RESUMO
Importance: The health outcomes of increased poverty and inequalities in low- and middle-income countries (LMICs) have been substantially amplified as a consequence of converging multiple crises. Brazil has some of the world's largest conditional cash transfer (Programa Bolsa Família [PBF]), social pension (Beneficio de Prestacão Continuada [BPC]), and primary health care (Estratégia de Saúde da Família [ESF]) programs that could act as mitigating interventions during the current polycrisis era of increasing poverty, slow or contracting economic growth, and conflicts. Objective: To evaluate the combined association of the Brazilian conditional cash transfer, social pension, and primary health care programs with the reduction of morbidity and mortality over the last 2 decades and forecast their potential mitigation of the current global polycrisis and beyond. Design, Setting, and Participants: This cohort study used a longitudinal ecological design with multivariable negative binomial regression models (adjusted for relevant socioeconomic, demographic, and health care variables) integrating the retrospective analysis from 2000 to 2019, with dynamic microsimulation models to forecast potential child mortality scenarios up to 2030. Participants included a cohort of 2548 Brazilian municipalities from 2004 to 2019, projected from 2020 to 2030. Data analysis was performed from September 2022 to February 2023. Exposure: PBF coverage of the target population (those who were poorest) was categorized into 4 levels: low (0%-29.9%), intermediate (30.0%-69.9%), high (70.0%-99.9%), and consolidated (≥100%). ESF coverage was categorized as null (0), low (0.1%-29.9%), intermediate (30.0%-69.9%), and consolidated (70.0%-100%). BPC coverage was categorized by terciles. Main outcomes and measures: Age-standardized, all-cause mortality and hospitalization rates calculated for the entire population and by age group (<5 years, 5-29 years, 30-69 years, and ≥70 years). Results: Among the 2548 Brazilian municipalities studied from 2004 to 2019, the mean (SD) age-standardized mortality rate decreased by 16.64% (from 6.73 [1.14] to 5.61 [0.94] deaths per 1000 population). Consolidated coverages of social welfare programs studied were all associated with reductions in overall mortality rates (PBF: rate ratio [RR], 0.95 [95% CI, 0.94-0.96]; ESF: RR, 0.93 [95% CI, 0.93-0.94]; BPC: RR, 0.91 [95% CI, 0.91-0.92]), having all together prevented an estimated 1â¯462â¯626 (95% CI, 1â¯332â¯128-1â¯596â¯924) deaths over the period 2004 to 2019. The results were higher on mortality for the group younger than age 5 years (PBF: RR, 0.87 [95% CI, 0.85-0.90]; ESF: RR, 0.89 [95% CI, 0.87-0.93]; BPC: RR, 0.84 [95% CI, 0.82-0.86]), on mortality for the group aged 70 years and older, and on hospitalizations. Considering a shorter scenario of economic crisis, a mitigation strategy that will increase the coverage of PBF, BPC, and ESF to proportionally cover the newly poor and at-risk individuals was projected to avert 1â¯305â¯359 (95% CI, 1â¯163â¯659-1â¯449â¯256) deaths and 6â¯593â¯224 (95% CI, 5â¯534â¯591-7â¯651â¯327) hospitalizations up to 2030, compared with fiscal austerity scenarios that would reduce the coverage of these interventions. Conclusions and relevance: This cohort study's results suggest that combined expansion of conditional cash transfers, social pensions, and primary health care should be considered a viable strategy to mitigate the adverse health outcomes of the current global polycrisis in LMICs, whereas the implementation of fiscal austerity measures could result in large numbers of preventable deaths.
Assuntos
Hospitalização , Pensões , Atenção Primária à Saúde , Humanos , Brasil/epidemiologia , Atenção Primária à Saúde/estatística & dados numéricos , Atenção Primária à Saúde/economia , Hospitalização/estatística & dados numéricos , Hospitalização/economia , Hospitalização/tendências , Feminino , Masculino , Pensões/estatística & dados numéricos , Adulto , Pré-Escolar , Pessoa de Meia-Idade , Adolescente , Criança , Mortalidade/tendências , Adulto Jovem , Lactente , Estudos Retrospectivos , Idoso , Estudos Longitudinais , Pobreza/estatística & dados numéricosRESUMO
Importance: Latin America has implemented the world's largest and most consolidated conditional cash transfer (CCT) programs during the last 2 decades. As a consequence of the COVID-19 pandemic, poverty rates have markedly increased, and a large number of newly low-income individuals, especially children, have been left unprotected. Objective: To evaluate the association of CCT programs with child health in Latin American countries during the last 2 decades and forecast child mortality trends up to 2030 according to CCT alternative implementation options. Design, Setting, and Participants: This cohort study used a multicountry, longitudinal, ecological design with multivariable negative binomial regression models, which were adjusted for all relevant demographic, socioeconomic, and health care variables, integrating the retrospective impact evaluations from January 1, 2000, to December 31, 2019, with dynamic microsimulation models to forecast potential child mortality scenarios up to 2030. The study cohort included 4882 municipalities from Brazil, Ecuador, and Mexico with adequate quality of civil registration and vital statistics according to a validated multidimensional criterion. Data analysis was performed from September 2022 to February 2023. Exposure: Conditional cash transfer coverage of the target (lowest-income) population categorized into 4 levels: low (0%-29.9%), intermediate (30.0%-69.9%), high (70.0%-99.9%), and consolidated (≥100%). Main Outcomes and Measures: The main outcomes were mortality rates for those younger than 5 years and hospitalization rates (per 1000 live births), overall and by poverty-related causes (diarrheal, malnutrition, tuberculosis, malaria, lower respiratory tract infections, and HIV/AIDS), and the mortality rates for those younger than 5 years by age groups, namely, neonatal (0-28 days), postneonatal (28 days to 1 year), infant (<1 year), and toddler (1-4 years). Results: The retrospective analysis included 4882 municipalities. During the study period of January 1, 2000, to December 31, 2019, mortality in Brazil, Ecuador, and Mexico decreased by 7.8% in children and 6.5% in infants, and an increase in coverage of CCT programs of 76.8% was observed in these Latin American countries. Conditional cash transfer programs were associated with significant reductions of mortality rates in those younger than 5 years (rate ratio [RR], 0.76; 95% CI, 0.75-0.76), having prevented 738â¯919 (95% CI, 695â¯641-782â¯104) child deaths during this period. The association of highest coverage of CCT programs was stronger with poverty-related diseases, such as malnutrition (RR, 0.33; 95% CI, 0.31-0.35), diarrhea (RR, 0.41; 95% CI, 0.40-0.43), lower respiratory tract infections (RR, 0.66, 95% CI, 0.65-0.68), malaria (RR, 0.76; 95% CI, 0.63-0.93), tuberculosis (RR, 0.62; 95% CI, 0.48-0.79), and HIV/AIDS (RR, 0.32; 95% CI, 0.28-0.37). Several sensitivity and triangulation analyses confirmed the robustness of the results. Considering a scenario of moderate economic crisis, a mitigation strategy that will increase the coverage of CCTs to protect those newly in poverty could reduce the mortality rate for those younger than 5 years by up to 17% (RR, 0.83; 95% CI, 0.80-0.85) and prevent 153â¯601 (95% CI, 127â¯441-180â¯600) child deaths by 2030 in Brazil, Ecuador, and Mexico. Conclusions and Relevance: The results of this cohort study suggest that the expansion of CCT programs could strongly reduce childhood hospitalization and mortality in Latin America and should be considered an effective strategy to mitigate the health impact of the current global economic crisis in low- and middle-income countries.
