	193,7212*	0,8833	0,0789
	(73,3357)	(2,5964)	(100,2243)	(0,6978)	(0,0745)
Observations	61.772	52.170	61.805	20.093	54.966
R-squared	0,0004	0,0010	0,0005	0,0018	0,0021
Number of UBS	2.187	1.905	2.186	1.086	2.087
Year FE	YES	YES	YES	YES	YES
Hospital controls	YES	YES	YES	YES	YES

• Source: Survey results. Robust standard error in parentheses *** p<0.01, ** p<0.05, * p<0.1.

Table 5
Robustness check, previous trends, for prenatal variables of the UBS

	First prenatal care 12 weeks	Pregnant women prenatal care	Pregnant women with 1 to 3 visits	Pregnant women with 4 to 5 consultations	Pregnant women plus consultations	Exams up to 20 weeks
Treatment	0,2822*	0,5940*	0,3330**	0,0778	0,2259	0,0392
	(0,1616)	(0,3034)	(0,1515)	(0,0613)	(0,1842)	(0,0341)
Treatment 2022/10	0,1632**	0,4118**	0,1476	0,0267**	0,2002	0,0332
	(0,0760)	(0,1984)	(0,1534)	(0,0113)	(0,1732)	(0,0316)
Treatment 2022/11	0,3688	0,7348*	0,4087**	0,0836	0,1977	0,0313
	(0,2477)	(0,4308)	(0,1863)	(0,0673)	(0,1741)	(0,0316)
Treatment 2022/12	0,3567	0,7230*	0,4124**	0,0504	0,2117	0,0340
	(0,2215)	(0,4100)	(0,1896)	(0,0384)	(0,1768)	(0,0324)
Observations	47.136	45.787	47.136	47.136	47.136	47.136
R-squared	0,0011	0,0015	0,0014	0,0007	0,0008	0,0007
Number of UBS	2.117	2.117	2.117	2.117	2.117	2.117
Year FE	YES	YES	YES	YES	YES	YES
Hospital controls	YES	YES	YES	YES	YES	YES

• Source: Survey results. Robust standard error in parentheses *** p<0.01, ** p<0.05, * p<0.1.

Building on the evaluation of the Avançar Program in primary health care, the evidence indicates a significant expansion in service volume at the Basic Health Units (UBSs) that received funding, especially in dental visits, general procedures, and prenatal consultations. Complementary findings by Lins and Menezes (2021) show that municipalities receiving larger federal transfers for primary care registered substantial declines in hospitalization rates for ambulatory care-sensitive conditions such as uncontrolled hypertension and diabetes. These results strengthen the argument that a well-structured primary care system can reduce overall hospital expenditure by preventing complications at earlier stages.

Overall, the Avançar assessment aligns closely with the established literature: targeted investments in infrastructure and organizational capacity improve both the efficiency and the quality of health service delivery. Nevertheless, challenges persist regarding equity, continuity of care, and the long-run sustainability of such initiatives. Continuous monitoring and rigorous impact evaluation therefore remain crucial to securing consistent and durable progress in population health outcomes.

4.3 Discussion of the Results

An examination of the Avançar in the Health results against the pertinent literature reveals several areas of convergence. The program’s positive effects on the number of dental visits, general procedures, and various prenatal-care indicators at the supported Basic Health Units (UBSs) broadly corroborate earlier findings on the benefits of investments in primary health care (PHC). They align with Kashiwakura et al. (2021), who document a positive correlation between higher per-capita health spending and improved UBS infrastructure, including additional rooms and a wider range of services. They are likewise consistent with evidence on the Family Health Strategy (ESF), which shows enhancements in access and service utilization (Macinko & Lima-Costa, 2012; Dourado et al., 2016), although Avançar’s spending is more narrowly focused on physical infrastructure.

Notably, the observed increases in general procedures and dental visits were not accompanied by a rise in overall individual consultations. This pattern suggests that Avançar’s infrastructure investments may have strengthened the capacity to perform a broader or more complex set of interventions within each visit rather than expanding the total number of visits. While this partly diverges from FHS studies reporting overall consultation growth (Macinko & Lima-Costa, 2012), it parallels Soares (2007), who finds that federal investments increased service provision (consultations, admissions) without expanding installed capacity (beds). The surge in dental services is also well-supported in international literature, underscoring the importance of oral-health care for overall health, particularly during pregnancy (Le et al., 2021).

