Testes diagnósticos nacionais: insumos essenciais para a vigilância sindrômica da Covid-19 / Brazilian diagnostic tests: essential health supplies for COVID-19 syndromic surveillance

RESUMO Existe ampla evidência que a contenção da pandemia de Covid-19 requer vigilância sindrômica e isolamento de casos suspeitos/confirmados. É essencial a disponibilidade de testes diagnósticos no Sistema Único de Saúde, que poderia ser facilitada pela soberania nacional no desenvolvimento e produção, considerando-se a alta demanda/escassez no mercado internacional. Este estudo identificou as etapas da pesquisa translacional de testes diagnósticos para Covid-19 no Brasil, verificando sua distribuição geográfica, entre outros indicadores. Estudo transversal, exploratório, partindo de banco público com 789 projetos de Pesquisa, Desenvolvimento e Inovação (PD&I) em Covid-19, complementado com outras buscas, inclusive no CVLattes dos pesquisadores. No banco, havia 89 projetos de testes diagnósticos. Em 45 casos, foi possível obter informações complementares para classificá-los conforme as etapas da pesquisa translacional. Identificaram-se 15 inovações que atingiram o estágio T3, ou seja, tiveram seus produtos incorporados em protocolos clínicos na atenção à saúde, mesmo considerando-se as profundas restrições orçamentárias em PD&I. O Brasil possui potencial de desenvolvimento e implementação de produtos tecnológicos na área de testes de diagnóstico para Sars-CoV-2. Políticas públicas de PD&I em saúde necessitam ser priorizadas para ampliação de cooperações nacionais e internacionais, a fim de promover efetiva autonomia nacional na vigilância sindrômica e à saúde da população.

ABSTRACT There is much evidence suggesting that mitigating the COVID-19 pandemic requires syndromic surveillance and isolation of suspected/confirmed cases. The availability of diagnostic tests in the Brazilian Unified Health System (SUS) is essential, which could be facilitated by national sovereignty in development and production, considering the high demand/lack of supply in the international market. This study identified the stages of translational research into diagnostic tests for COVID-19 in Brazil, verifying their geographic distribution, among other indicators. A cross-sectional, exploratory study based on a public database with 789 Research, Development, and Innovation (RD&I) projects regarding COVID-19, complemented by other searches, including the researchers' curricula (CVLattes). There were 89 diagnostic test projects in the database. In 45 cases, it was possible to obtain additional information to classify them according to the translational research stages. Fifteen innovations that reached the T3 stage were identified, with their products incorporated into clinical protocols in healthcare, even considering the deep budget restrictions in RD&I. Brazil has the potential to develop and implement technological products in the field of diagnostic tests for SARS-CoV-2. Public health RD&I policies need to be prioritized to expand national and international cooperation to promote effective national autonomy in syndromic surveillance and population health.

Structure and responsiveness: are Primary Health Care Units prepared to face COVID-19? / Estrutura e responsividade: a Atenção Primária à Saúde está preparada para o enfrentamento da Covid-19?

ABSTRACT The COVID-19 pandemic reinforced the need for global efforts to grant universal health coverage and access, which imposes management challenges for Primary Health Care (PHC). This study aimed to develop and apply an instrument to assess the PHC Units' responsiveness to COVID-19, based on co-production efforts between university researchers and PHC technical teams. The instrument composed of two modules, included identification, operating hours, workforce, work process, structure, equipment, furniture, supplies, Personal Protection Equipment (PPE), Symptomatic Respiratory Patient (SRP) examinations and follow-up, information, surveillance, integration, communication, and management. All the 165 PHC Units in Brasília were invited to complete the instrument. Main results: there was physical structure adaptation (adequate configuration of waiting rooms, internal and external spaces allowing safe distance); provision of PPE and COVID-19 tests; active search for SRP/COVID-19 suspects by phone, mobile or home visits; monitoring flows of patient transfer and telehealth implementation. In conclusion, the PHC Units reorganized their services to meet the demands of the pandemic context. Providing information about structure and responsiveness of PHC Units may subside health systems for planning and decision-making at different levels of management, which is crucial to determine strategies to empower and reinforce PHC responsivity in situations of pandemics and other calamities.