Assuntos
COVID-19 , Infecções por HIV , Desnutrição , Infecções Respiratórias , Tuberculose , Lactente , Recém-Nascido , Humanos , Criança , Mortalidade da Criança , América Latina/epidemiologia , Estudos de Coortes , Pandemias , Estudos Retrospectivos , COVID-19/epidemiologia , Infecções Respiratórias/epidemiologia , Tuberculose/epidemiologia , Desnutrição/epidemiologia , Infecções por HIV/epidemiologiaRESUMO
Background: As of December 31, 2020, Brazil had the second-highest burden of COVID-19 worldwide. Given the absence of federal government coordination, it was up to the local governments to maintain healthcare provision for non-COVID health issues. In this descriptive study, we aimed to discuss the SUS functionality and resilience, describing the impact of the pandemic on non-COVID health services delivery while considering the regional inequalities of the allocation of financing health system, health infrastructure and health workforce. Methods: We used input-output framework based on the World Health Organization (WHO) Health System Building Blocks to estimate health system functionality and resilience. An ecological assessment was designed to calculated mean relative changes to compare the first year of the pandemic in Brazil with the previous one. All data used in this study were anonymized and made available by the Brazilian Ministry of Health. Input indicators were categorized in health system financing (federal funding received as well as expenditure of both state and city governments), health system's infrastructure (hospital beds) and health workforce (healthcare workers positions). Output indicators were categorized into nine different groups of service delivery procedures. To explore the relationship between the variation in procedures with socioeconomic conditions, we used the Socioeconomic Vulnerability Index (SVI). Findings: State governments had a 38·6% increase in federal transfers, while municipal governments had a 33·9% increase. The increase of ICU beds reached its peak in the third quarter of 2020, averaging 72·1% by the end of the year. The country also saw an increase in jobs for registered nurses (13·6%), nurse assistants (8·5%), physiotherapists (7·9%), and medical doctors (4·9%). All procedures underwent expressive reduction: Screenings (-42·6%); Diagnostic procedures (-28·9%); Physician appointments (-42·5%); Low and medium complexity surgeries (-59·7%); High complexity surgeries (-27·9%); Transplants (-44·7%); Treatments and clinical procedures due to injuries of external causes (-19·1%); Irrepressible procedures (-8·5%); and Childbirths (-12·6%). The most significant drop in procedures happened in the first quarter of the pandemic, followed by progressive increase; most regions had not yet recovered by the end of 2020. State-level changes in numbers of procedures point towards a negative trend with SVI. Interpretation: The Brazilian Government did not consider that socioeconomically vulnerable states were at a higher risk of being impacted by the overburden of the health system caused by the COVID-19, which resulted in poorer health system functionality for those vulnerable states. The lack of proper planning to improve health system resilience resulted in the decrease of a quarter of the amount of healthcare procedures increasing the already existing health disparities in the country. Funding: MCTIC/CNPQ/FNDCT/MS/SCTIE/DECIT No 07/2020.
RESUMO
Após a fase aguda da pandemia de covid-19, que originou uma crise sanitária mundial, matando aproximadamente 700 mil pessoas no Brasil, parece importante refletir sobre a necessidade de se aumentar os recursos destinados ao Sistema Único de Saúde (SUS). Criado na Constituição federal de 1988, o SUS sofreu desde seu nascedouro com o esvaziamento do orçamento da seguridade social e o subfinanciamento das ações e serviços públicos de saúde. A partir de 2016, após a queda da presidente Dilma Rousseff, essa situação se agravou, provocando, entre outros, um processo de desfinanciamento do SUS, no contexto do aumento da pobreza e da desigualdade. Neste cenário, a 'eficiência' aparece como panaceia administrativa, a qual, em nosso caso, acaba servindo para reforçar a ideia de que os problemas do SUS resultam da falsa dicotomia entre financiamento e gestão quando é plausível admitir, que boa parte de seus problemas de gestão, tenham decorrido em razão de um quadro de restrição orçamentária.