Regarding prenatal care, Avançar’s outcomes concur with research indicating that stronger PHC can improve maternal-child health (Stenberg et al., 2019). Significant increases in the share of women receiving their first prenatal visit by the 12th week, the total number of pregnant women in care, and the number of early-pregnancy consultations suggest better access and earlier enrollment of expectant mothers. These gains likely reflect meaningful advances in the restructured UBSs’ capacity to provide adequate monitoring, potentially reducing complications and improving maternal and infant health - benefits extensively documented for PHC programs such as the FHS (Macinko et al., 2007; Aquino et al., 2009; Rocha & Soares, 2010).

5. Final Considerations

This study aimed to investigate the effects of the Avançar RS Program, specifically the segment focused on the health sector, on indicators of health service provision in the state of Rio Grande do Sul. The adopted methodology was based on the econometric difference-in-differences method and utilized data from Basic Health Units (UBS), focusing on the renovations and expansions promoted by the program.

The results obtained reveal positive impacts of the Avançar Program on the provision of health services. In the case of UBS, a significant increase was observed in the number of dental consultations and general procedures performed after the renovations and expansions. Additionally, there were improvements in prenatal care indicators, indicating healthier and safer pregnancies for the women benefited.

In summary, the results presented in this study suggest that the Avançar Program had a positive impact on the provision of health services and the quality of care in the state of Rio Grande do Sul. However, it is necessary to continue monitoring and evaluating the results to ensure the effectiveness and sustainability of the health policies implemented by the state government.

While every empirical evaluation faces methodological challenges, those affecting this study are largely typical of real-time program analyses and do not undermine the relevance of the findings. The number of upgraded UBS facilities is modest and the post-intervention window relatively short, yet both provide an early snapshot of Health Avançar’s immediate effects. The parallel-trends assumption was probed with several robustness checks; any remaining baseline differences between treated and control groups point more to future refinements than to serious bias. Although the indicators examined focus on service volume, they represent an essential first step; combining these administrative data with clinical quality measures in subsequent research rounds will allow a fuller assessment of health outcomes.

From a public-policy perspective, the results underscore that well-targeted, relatively modest capital investments can unlock idle capacity in primary care. To magnify and sustain these gains, policymakers should: (i) secure recurrent funding for staff, supplies, and maintenance so that physical improvements remain effective over time; (ii) coordinate Avançar resources with federal initiatives such as the Family Health Strategy (ESF) to integrate teams and expand community outreach; (iii) prioritize future funding cycles for municipalities exhibiting both coverage gaps and proven managerial readiness, balancing equity with efficiency; and (iv) institutionalize periodic impact evaluations - adding quality indicators and longer follow-up - to fine-tune guidelines and build an evidence base for similar programs across Brazil. In this way, the initiative can convert early productivity gains into lasting improvements in population health and public resource use.

Agradecimentos

Os autores agradecem a equipe editorial da Revista Nova Economia. Os autores agradecem a Secretaria da Fazenda do Estado do Rio Grande do Sul (SEFAZ/RS) e a Fundação de Amparo à Pesquisa do Estado do Rio Grande do Sul (FAPERGS), pelo financiamento da pesquisa, via Edital FAPERGS 05/2022 - Programa de Apoio à Pesquisa Aplicada em Finanças Públicas - PFP.