RESUMO A pandemia de Covid-19 reforçou a necessidade de esforços globais para garantir cobertura e acesso universal à saúde, impondo desafios na gestão da Atenção Primária à Saúde (APS). Este estudo objetivou desen- volver e aplicar um instrumento de avaliação da responsividade das Unidades Básicas de Saúde (UBS) diante da Covid-19, baseado na coprodução entre pesquisadores universitários e equipes técnicas da APS. O instrumento, dividido em dois módulos, incluiu identificação; horário de funcionamento; processo de trabalho; estrutura física, equipamentos, mobiliário, suprimentos e Equipamentos de Proteção Individual (EPI); atendimento, exames e acompanhamento de Usuários Sintomáticos Respiratórios (USR); vigilância, integração, comunicação e gestão. Todas as 165 UBS foram convidadas a completar o instrumento. Principais resultados: houve readequação da estrutura física (salas de espera, espaços internos/externos); fornecimento de EPI e de testes Covid-19, busca ativa de USR/suspeitos Covid-19 por telefone/visitas domiciliares, monitoramento de fluxos de transferência de pacientes e telessaúde. Concluindo, as UBS reorganizaram seus serviços para atender necessidades da pandemia. Fornecer informações sobre estrutura e capacidade de resposta das UBS pode subsidiar sistemas de saúde para planejamento e tomada de decisões, em diferentes níveis de gestão, crucial para determinar estratégias para reforçar a responsividade da APS em situações de pandemias e outras calamidades.

Inpatient flow for Covid-19 in the Brazilian health regions / Fluxo de internação por Covid-19 nas regiões de saúde do Brasil

ABSTRACT The study aims to investigate the flows of Covid-19 hospitalizations in the 450 Brazilian health regions and 117 health macro-regions between March and October 2020. This descriptive study includes all Covid-19 hospitalizations registered in the Influenza Epidemiological Surveillance Information System between the eighth and forty-fourth epidemiological weeks of 2020. In Brazil, 397,830 admissions were identified for Covid-19. Emigration was 11.9% for residents in health regions and 6.8% in macro-regions; this pattern was also maintained during the peak period of Covid-19 hospitalizations. The average evasion for residents of health regions was 17.6% in the Northeast and 8.8% in the South. Evasion was more accentuated in health regions with up to 100 thousand inhabitants(36.9%), which was 7 times greater than that observed in health regions with more than 2 million inhabitants (5.2%). The negative migratory efficacy indicator (-0.39) revealed a predominance of evasion. Of the 450 Brazilian health regions, 117 (39.3%) had a coefficient of migratory efficacy between-1 and-0.75, and 113 (25.1%) between-0.75 and-0.25. Results indicate that the regionalization of the health system exhibited adequate organization of healthcare in the territory; however, the long distances traveled are still worrisome.

RESUMO Objetivou-se investigar os fluxos de internações por Covid-19 nas 450 regiões e 117 macrorregiões de saúde brasileiras, de março a outubro de 2020. Realizou-se estudo descritivo, compreendendo todas as internações por Covid-19 registradas no Sistema de Informação de Vigilância Epidemiológica da Gripe entre a 8ª e a 44ª semanas epidemiológicas de 2020. Identificaram-se 397.830 internações por Covid-19 no Brasil. A evasão foi de 11,9% dos residentes nas regiões de saúde e de 6,8% nas macrorregiões; padrão que se manteve no período de pico das internações por Covid-19. Houve, em média, 17,6% de evasão dos residentes das regiões de saúde do Nordeste e de 8,8% das do Sul. A evasão foi mais acentuada nas regiões de saúde com até 100 mil/hab. (36,9%), a qual foi 7 vezes maior que a verificada naquelas com mais de 2 milhões/habitantes (5,2%). O indicador de eficácia migratória negativo (-0,39) indicou predomínio da evasão. Das 450 regiões de saúde brasileiras, 117 (39,3%) apresentaram coeficiente de eficácia migratória entre-1 e-0,75; e 113 (25,1%), entre-0,75 e-0,25. Os resultados indicam que a regionalização do sistema de saúde mostrou-se adequada na organização do atendimento no território, porém, as longas distâncias percorridas ainda são preocupantes.