Assuntos
Sistema Único de Saúde , Alocação de Recursos para a Atenção à Saúde , Administração em Saúde , Gastos Públicos com SaúdeRESUMO
Objetivo: Relatar os 10 anos da ferramenta de cooperação técnica desenvolvida pela Organização Pan-Americana da Saúde/Organização Mundial da Saúde (OPAS/OMS) no Brasil, por meio dos Laboratórios de Inovação em Saúde (LIS). Métodos: Estudo descritivo do tipo relato de experiência. Resultados: A iniciativa identifica, sistematiza e divulga experiências inovadoras e bem-sucedidas pelos profissionais de saúde no Sistema Único de Saúde (SUS). Aborda temas sobre redes de atenção em saúde, atenção à saúde a populações em situação de vulnerabilidade, ampliação do acesso à atenção primária à saúde e, na edição mais recente, as contribuições da Enfermagem para o fortalecimento do SUS. A cooperação técnica é realizada em parceria com o Conselho Federal de Enfermagem, Ministério da Saúde, Conselho Nacional de Secretários de Saúde, entre outros. Conclusão: Além da disseminação de conhecimento, as experiências divulgadas têm um efeito de superação e motivação, tornando-se um reconhecimento da qualidade das equipes de saúde. (AU)
Objective: To report the 10 years of the technical cooperation tool developed by the Pan American Health Organization/World Health Organization (PAHO/WHO) in Brazil, through the Health Innovation Laboratories (LIS). Methods: Descriptive study of the experience report type. Results: The initiative identifies, systematizes and disseminates innovative and successful experiences practiced in the Unified Health System (SUS) by health professionals and addresses issues on health care networks, health care for populations in vulnerable situations, expansion of access to care primary health care and, in the most recent edition, focusing on the contributions of the Nursing category to the strengthening of the SUS. Technical cooperation is carried out in partnership with the Federal Council of Nursing, the Ministry of Health, the National Council of Health Secretaries, among others. Conclusion: In addition to the dissemination of knowledge, the experiences disseminated have an overcoming and motivational effect, becoming a recognition of the quality of healthcare teams. (AU)
Objetivo: Informar los 10 años de la herramienta de cooperación técnica desarrollada por la Organización Panamericana de la Salud/Organización Mundial de la Salud (OPS / OMS) en Brasil, a través de los Laboratorios de Innovación en Salud (LIS). Métodos: Estudio descriptivo del tipo de relato de experiencia. Resultados: La iniciativa identifica, sistematiza y difunde experiencias innovadoras y exitosas practicadas en el Sistema Único de Salud (SUS) por profesionales de la salud y aborda temas sobre redes de atención de salud, atención a poblaciones en situación de vulnerabilidad, ampliación del acceso a la atención primaria de salud y, en la edición más reciente, enfocada en los aportes de la categoría Enfermería al fortalecimiento del SUS. La cooperación técnica se realiza en alianza con el Consejo Federal de Enfermería, el Ministerio de Salud, el Consejo Nacional de Secretarios de Salud, entre otros. Conclusión: Además de la difusión del conocimiento, las experiencias difundidas tienen un efecto superador y motivador, convirtiéndose en un reconocimiento a la calidad de los equipos de salud. (AU)
Assuntos
Difusão de Inovações , Cooperação Técnica , Sistema Único de Saúde , Gestão do ConhecimentoAssuntos
Betacoronavirus , Infecções por Coronavirus/prevenção & controle , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Atenção Primária à Saúde/organização & administração , Brasil/epidemiologia , COVID-19 , Infecções por Coronavirus/epidemiologia , Implementação de Plano de Saúde/organização & administração , Acessibilidade aos Serviços de Saúde/organização & administração , Número de Leitos em Hospital/estatística & dados numéricos , Unidades Hospitalares/organização & administração , Humanos , Pneumonia Viral/epidemiologia , SARS-CoV-2 , Telemedicina/organização & administraçãoRESUMO
OBJECTIVE: To forecast the impact of alternative scenarios of coverage changes in Brazil's Family Health Strategy (Estratégia Saúde da Família) (ESF)-due to fiscal austerity measures and to the end of the Mais Médicos (More Doctors) Program (PMM)-on overall under-5 mortality rates (U5MRs) and under-70 mortality rates (U70MRs) from ambulatory care sensitive conditions (ACSCs) up through 2030. METHODS: A synthetic cohort of 5 507 Brazilian municipalities was created for the period 2017-2030. A municipal-level microsimulation model was developed and validated using longitudinal data. Reductions in ESF coverage, and its effects on U5MRs and U70MRs from ACSCs, were forecast based on two probable austerity scenarios, as compared to the maintenance of current ESF coverage. Fixed effects longitudinal regression models were employed to account for secular trends, demographic and socioeconomic changes, variables related to health care, and program duration effects. RESULTS: In comparison to maintaining stable ESF coverage, with the decrease in ESF coverage due to austerity measures and PMM termination, the mean U5MR and U70MR would be 13.2% and 8.6% higher, respectively, in 2030. The end of PMM would be responsible for a mean U5MR from ACSCs that is 4.3% higher and a U70MR from ACSCs that is 2.8% higher in 2030. The reduction of PMM coverage due only to the withdrawal of Cuban doctors who have been working in PMM would alone be responsible for a U5MR that is 3.2% higher, and a U70MR that is 2.0% higher in 2030. CONCLUSIONS: Reductions in primary health care coverage due to austerity measures and the end of the PMM could be responsible for many avoidable adult and child deaths in coming years in Brazil.