References

• AQUINO, R.; OLIVEIRA, N. F.; BARRETO, M. L. Impact of the Family Health Program on infant mortality in Brazilian municipalities. American Journal of Public Health, Washington, DC, v. 99, n. 1, p. 87-93, 2009.
• BHALOTRA, S.; ROCHA, R.; SOARES, R. R. Can universalization of health work? Evidence from health systems restructuring and expansion in Brazil. Bonn: IZA, 2019. (IZA Discussion Paper, 12111).
• CARRETS, F. D.; TEIXEIRA, G. S.; BALBINOTTO NETO, G. O Programa Estratégia Saúde da Família e indicadores de percepção dos serviços de saúde no Brasil: uma análise para população com 50 anos ou +. In: ENCONTRO ANPEC SUL, 2022. Proceedings […]. Available from: https://www.anpec.org.br/sul/2022/submissao/files_I/i8-a5e1ba99f60813eb6aba54d1e52bb055.pdf Accessed on: July 2023.
  » https://www.anpec.org.br/sul/2022/submissao/files_I/i8-a5e1ba99f60813eb6aba54d1e52bb055.pdf
• CÔRTES, L. S.; RIANI, J. L. R.; FERREIRA, S. Impact of water and sewage privatization on tariffs and access to services in Brazil. Revista Brasileira de Estudos de População, Campinas, v. 40, e0256, 2023. https://doi.org/10.20947/S0102-3098a0256
  » https://doi.org/10.20947/S0102-3098a0256
• COSTA, G. W. The effects of Brazil’s Family Health Strategy on educational outcomes. 2018. Thesis (PhD)-Universidade Federal do Rio Grande do Sul, Porto Alegre, 2018.
• DOURADO, I.; MEDINA, M. G.; AQUINO, R. The effect of the Family Health Strategy on usual source of care in Brazil: data from the 2013 National Health Survey (PNS 2013). International Journal for Equity in Health, v. 15, n. 1, p. 151, 2016.
• FUNTOWICZ, A.; KOMATSU, B. K.; MENEZES-FILHO, N. The impacts of the Family Health Program on elementary school enrollments. In: ENCONTRO NACIONAL DE ECONOMIA (ANPEC), 2018. Proceedings […]. Available from: https://www.anpec.org.br/encontro/2018 Accessed on: July 2023.
  » https://www.anpec.org.br/encontro/2018
• FUJII, T. Sources of health financing and health outcomes: a panel data analysis. Health Economics, v. 27, n. 12, p. 1996-2015, 2018.
• GANI, A. Health care financing and health outcomes in Pacific Island countries. Health Policy and Planning, v. 24, n. 1, p. 72-81, 2009.
• GUANAIS, F. C. The combined effects of the expansion of primary health care and conditional cash transfers on infant mortality in Brazil, 1998-2010. American Journal of Public Health, v. 103, n. 11, p. 2000-2006, 2013.
• HELLWIG, F.; PARFITT, R.; WEBER, G. Impact of Brazilian Family Health Strategy on reproductive health: analysis at individual and population levels. International Journal of Epidemiology, v. 50, suppl. 1, p. dyab168.278, 2021.
• INSTITUTO DE PESQUISA ECONÔMICA APLICADA (IPEA). Avaliação de políticas públicas: guia prático de análise ex post. v. 2. Brasília: IPEA, 2018. Available from: http://www.ipea.gov.br Accessed on: July 2023.
  » http://www.ipea.gov.br
• KASHIWAKURA, H. K. et al. Retrato da Atenção Básica no Brasil: gastos e infraestrutura em municípios brasileiros. Ciência & Saúde Coletiva, v. 26, suppl. 2, p. 3397-3408, 2021. https://doi.org/10.1590/1413-81232021269.2.37112019
  » https://doi.org/10.1590/1413-81232021269.2.37112019
• LE, Q. A. et al. Periodontitis and preeclampsia in pregnancy: a systematic review and meta-analysis. Maternal and Child Health Journal, [s.l.], 2021. https://doi.org/10.1007/s10995-022-03556-6
  » https://doi.org/10.1007/s10995-022-03556-6
• LINS, J. G. M. G.; MENEZES, T. A. Avaliando o impacto do financiamento governamental federal em saúde na eficácia da atenção primária: evidências para o Brasil mediante internações hospitalares. Economia e Sociedade, v. 30, n. 3, p. 1001-1032, 2021.
• MACINKO, J. et al. Going to scale with community-based primary care: an analysis of the Family Health Program and infant mortality in Brazil, 1999-2004. Social Science & Medicine, v. 65, n. 10, p. 2070-2080, 2007.
