Brazilian Health System Primary Health Care in Action

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Brazilian Health System Primary Health Care in
Action
José Gomes Temporão Minister of Health of
Brazil Francisco Campos Secretary,
MOH/Brazil Istanbul, May, 2009
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Brazil
Official Name Federative Republic of Brazil
Republican State Powers Executive (President,
Ministers, etc.), Legislative (Two houses
Senate and House of Representatives) and
Judicial (Supreme Court and other federal
courts). Brazilian Federation Comprised by
three distinct political entities (Federal,
State and Municipal), each of them with
autonomous administration (without hierarchical
submission). Area 8.511.996 square
kilometres Geographical macro regions North,
Northeast, Southwest, South and
Center-west Number of states 26 States and a
Federal District Number of municipalities
5.562 Federal Health Management Ministry of
Health State Health Management State Health
Secretariat Municipal Health Management
Municipality Health Secretariat
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Context brief data on Brazil

• Population (2007) 184 million
• Territory 8.5 millions sq. Km
• GDP (2006) US 1.2 trillion
• Life expectancy at birth (2006) 72.35 yrs
• Infant Mortality Rate (2007) 19.3/1.000 live
  births
• Total Health Expenditures (2006) US 87.3
  billion
• Health Expenditure as of GDP (2006) 7.48

JCN 10/2007
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RIO DE JANEIRO
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Targeting equityBRAZIL an unequal country that
chose to build an universal health system
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Per capita income at municipal level, 2000
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Context Age structure
MEN WOMEN
MEN WOMEN
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Brazilians are living longer
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But regional differences persist Life expectancy
- Average Brazil, Alagoas State and Rio Grande do
Sul state
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Infant lives are being saved, however important
regional inequalities still persist
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Infant Mortality Rates - IMR lt 1 year old with
EARLY AND LATE NEONATAL AND POS-NEONATAL
COMPONENTS. BRAZIL, 1996 - 2007
Infant(0-365d) Early Neo (0-6 d) Late Neo (7-27
d) Pos-Neo (28-365 d)
Source Ministry of Health - Brazil
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Milestones of the Unified Health System

• Sanitary Reform movement of the 80s a social
  movement against the political repression and
  regressive social policies of 20 years of
  military dictatorship
• 1988 Constitution Health as a citizens right
• Health Laws general guidelines (September 19,
  1990) and social control (December 28, 1990).
• Main purpose universal health care provided to
  all citizens
• Access should be
• - Universal
• - Integral
• - Comprehensive

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Within this context Brazil has developed Primary
Care and the Family Health Strategy
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Brasil is a model in Primary Health Care, says WHO
Strength Idea 30 years after Alma Ata
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Developing Primary Health Care as a cornerstone
for reaching an universal, accessible, integral,
comprehensive and equitable Brazilian Health
System
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Six major points in PHC change
1 Definition of a national standard Family
Health Team and its essential functions,
integrated with a larger health network 2
Identify of responsibilities of each level of
government in managing the program 3 Changes
in funding and increase in budget provisions for
PHC 4 Monitoring and evaluation system
development. 5 Support for local management
and users 6 Increase the political importance
of implementing Family Health
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Family Health Strategy
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Family Health Strategy

• Team composition at least a physician, a nurse,
  a nurse aid and 4 to 12 community health agents.
  Most teams include a dentist (65)
• User fees are not allowed and there is no
  evidence of informal payments
• Employment contracts are the responsibility of
  municipalities Each team assigned to a
  geographical area, with about 1,000 families
• Team must visit the households
• Teams must understand social processes and
  conditions in their ascribed areas
• Teams work with each other on clinical, public
  health, health promotion, and social issues
• Community Health Agent ease and improve the
  linking of the primary care professionals and the
  community (cultural competence).