RESUMO
OBJECTIVE: To formulate strategic recommendations to strengthen primary health care (PHC) in Brazil's Unified Health System (SUS) based on expert consultation. METHOD: The present qualitative study, developed from March to August, 2018, included administration of an open questionnaire followed by consensus building among 20 participants representing the five Brazilian regions, selected using the criterion of recognized professional expertise in the field of PHC. Participants answered an online questionnaire created by the authors. The findings were systematized as recommendations, which were submitted for priority ranking by the expert group using a one-round Delphi technique. The final recommendations were discussed in a face-to-face workshop. RESULTS: Of 20 experts, 18 answered the open questionnaire, generating 84 themes for analysis, which were systematized into 44 proposals. Evaluation of these proposals resulted in 20 recommendations, emphasizing expansion of the Family Health Strategy (FHS); enhanced access to PHC; training of professionals for multidisciplinary work in the PHC setting; allocation of technologies to ensure PHC resolvability; improvement of regulation/coordination of services to strengthen a foundational role of PHC in the SUS; human resources, provision of professionals, and support/stimulus for teams; production and dissemination of knowledge; transparency in PHC initiatives; and mediating role of PHC in the healthcare system. CONCLUSIONS: The findings support the FHS as the best model to ensure a strong PHC in the SUS, combined with policies that prioritize essential PHC attributes, especially through innovation in care, management, and communication technologies.
OBJETIVO: Formular recomendaciones estratégicas para fortalecer la atención primaria de salud (APS) en el Sistema Único de Salud (SUS) en Brasil a partir de una consulta a expertos. MÉTODO: Este estudio cualitativo, realizado entre marzo y agosto del 2018, consistió en emplear un cuestionario abierto y lograr consenso entre 20 participantes representativos de las cinco macrorregiones brasileñas, seleccionados por su reconocida experiencia profesional en la APS. Los participantes respondieron 20 preguntas abiertas en un cuestionario en línea elaborado por los investigadores. Los hallazgos se sistematizaron en forma de recomendaciones, sometidas por el grupo de expertos a una evaluación de prioridades con la metodología Delfos en una sola ronda. Las recomendaciones finales se debatieron en un taller presencial. RESULTADOS: Dieciocho de los 20 especialistas respondieron al cuestionario abierto, que produjo 84 temas sistematizados en 44 propuestas. Después de la evaluación, se formularon 20 recomendaciones, en las cuales se acentuaron la expansión de la estrategia de salud de la familia; la ampliación del acceso a la APS; la formación de profesionales para el trabajo multidisciplinario en la APS; la asignación de tecnologías para garantizar la resolutividad en la APS; el perfeccionamiento de la regulación y la coordinación de servicios para fortalecer la APS como elemento estructurante del SUS; la estructura y el financiamiento; los recursos humanos, la dotación de profesionales, el apoyo y el estímulo a los equipos; la producción y divulgación del conocimiento; la transparencia en las actividades de APS; y la función mediadora de la APS en el sistema de atención de salud. CONCLUSIONES: Los hallazgos refuerzan la estrategia de salud de la familia como el mejor modelo para garantizar una APS fuerte en el SUS, vinculada a políticas que prioricen los atributos esenciales de la APS, sobre todo por medio de innovación en materia de tecnologías asistenciales, de gestión y de comunicación.
RESUMO
RESUMO Neste estudo, examinaram-se estratégias adotadas por países com sistemas públicos de saúde que expandiram a oferta de leitos por meio da utilização de hospitais privados na resposta à Covid-19. Utilizou-se estudo de casos selecionados para explorar o contexto institucional em que as medidas foram implementadas, os instrumentos de gestão utilizados e como se caracterizou a ação governamental em oito países: Austrália, Espanha, Irlanda, Itália, Chile, México e Peru, além do Brasil. Esta análise pode auxiliar a identificar mecanismos de gestão de sistema de saúde necessários para a coordenação de ações governamentais para resposta a situações de Emergência em Saúde Pública (ESP), bem como para aperfeiçoar a governança dos sistemas de saúde na relação entre os setores público e privado.
ABSTRACT In this study, strategies adopted by countries with public health systems that expanded the supply of beds through the use of private hospitals in response to Covid-19 were examined. The study of selected cases was used to explore the institutional context in which measures were implemented, the management tools used and how to characterize government action in eight countries: Australia, Spain, Ireland, Italy, Chile, Mexico and Peru, in addition to Brazil. This analysis can help to identify health system management mechanisms necessary for the coordination of government actions to respond to Public Health Emergency situations, as well as improve the governance of health systems in the relationship between public and private sectors.