Spatial distribution of the "Mais Médicos (More Doctors) Program" and social vulnerability: an analysis of the Brazilian metropolitan regions.

BACKGROUND: The "Mais Médicos (More Doctors) Program" established in 2013 by the Brazilian Government aimed to reduce inequalities by means of an emergency provision of physicians, the improvement of medical care service in the Brazilian Unified Health System, and the expansion of medical education training in Brazil. In this context, equity should be considered when defining priorities and allocating resources. This study describes the distribution of physicians for the Program in five Brazilian metropolitan regions (MRs) and analyses whether the most vulnerable areas within each one of these regions had been prioritized in compliance with the legislation framework of the program. METHODS: This is a quantitative cross-sectional study. Official secondary data was analyzed to verify the relationship between the Index of Social Vulnerability, set up by the Institute of Applied Economic Research, and the physician allocation provided by the Program. The data were organized into categories and quintiles. For spatialization purposes, the QGIS 3.4 Madeira software was used. RESULTS: There are 2592 primary health care units, (in Portuguese, UBS), within the five MRs studied; 981 of these hosted at least one physician from the Program. In the Manaus, Recife, and the DF MRs, the 4th and 5th quintiles (the most vulnerable ones) hosted physicians in more significant proportions than the other quintiles, namely, 71.4%, 71.4%, and 52.2%, respectively, exceeding the national average (51.7%). It is worth mentioning that in the São Paulo MR, the units located in the most vulnerable quintiles (4th and 5th) also hosted physicians in proportions significantly higher than others (45.8%); however, this proportion did not reach 50%. There was no significant difference in the allocation of physicians in the Porto Alegre MR, indicating that there was no prioritization of the UBS according to vulnerability. CONCLUSIONS: These results appoint to the enormous gaps of vulnerability existing both between the analyzed MRs and internally in each one of them. It emphasizes the need for criteria for the allocation of physicians so as not to increase inequities. It also highlights the importance of the continuity of the "Mais Médicos (More Doctors) Program" in the metropolitan regions, above all, in areas of extreme vulnerabilities. On the other hand, they contribute to the national debate about the importance of public policies regarding constitutional rights related to access to health care and the relevance of primary care and the "Mais Médicos (More Doctors) Program" for the reduction of disparities regarding access to health care, especially for the citizens who live in regions of greater vulnerability, whether it is inside or outside large metropolitan regions.

Cost of providing doctors in remote and vulnerable areas: Programa Mais Médicos in Brazil.

OBJECTIVE: To evaluate the Programa Mais Médicos (More Doctors Program; PMM) in Brazil by estimating the proportional increase in the number of doctors in participating muni-cipalities and the program costs, stratified by cost component and funding source. METHODS: Official data from the 2013 edition of Demografia Médica no Brasil (Medical Demography in Brazil) was used to estimate the number of doctors prior to PMM. The number of doctors at the end of the fourth PMM recruiting cycle (July 2014) was obtained from the Ministry of Health. Cost components were identified and estimated based on PMM legislation and guidelines. The participating municipalities were chosen based on four criteria, all related to vulnerability. RESULTS: The PMM provided an additional 14 462 physicians to highly vulnerable, remote areas in 3 785 municipalities (68% of the total) and 34 Special Indigenous Sanitary Districts. There was a greater increase of physicians in the poorest regions (North and Northeast). The estimated annual cost of US$ 1.1 billion covered medical provision, continuing education, and supervision/mentoring. Funding was largely centralized at the federal level (92.6%). CONCLUSION: The cost of PMM is considered relatively moderate in comparison to its potential benefits for population health. The greater increase of doctors for the poorest and most vulnerable met the target of correcting imbalances in health worker distribution. The PMM experience in Brazil can contribute to the debate on reducing physician shortages.