• MACINKO, J.; LIMA COSTA, M. F. Access to, use of and satisfaction with health services among adults enrolled in Brazil’s Family Health Strategy: evidence from the 2008 National Household Survey. Tropical Medicine & International Health, v. 17, n. 1, p. 36-42, 2012.
• PONCZEK, V. P.; SOUZA, A. P.; EMERSON, P. Child labor and learning. Economic Development and Cultural Change, Chicago, IL, v. 65, n. 2, p. 265-296, 2017. https://doi.org/10.1086/688895
  » https://doi.org/10.1086/688895
• PROJETO DE AVALIAÇÃO DO DESEMPENHO DO SISTEMA DE SAÚDE (PROADESS). Materiais técnicos. [s.d.]. Available from: https://www.proadess.icict.fiocruz.br/index.php?pag=matp Accessed on: July 2023.
  » https://www.proadess.icict.fiocruz.br/index.php?pag=matp
• REIS, M. Public primary health care and children’s health in Brazil: evidence from siblings. Journal of Population Economics, v. 27, n. 2, p. 421-445, 2014.
• RIBEIRO, F. G. et al. An empirical assessment of the Healthy Early Childhood Program in Rio Grande do Sul State, Brazil. Cadernos de Saúde Pública, v. 34, p. e00027917, 2018.
• RIBEIRO, F. G. et al. Avaliação de impactos sinérgicos entre o Programa Bolsa Família e o Programa Primeira Infância Melhor no Rio Grande do Sul. Planejamento e Políticas Públicas, v. 60, p. 235-263, 2021.
• ROCHA, R.; FURTADO, I.; SPINOLA, P. Financing needs, spending projection, and the future of health in Brazil. Health Economics, v. 30, n. 5, p. 1082-1094, 2021.
• ROCHA, R.; SOARES, R. R. Evaluating the impact of community-based health interventions: evidence from Brazil's Family Health Program. Health Economics, v. 19, suppl. 1, p. 126-158, 2010.
• SANTOS, A. M. A.; JACINTO, P. A. The impact of the Family Health Program on children’s health in rural Brazil. Revista de Economia e Sociologia Rural, v. 55, n. 2, p. 227-246, 2017.
• SILVA, M. B. O.; BECKER, K. L. Impact analysis of the Family Health Strategy on preventive health measures and NCDs among adults in Brazil. In: ENCONTRO ANPEC NACIONAL, 2022. Proceedings […]. Available from: https://www.anpec.org.br/encontro/2022/submissao/files_I/i12-88e6135a17b4f831f76f63501389ac6.pdf Accessed on: July 2023.
  » https://www.anpec.org.br/encontro/2022/submissao/files_I/i12-88e6135a17b4f831f76f63501389ac6.pdf
• SOARES, A. Formation and challenges of the health system in Brazil: analysis of investments to expand service provision. Cadernos de Saúde Pública, v. 23, p. 1565-1572, 2007.
• STENBERG, K. et al. Guide posts for investment in primary health care and projected resource needs in 67 low-income and middle-income countries: a modelling study. The Lancet Global Health, v. 7, n. 6, p. e772-e783, 2019.
• VIACAVA, F. et al. Uma metodologia de avaliação do desempenho do sistema de saúde brasileiro. Ciência & Saúde Coletiva, Rio de Janeiro, v. 9, n. 3, p. 711-724, 2004.

• Disponibilidade dos Dados de Pesquisa
  Os dados podem ser obtidos junto aos autores mediante solicitação devidamente justificada.

• 1
  For other examples of applications of the difference-in-differences method for impact assessments and the establishment of causal relationships, see Rocha and Soares (2010), Ponczek, Souza and Emerson (2017), and Cortês, Riani e Ferreira (2023).

• JEL Codes:
  I11, I18, C23.
• Códigos JEL:
  I11, I18, C23.

Edited by

• Editor responsável

  Lucas Resende de Carvalho (Editor Associado).

  Centro de Desenvolvimento e Planejamento Regional,

  Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil.

  ORCID: https://orcid.org/0000-0002-3618-3967

Data availability

Os dados podem ser obtidos junto aos autores mediante solicitação devidamente justificada.

Publication Dates

• Publication in this collection
  19 Jan 2026
• Date of issue
  2025

History

• Received
  21 Jan 2025
• Accepted
  18 Aug 2025