RESUMO
ABSTRACT Objective. To forecast the impact of alternative scenarios of coverage changes in Brazil's Family Health Strategy (Estratégia Saúde da Família) (ESF)—due to fiscal austerity measures and to the end of the Mais Médicos (More Doctors) Program (PMM)—on overall under-5 mortality rates (U5MRs) and under-70 mortality rates (U70MRs) from ambulatory care sensitive conditions (ACSCs) up through 2030. Methods. A synthetic cohort of 5 507 Brazilian municipalities was created for the period 2017-2030. A municipal-level microsimulation model was developed and validated using longitudinal data. Reductions in ESF coverage, and its effects on U5MRs and U70MRs from ACSCs, were forecast based on two probable austerity scenarios, as compared to the maintenance of current ESF coverage. Fixed effects longitudinal regression models were employed to account for secular trends, demographic and socioeconomic changes, variables related to health care, and program duration effects. Results. In comparison to maintaining stable ESF coverage, with the decrease in ESF coverage due to austerity measures and PMM termination, the mean U5MR and U70MR would be 13.2% and 8.6% higher, respectively, in 2030. The end of PMM would be responsible for a mean U5MR from ACSCs that is 4.3% higher and a U70MR from ACSCs that is 2.8% higher in 2030. The reduction of PMM coverage due only to the withdrawal of Cuban doctors who have been working in PMM would alone be responsible for a U5MR that is 3.2% higher, and a U70MR that is 2.0% higher in 2030. Conclusions. Reductions in primary health care coverage due to austerity measures and the end of the PMM could be responsible for many avoidable adult and child deaths in coming years in Brazil.(AU)
RESUMEN Objetivo. Proyectar el impacto de los distintos escenarios alternativos de cambios en la cobertura de la estrategia de salud familiar de Brasil (Estratégia Saúde da Família o ESF) —motivados por medidas de austeridad y la desaparición del programa Mais Médicos (PMM)— en las tasas generales de mortalidad de menores de 5 años y menores de 70 años debidas a trastornos sensibles al cuidado ambulatorio hasta el año 2030. Métodos. Se formó una cohorte sintética de 5 507 municipios brasileños para el período 2017-2030. Se elaboró un modelo de microsimulación a escala municipal y se lo validó empleando datos longitudinales. Se proyectaron las reducciones de la cobertura de la ESF y sus efectos sobre la tasa de mortalidad de menores de 5 años y menores de 70 años debida a trastornos sensibles al cuidado ambulatorio con base en dos contextos probables de austeridad, en comparación con el mantenimiento de la actual cobertura de la ESF. Se emplearon modelos de regresión longitudinal con efectos fijos para dar cuenta de las tendencias históricas, los cambios demográficos y socioeconómicos, las variables relacionadas con la atención de salud y los efectos de la duración del programa. Resultados. En comparación con el mantenimiento de una cobertura estable de la ESF, ante su disminución por medidas de austeridad y la desaparición del PMM, las tasas medias de mortalidad de menores de 5 años y menores de 70 aumentarían en 13,2 % y 8,6 % respectivamente para el año 2030. La desaparición del PMM sería responsable de una tasa media de mortalidad de menores de 5 años debida a trastornos sensibles al cuidado ambulatorio que será un 4,3 % mayor y, en el caso de los menores de 70 años, un 2,8 % mayor para el año 2030. Tan solo la reducción de la cobertura de PMM exclusivamente a raíz de la retirada de los médicos cubanos que han trabajado en este programa daría cuenta de un incremento del 3,2 % de la tasa de mortalidad de menores de 5 años y del 2,0 % en el caso de los menores de 70 años para el año 2030. Conclusiones. Las reducciones de la cobertura de la atención primaria de salud debidas a medidas de austeridad y la desaparición del PMM podrían ser responsables de muchas muertes evitables de niños y adultos en los próximos años en Brasil.(AU)
RESUMO Objetivo. Fazer uma projeção da repercussão de cenários alternativos, com a mudança na cobertura da Estratégia de Saúde da Família (ESF) no Brasil decorrente de medidas de austeridade fiscal e do fim do Programa Mais Médicos, nas taxas de mortalidade em crianças menores de 5 anos (TM-5) e taxas de mortalidade em indivíduos até 70 anos (TM-70) por causas sensíveis à atenção ambulatorial até 2030. Métodos. Esta análise se baseou em uma coorte sintética de 5.507 municípios brasileiros criada para o período 2017-2030. Um modelo de microssimulação ao nível municipal foi desenvolvido e validado com dados longitudinais. A diminuição da cobertura da ESF e sua repercussão nas TM-5 e TM-70 por causas sensíveis à atenção ambulatorial foram projetadas em dois cenários prováveis de austeridade comparados à continuidade da cobertura atual da ESF. Modelos de regressão com efeitos fixos para dados longitudinais foram usados para levar em consideração as tendências seculares, as variações populacionais e socioeconômicas, as variáveis relacionadas à assistência de saúde e os efeitos da continuidade do programa. Resultados. Comparando-se à continuidade da cobertura estável da ESF, com a diminuição da cobertura decorrente de medidas de austeridade e do fim do Programa Mais Médicos, as TM-5 e TM-70 médias seriam 13,2% e 8,6% maiores em 2030. O fim do Programa Mais Médicos resultaria em um aumento de 4,3% na TM-5 média e de 2,8% na TM-70 média por causas sensíveis à atenção ambulatorial em 2030. A diminuição da cobertura do Programa Mais Médicos decorrente exclusivamente da saída dos médicos cubanos do programa estaria associada a um aumento de 3,2% na TM-5 e de 2,0% na TM-70 em 2030. Conclusões. A diminuição na cobertura da atenção primária à saúde decorrente de medidas de austeridade e do fim do Programa Mais Médicos teria como resultado muitas mortes evitáveis em adultos e crianças no Brasil nos anos que estão por vir.(AU)
Assuntos
Humanos , Atenção Primária à Saúde/organização & administração , Simulação por Computador , Avaliação de Programas e Projetos de Saúde/métodos , Brasil , Estudos de Coortes , Mortalidade/tendênciasRESUMO
This article emphasizes PHC as a fundamental strategy for the sustainability of the SUS, based on its impact on health indicators. The attributes and requirements for Robust PHC are based on statements from researchers, policy makers and institutions, including the PAHO/WHO Representation in Brazil. The model proposed is the result of discussions with workers, researchers and health managers in Brazil, endorsing the commitments outlined in the Alma Ata Declaration. The article details the methodology of Health Innovation Laboratories used by PAHO/WHO in Brazil to systematize knowledge generated by innovative health experiences, including the Healthy Brasilia Project, an ongoing activity run by the Health Department of the Federal District (DF) of Brasilia, which has made important changes in the healthcare model, with emphasis on the expansion of Family Health Strategy coverage. This article analyzes the results of the Innovation Laboratories in Robust PHC in the FD that will be consolidated in a Case Study. The initiative aims to raise awareness amongst managers and health workers about innovation in health processes and policies that are essential for the sustainability of theSUS, focusing on the exchange of knowledge between peers about relevant initiatives in PHCin Brazil.
