Analysis of the implementation on National Policy of Comprehensive Health for the Black Population based on state and municipal basic information surveys and its relationship with Primary Health Care

Felício, Julyane Cristina dos Santos; Cunha, Ana Paula da; Santos, Márcia Pereira Alves dos; Cruz, Marly Marques da

doi:10.1590/S0104-12902026250531pt

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Dossier Anti-racist actions in Primary Health Care: a challenge for ensuring equity • Saude soc. 35 (2) • 2026 • https://doi.org/10.1590/S0104-12902026250531en linkcopy

Analysis of the implementation on National Policy of Comprehensive Health for the Black Population based on state and municipal basic information surveys and its relationship with Primary Health Care

Authorship SCIMAGO INSTITUTIONS RANKINGS

This study analyzed the implementation of the National Policy for Comprehensive Health Care for the Black Population (PNSIPN) across Brazilian states and municipalities, examining its association with Primary Health Care (PHC) coverage and the proportion of the Black population using secondary data from the ESTADIC-MUNIC survey (2021). In the state-level analysis, we adopted the K-means cluster analysis to identify implementation profiles. At the municipal level, a fractional logit regression model suitable for proportional outcomes was applied, incorporating all explanatory variables simultaneously. The findings revealed significant regional disparities, with states exhibiting varied combinations of PHC coverage, Black population proportions, and policy implementation levels. At the municipal level, both health plans showed low institutionalization of the PNSIPN. Greater PHC coverage was associated with lower policy implementation levels, regardless of the proportion of the Black population. The PNSIPN remains weakly institutionalized at both state and municipal levels, with actions concentrated in a limited number of territories. A notable gap persists between normative commitments, such as plans and councils, and the effective implementation of actions aimed at racial equity. While PHC expansion may support PNSIPN implementation, structural barriers continue to hinder sustained progress, particularly in areas with a higher proportion of Black residents.

Keywords:
Public Nondiscrimination Policies; Black Population; Organization and Administration; State Health Plans; Brazil.

ESTADIC
Actions	States N = 27 (100%)
Actions	Yes	No	p -value	95% CI
1) Existence of the State Health Plan	27 (100%)	0 (0%)	_	_
2) Inclusion in the State Health Plan of the actions foreseen in the PNSIPN	23 (85%)	4 (15%)	0,0003	67.5 % - 94.1 %
3) Insertion of the topics of the Black population’s health and combating racism in the courses and training processes of personnel employed in the Health sector	18 (67%)	9 (33%)	0,122	47.8 % - 81.4 %
Grouped actions (1 + 2+ 3) of the PNSIPN in the state sphere	16 (59%)	11 (41%)	0,44	40.7 % - 77.8%
MUNIC
Actions	Municipalities N = 5,570 (100%)
Actions	Yes	No	p -value	95% CI
1) Participation of the health management body in any Regional Management Board	5,129 (92%)	441 (8%)	<0.001	91.0% - 92.7%
2) Existence of the Municipal Health Plan	5,487 (99%)	83 (1%)	<0.001	98.6% - 99.4%
3) Inclusion of actions foreseen in the PNSIPN in the Municipal Health Plan	1,781 (32%)	3,789 (68%)	<0.001	30.7% - 33.7%
4) Inclusion of topics related to the health of the Black population and combating racism	1,725 (31%)	3,845 (69%)	<0.001	29.5% - 32.6%
5) Existence of a specific body to conduct, coordinate, and monitor health actions aimed at the Black population in the municipality	371 (7%)	5,199 (93%)	<0.001	6.4% - 7.6%
6) Inclusion of combating gender and sexual orientation discrimination in training courses and processes for personnel employed in the Health sector	2,833 (51%)	2,737 (49%)	0.757	49.5% - 52.6%
Grouped actions (1 + 2 + 3 + 4 + 5 + 6) of the PNSIPN in the municipal sphere	199 (3,6 %)	5,371 (96,4 %)	< 0.001	3.1 % - 4.1 %

Cluster	UF	Mean			Main characteristics	Possible implication
Cluster	UF	PIR	PHC*	Black pop %	Main characteristics	Possible implication
C0 - High % Black pop + High coverage, low implementation rate	RO, AM, PA, CE, RN, SE, MG, MT, GO, DF	0.27	93%	68%	High proportion of Black population, primary health care coverage close to 100%, low implementation rate	Suggests management/funding barriers despite good healthcare coverage
C1 - % Low % Black pop, intermediate implementation rate	RJ, SP, PR, SC, RS	0.62	82%	36%	Moderate proportion of Black population, primary health care coverage below 85%, average implementation rate	This may reflect states with better overall infrastructure, but coverage still expanding
C2 - High % Black pop + Very high coverage, high implementation rate	AC, RR, AP, TO, MA, PI, PB, PE, AL, BA, ES, MS	0.85	106%**	71%	Very high proportion of Black population, coverage often above 100%, high implementation rate	This indicates that some states with a predominantly Black population have managed to make simultaneous progress in both coverage and implementation of the policy

Explanatory variable	Adjusted OR	95% CI	p-value
PHC coverage	0.79	0.72 - 0.86	< 0.001
% Black population	1	0.99 - 1.01	0.27

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Faculdade de Saúde Pública, Universidade de São Paulo. Associação Paulista de Saúde Pública. Av. dr. Arnaldo, 715, Prédio da Biblioteca, 2º andar sala 2, 01246-904 São Paulo - SP - Brasil, Tel./Fax: +55 11 3061-7880 - São Paulo - SP - Brazil
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[1] Source: ESTADIC, 2021; e-GESTOR, 2023; IBGE, 2025;

[TFN3] ^*
Primary health care coverage.

[TFN4] ^**
Coverage excess. PIR = Policy Implementation Rate.