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Evolution of the implementation ofFamily Health
Teams - BRAZIL, 1998/2006
2006
2005
2004
FONTE SIAB - Sistema de Informação da Atenção
Básica
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Implementing of FHT, Oral Health Teams and
Community Health Agents BRAZIL, March 2009
ESF 29.149 municipalities - 5.233 ACS
228.412 municipalities - 5.350 ESB
17.588 municipalities 4.567
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Evolution of PHC resources Brasil (Reais,
million)
SOURCE National Health Fund
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Outcomes in theBrazilian PHC Strategy
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Reduction of Infant Mortality Rate
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10 increase in FHT coverage resulted in 4,6
decrease in INFANT mortality
This study is a longitudinal ecological analysis
using panel data from secondary sources. Analyses
controlled for state level measurements of access
to clean water and sanitation, average income,
women literacy and fertility, physicians and
nurses per 10,000 population, and hospital beds
per 1,000 population. Additional analyses
controlled for immunization coverage and tested
interactions between Family Health Program and
proportionate mortality from diarrhea and acute
respiratory infections.
Setting 13 years (1990-2002) data from 26
Brazilian States and Federal District
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(No Transcript)
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Aquino et al. presented their study on the FHS
impact on infant mortality. Their findings show
that the FHS contributed to a decrease in infant
mortality rates. The FHS effects were greater in
areas with the highest infant mortality rates and
the lowest human development indexes before the
program was begun, suggesting that the FHS can
contribute to decreases in health social
inequities in Brazil. Rosana Aquino, 2008
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Changes in Infant Mortality Rates in Brazilian
Municipatilities grouped by FHT coverage and HDI,
1998-2003
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Prevalence of exclusive breast feeding (up to 4
months) and malnutrition in children up to 1 year
old, in areas covered by the Family Health
Strategy 1999/2005
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Women Health
Proportion of children born with no prenatal care
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CHALLENGES
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Old and New Challenges for the Family Health
Strategy

• Lack of infrastructure - need to improve and be
  more efficient
• Financial issues hospitals X PHC
• Burnout of good FH professionals after 5 years
• Old practice contagion in the Family Health
  Teams
• Professional qualification few medical
  residencies, very few master degrees, no PhD and
  high resistance to start family medicine
  departments at the universities
• Lack of social prestige
• Difficult integration to the service network

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CHALLENGES IN HR in the service field

• Lack of quality and quantity of trained Family
  Health Professionals
• Turnover of professionals, in special the
  difficulty in keeping them in remote and rural
  areas, as well as in violent outskirts of big
  cities
• Social recognition of family doctors as key
  professionals in a comprehensive health system
  whose role has no less meaning than that of
  specialists
• No stability of many contracts
• Corporate behavior
• Poor management capability in a decentralized
  system with more than 5000 municipalities and 26
  states and the Federal District

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Challenges in HR in the Scholarly Arena

• Resistance of educational institutions toward the
  needs of the health system and population
• Low accountability and social commitment of
  medical schools with the public system
• Resistance by medical schools to create an
  academic field for Family Medicine
• Redirecting the production of research in PHC to
  community-based needs

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Facing the Challenges

• Implement in-service training methodologies for
  post-graduate courses multi disciplinary
  internship programs and specialization
• Implement partnerships with universities to
  create attractive programs that are able to keep
  professionals in PHC teams
• Give specific funds to the universities to
  support PHC
• Stimulate redirecting the research production in
  PHC and community-based needs, developing a high
  level PHC research network

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Facing the Challenges

• Funding for low HDI cities, cities in the Amazon
  region, and lately, for violent areas in the big
  cities and better pay for health professionals
• Build management capacity for the
  decentralized system
• Advocacy for PHC and FH International, National
  and Regional Conferences, Exhibitions and
  Meetings (2008 III National Exhibition with 7.000
  participants)
• Strengthen the Family Medicine association
  SBMFC
• Stimulate regular contract with the PHC workers
• Invest in better infrastructure
• Create the TEIAS Health Care Integrated
  Territories, based on FHT

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Healthcare integrated network territories
Legend
Dental Care Center
Support
Family Care Support Cluster (NASF)
Psyco-social Care Center (CAP)
Pharmacy
Emergency Department Unit (UPA)
Hospitals
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THANK YOU!