O artigo defende a APS como estratégia fundamental para a sustentabilidade do SUS, subsidiado em resultados sobre o impacto da APS nos indicadores de saúde e outras áreas. São apresentados os atributos e requisitos para uma APS Forte, defendidos por pesquisadores, formuladores de políticas e instituições, entre elas a Representação da OPAS/OMS no Brasil. O formato advogado é fruto de discussão realizada com trabalhadores, pesquisadores e gestores de saúde do país, reafirmando os compromissos da Declaração de Alma Ata. O artigo detalha a metodologia de Laboratórios de Inovação em Saúde, utilizada pela OPAS/OMS no Brasil para identificar e sistematizar experiências inovadoras em saúde, incluindo o acompanhamento do Projeto Brasília Saudável, da Secretaria de Saúde do DF, que vem apresentando importantes transformações no modelo de atenção à saúde, com ênfase na ampliação da cobertura da Estratégia Saúde da Família. O artigo resgata e analisa os trabalhos desenvolvidos pelo Laboratório de Inovação em APS Forte no DF até o momento e que serão sistematizados em Estudo de Caso. A iniciativa visa sensibilizar gestores e trabalhadores em saúde para a inovação em processos e políticas de saúde, sendo essencial para a sustentabilidade do SUS, privilegiando troca de conhecimentos entre pares sobre iniciativas adotadas na APS do Brasil.
Assuntos
Difusão de Inovações , Saúde da Família , Programas Nacionais de Saúde/organização & administração , Atenção Primária à Saúde/organização & administração , Brasil , Política de Saúde , Humanos , Indicadores de Qualidade em Assistência à SaúdeRESUMO
In 1988, the Brazilian Constitution defined health as a universal right and a state responsibility. Progress towards universal health coverage in Brazil has been achieved through a unified health system (Sistema Único de Saúde [SUS]), created in 1990. With successes and setbacks in the implementation of health programmes and the organisation of its health system, Brazil has achieved nearly universal access to health-care services for the population. The trajectory of the development and expansion of the SUS offers valuable lessons on how to scale universal health coverage in a highly unequal country with relatively low resources allocated to health-care services by the government compared with that in middle-income and high-income countries. Analysis of the past 30 years since the inception of the SUS shows that innovations extend beyond the development of new models of care and highlights the importance of establishing political, legal, organisational, and management-related structures, with clearly defined roles for both the federal and local governments in the governance, planning, financing, and provision of health-care services. The expansion of the SUS has allowed Brazil to rapidly address the changing health needs of the population, with dramatic upscaling of health service coverage in just three decades. However, despite its successes, analysis of future scenarios suggests the urgent need to address lingering geographical inequalities, insufficient funding, and suboptimal private sector-public sector collaboration. Fiscal policies implemented in 2016 ushered in austerity measures that, alongside the new environmental, educational, and health policies of the Brazilian government, could reverse the hard-earned achievements of the SUS and threaten its sustainability and ability to fulfil its constitutional mandate of providing health care for all.
Assuntos
Acessibilidade aos Serviços de Saúde/organização & administração , Programas Nacionais de Saúde/organização & administração , Cobertura Universal do Seguro de Saúde/legislação & jurisprudência , Brasil , Programas Governamentais/legislação & jurisprudência , Programas Governamentais/organização & administração , Política de Saúde , Acessibilidade aos Serviços de Saúde/legislação & jurisprudência , Humanos , Programas Nacionais de Saúde/legislação & jurisprudência , Fatores Socioeconômicos , Cobertura Universal do Seguro de Saúde/economiaRESUMO
Resumo O artigo defende a APS como estratégia fundamental para a sustentabilidade do SUS, subsidiado em resultados sobre o impacto da APS nos indicadores de saúde e outras áreas. São apresentados os atributos e requisitos para uma APS Forte, defendidos por pesquisadores, formuladores de políticas e instituições, entre elas a Representação da OPAS/OMS no Brasil. O formato advogado é fruto de discussão realizada com trabalhadores, pesquisadores e gestores de saúde do país, reafirmando os compromissos da Declaração de Alma Ata. O artigo detalha a metodologia de Laboratórios de Inovação em Saúde, utilizada pela OPAS/OMS no Brasil para identificar e sistematizar experiências inovadoras em saúde, incluindo o acompanhamento do Projeto Brasília Saudável, da Secretaria de Saúde do DF, que vem apresentando importantes transformações no modelo de atenção à saúde, com ênfase na ampliação da cobertura da Estratégia Saúde da Família. O artigo resgata e analisa os trabalhos desenvolvidos pelo Laboratório de Inovação em APS Forte no DF até o momento e que serão sistematizados em Estudo de Caso. A iniciativa visa sensibilizar gestores e trabalhadores em saúde para a inovação em processos e políticas de saúde, sendo essencial para a sustentabilidade do SUS, privilegiando troca de conhecimentos entre pares sobre iniciativas adotadas na APS do Brasil.
Abstract This article emphasizes PHC as a fundamental strategy for the sustainability of the SUS, based on its impact on health indicators. The attributes and requirements for Robust PHC are based on statements from researchers, policy makers and institutions, including the PAHO/WHO Representation in Brazil. The model proposed is the result of discussions with workers, researchers and health managers in Brazil, endorsing the commitments outlined in the Alma Ata Declaration. The article details the methodology of Health Innovation Laboratories used by PAHO/WHO in Brazil to systematize knowledge generated by innovative health experiences, including the Healthy Brasilia Project, an ongoing activity run by the Health Department of the Federal District (DF) of Brasilia, which has made important changes in the healthcare model, with emphasis on the expansion of Family Health Strategy coverage. This article analyzes the results of the Innovation Laboratories in Robust PHC in the FD that will be consolidated in a Case Study. The initiative aims to raise awareness amongst managers and health workers about innovation in health processes and policies that are essential for the sustainability of theSUS, focusing on the exchange of knowledge between peers about relevant initiatives in PHCin Brazil.
Assuntos
Humanos , Atenção Primária à Saúde/organização & administração , Saúde da Família , Difusão de Inovações , Programas Nacionais de Saúde/organização & administração , Brasil , Indicadores de Qualidade em Assistência à Saúde , Política de SaúdeRESUMO
BACKGROUND: Brazil's Estratégia Saúde da Família (ESF) is one of the largest and most robustly evaluated primary healthcare programmes of the world, but it could be affected by fiscal austerity measures and by the possible end of the Mais Médicos programme (MMP)-a major intervention to increase primary care doctors in underserved areas. We forecast the impact of alternative scenarios of ESF coverage changes on under-70 mortality from ambulatory care-sensitive conditions (ACSCs) until 2030, the date for achievement of the Sustainable Development Goals (SDGs). METHOD: A synthetic cohort of 5507 Brazilian municipalities was created for the period 2017-2030. A municipal-level microsimulation model was developed and validated using longitudinal data and estimates from a previous retrospective study evaluating the effects of municipal ESF coverage on mortality rates. Reductions in ESF coverage, and its effects on ACSC mortality, were forecast based on two probable austerity scenarios, compared with the maintenance of the current coverage or the expansion to 100%. Fixed effects longitudinal regression models were employed to account for secular trends, demographic and socioeconomic changes, healthcare-related variables, and programme duration effects. RESULTS: Under austerity scenarios of decreasing ESF coverage with and without the MMP termination, mean ACSC mortality rates would be 8.60% (95% CI 7.03-10.21%; 48,546 excess premature/under-70 deaths along 2017-2030) and 5.80% (95% CI 4.23-7.35%; 27,685 excess premature deaths) higher respectively in 2030 compared to maintaining the current ESF coverage. Comparing decreasing ESF coverage and MMP termination with achieving 100% ESF coverage (Universal Health Coverage scenario) in 2030, mortality rates would be 11.12% higher (95% CI 9.47-12.76%; 83,937 premature deaths). Reductions in ESF coverage would have stronger effects on mortality from infectious diseases and nutritional deficiencies and would disproportionately impact poorer municipalities, with the concentration index for ACSC mortality 11.77% higher (95% CI 0.31-22.32%) and also ending historical declines in racial health inequalities between white and black/pardo Brazilians. CONCLUSIONS: Reductions in primary healthcare coverage due to austerity measures are likely to be responsible for many avoidable deaths and may preclude achievement of SDGs for health and inequality in Brazil and in other low- and middle-income countries.
Assuntos
Política de Saúde/tendências , Cobertura Universal do Seguro de Saúde/normas , Brasil , Feminino , Humanos , Masculino , Mortalidade , Estudos RetrospectivosRESUMO
El Programa Más Médicos (PMM) del Gobierno Federal de Brasil implantado en el año 2013 cuenta entre sus principales actores con los médicos cubanos (alrededor del 63 por ciento de los profesionales inscritos), los cuales participan a través de un Convenio con la Organización Panamericana de la Salud (OPS). Como en cualquier intervención un objetivo primordial es evaluar los resultados. En este caso, para la Atención Primaria de Salud, se tiene una herramienta de evaluación como el PCATool, instrumento ya validado en Brasil. Por razones prácticas de tiempo y económicas se decide evaluar la factibilidad de aplicar este instrumento, en el caso de la versión para profesionales, a través de Internet. Los resultados validan la aplicación online de esta herramienta de evaluación(AU)
The Mais Médicos Program (PMM) of the Federal Government of Brazil implemented in 2013 counts among its main actors with Cuban doctors (around 63 percent of the registered professionals), who participate through an Agreement with the Pan American Health Organization (PAHO). As in any intervention, a primary objective is to evaluate the results. In this case, for Primary Health Care, there is an evaluation tool such as PCATool, an instrument already validated in Brazil. For practical time and economic reasons, it was decided to evaluate the feasibility of applying this instrument, in the case of the professional version, through the Internet. The results validate the online application of this evaluation tool(AU)
Assuntos
Humanos , Masculino , Feminino , Atenção Primária à Saúde , Design de Software , Estudos de Validação como Assunto , Brasil , Análise de VariânciaRESUMO
Universal health coverage can be understood as a goal encompassing a series of structural measures that allow health care systems to enhance access to health care. Primary health care (PHC) should be seen as an essential component of this process, in charge of re-organizing services according to the health needs of the population. A Brazilian physician recruitment program, Programa Mais Médicos (More Doctors), has introduced a set of measures that strengthen PHC. Based on a conceptual review of universal health coverage and on an analysis of the More Doctor Program from the perspective of the results obtained in terms of strengthening PHC in the public Unified Health System (SUS), the aim of the present article was to discuss the potential contribution of the More Physicians Program to the progress towards universal coverage in the SUS. It is concluded that the More Doctors Programs is a driver of universal coverage in the public health care system in Brazil.
La cobertura universal de salud puede entenderse como una meta que abarca una serie de medidas estructurales que permiten a los sistemas de atención médica mejorar el acceso a la atención médica. La atención primaria de salud (APS) debe ser vista como un componente esencial de este proceso, responsable de la reorganización de los servicios, tomando en cuenta las necesidades de salud de la población. El programa Más Médicos, ha introducido en Brasil un conjunto de medidas que fortalecen la APS. Con base en una revisión conceptual de la cobertura universal de salud y de un análisis del programa Más Médicos desde la perspectiva de los resultados obtenidos en términos de fortalecimiento de la APS en el Sistema Único de Salud público (SUS), el objetivo del presente artículo fue analizar la contribución potencial del programa Más Médicos al progreso hacia la cobertura universal en el SUS. Se concluye que el programa Más Médicos es un motor de cobertura universal en el sistema de salud pública en Brasil.
RESUMO
OBJECTIVE: To assess the performance of primary health care (PHC) in Brazil and its association with the More Doctors Program (Programa Mais Médicos, PMM). METHOD: This nationwide cross-sectional study used the Primary Care Assessment Tool validated for Brazilian Portuguese (PCATool-Brasil) to determine the achievement of PHC according to user experience associated with three physician categories: Brazilian physicians participating in the PMM, Cuban physicians participating in the PMM, and Brazilian physicians not linked to the PMM. The following PHC scores were calculated: overall PCA score, accessibility (first contact), and longitudinality. The association between PHC scores, physician category, and other user and physician characteristics was investigated using multilevel analysis. RESULTS: The overall PCA score for Brazil was 6.78, and the longitudinality score was 7.43. There was no difference in these scores among the three physician categories. The overall accessibility score was 4.24. A small but significant difference (P < 0.001) in accessibility score was detected among physician categories: 4.43 for Cuban physicians participating in the PMM (CI: 4.32-4.54), 4.08 for Brazilian physicians participating in the PMM(CI: 3.98-4.18), and 4.20 for Brazilian physicians not linked to the PMM (CI: 4.09-4.32). Age, socioeconomic level, presence of chronic diseases, and home visits by physicians positively influenced the overall PCA score on multilevel analysis. CONCLUSIONS: The type of physician did not influence the primary care orientation (overall score) of the healthcare system in Brazil. PMM was associated with higher accessibility sores in more socioeconomically vulnerable areas. Multilevel analysis showed that PCH may be strengthened by the reinforcement of essential physician roles (such as home visits) and by improving access for socioeconomically vulnerable, younger populations or those without chronic diseases.
OBJETIVO: Evaluar la calidad de la atención primaria de salud (APS) en Brasil y su relación con el Programa Más Médicos (PMM). MÉTODOS: Estudio transversal de alcance nacional em el que se utilizó la herramienta PCATool-Brasil para evaluar la calidad de la APS a partir de la experiencia de los usuarios vinculados a tres categorías de médicos: médicos brasileños del PMM, médicos cubanos del PMM y médicos brasileños no vinculados al PMM. Se calcularon los siguientes puntajes: Puntaje general de APS, Puntaje de acceso y Puntaje de longitudinalidad. Se investigaron mediante análisis multinivel la asociación entre el Puntaje general obtenido, la categoría del médico y otras características de los usuarios y los profesionales. RESULTADOS: El Puntaje general de APS para Brasil fue 6,78, y el Puntaje de longitudinalidad, 7,43. No hubo diferencia entre estos puntajes para las tres categorías de médicos. El Puntaje de acceso para Brasil fue de 4,24 y mostró una diferencia pequeña, pero significativa (p <0,001) entre las categorías de médicos: médicos cubanos del PMM 4,43 (IC: 4,32-4,54), médicos brasileños del PMM 4,08 (IC: 3,98-4,18) y médicos brasileños no vinculados al PMM 4,20 (IC: 4,09-4,32). En el análisis multinivel, la edad, el estrato socioeconómico, la presencia de enfermedades crónicas y el hecho de que el médico realizara visitas domiciliarias influyeron positivamente em el Puntaje general. CONCLUSIONES: El tipo de médico no influyó en el grado de orientación a los atributos de la APS (Puntaje general) en Brasil. El PMM se asoció com mayores Puntajes de acceso en las regiones de mayor vulnerabilidad socioeconómica. Con el análisis multinivel se identificó que el fortalecimiento de la APS también puede ser alcanzado reforzando los roles fundamentales de los médicos que trabajan en la APS (como las visitas domiciliarias) y mejorando el acceso de las poblaciones de mayor vulnerabilidad socioeconómica y de las personas más jóvenes o sin enfermedades crónicas.
RESUMO
A cobertura universal pode ser entendida como uma meta que engloba diversas medidas que permitem a ampliação do acesso pelos sistemas de saúde. A atenção primária à saúde (APS) deve ser vista como um aspecto essencial desse processo, com papel de re-organização dos serviços com base nas necessidades em saúde. O Programa Mais Médicos no Brasil traz uma série de medidas para fortalecer a APS no país. A partir de uma revisão conceitual de cobertura universal em saúde e de uma análise do Programa Mais Médicos sob a ótica dos resultados obtidos em termos de fortalecimento da APS no Sistema Único de Saúde (SUS), o objetivo do artigo foi discutir a potencial contribuição do Programa Mais Médicos para o avanço do sistema de saúde brasileiro rumo à cobertura universal. Conclui-se que o Programa Mais Médicos é um propulsor para o alcance da cobertura universal no SUS.(AU)
Universal health coverage can be understood as a goal encompassing a series of structural measures that allow health care systems to enhance access to health care. Primary health care (PHC) should be seen as an essential component of this process, in charge of re-organizing services according to the health needs of the population. A Brazilian physician recruitment program, Programa Mais Médicos (More Doctors), has introduced a set of measures that strengthen PHC. Based on a conceptual review of universal health coverage and on an analysis of the More Doctor Program from the perspective of the results obtained in terms of strengthening PHC in the public Unified Health System (SUS), the aim of the present article was to discuss the potential contribution of the More Physicians Program to the progress towards universal coverage in the SUS. It is concluded that the More Doctors Programs is a driver of universal coverage in the public health care system in Brazil.(AU)
La cobertura universal de salud puede entenderse como una meta que abarca una serie de medidas estructurales que permiten a los sistemas de atención médica mejorar el acceso a la atención médica. La atención primaria de salud (APS) debe ser vista como un componente esencial de este proceso, responsable de la reorganización de los servicios, tomando en cuenta las necesidades de salud de la población. El programa Más Médicos, ha introducido en Brasil un conjunto de medidas que fortalecen la APS. Con base en una revisión conceptual de la cobertura universal de salud y de un análisis del programa Más Médicos desde la perspectiva de los resultados obtenidos en términos de fortalecimiento de la APS en el Sistema Único de Salud público (SUS), el objetivo del presente artículo fue analizar la contribución potencial del programa Más Médicos al progreso hacia la cobertura universal en el SUS. Se concluye que el programa Más Médicos es un motor de cobertura universal en el sistema de salud pública en Brasil.(AU)