Cost of providing doctors in remote and vulnerable areas: Programa Mais Médicos in Brazil / El costo de dotar de médicos a las zonas remotas y vulnerables: Programa Mais Médicos en el Brasil / O custo da provisão de médicos para áreas remotas e vulneráveis: Programa Mais Médicos no Brasil

Objective. To evaluate the Programa Mais Médicos (More Doctors Program; PMM) in Brazil by estimating the proportional increase in the number of doctors in participating municipalities and the program costs, stratified by cost component and funding source. Methods. Official data from the 2013 edition of Demografia Médica no Brasil (Medical Demography in Brazil) was used to estimate the number of doctors prior to PMM. The number of doctors at the end of the fourth PMM recruiting cycle (July 2014) was obtained from the Ministry of Health. Cost components were identified and estimated based on PMM legislation and guidelines. The participating municipalities were chosen based on four criteria, all related to vulnerability. Results. The PMM provided an additional 14 462 physicians to highly vulnerable, remote areas in 3 785 municipalities (68% of the total) and 34 Special Indigenous Sanitary Districts. There was a greater increase of physicians in the poorest regions (North and Northeast). The estimated annual cost of US$ 1.1 billion covered medical provision, continuing education, and supervision/mentoring. Funding was largely centralized at the federal level (92.6%). Conclusion. The cost of PMM is considered relatively moderate in comparison to its potential benefits for population health. The greater increase of doctors for the poorest and most vulnerable met the target of correcting imbalances in health worker distribution. The PMM experience in Brazil can contribute to the debate on reducing physician shortages.(AU)

Objetivo. Evaluar el Programa "Mais Médicos" en el Brasil mediante el cálculo del aumento proporcional del número de médicos en los municipios participantes y los costos del programa, con estratificación por componente del costo y fuente de financiamiento. Métodos. Se utilizaron datos oficiales de la edición del 2013 de Demografia médica no Brasil [demografía médica en el Brasil] para calcular el número de médicos antes del Programa "Mais Medicos". El número de médicos al final del cuarto ciclo de reclutamiento del programa (julio del 2014) se obtuvo del Ministerio de Salud. Se determinaron y calcularon los componentes de costos sobre la base de la legislación y las directrices del programa. Se eligieron los municipios participantes según cuatro criterios, todos relacionados con la vulnerabilidad. Resultados. Mediante el Programa "Mais Médicos" se destinaron 14 462 médicos más a zonas sumamente vulnerables y remotas en 3 785 municipios (68% del total) y 34 distritos sanitarios indígenas especiales. El aumento del número de médicos fue mayor en las zonas más pobres (al Norte y Nordeste). El costo anual estimado de US$ 1 100 millones incluyó la dotación de médicos, la educación continua y la supervisión y tutoría. El financiamiento estuvo principalmente centralizado en el nivel federal (92,6%). Conclusiones. Se considera que el costo del Programa "Mais Médicos" es relativamente moderado en relación con los posibles beneficios para la salud de la población. Con el mayor aumento de la dotación de médicos en las poblaciones más pobres y vulnerables se cumplió el objetivo de corregir los desequilibrios en la distribución del personal de salud. La experiencia de este programa en el Brasil puede contribuir al debate sobre cómo paliar la escasez de médicos.(AU)

Objetivo. Avaliar o Programa Mais Médicos (PMM) no Brasil estimando o aumento proporcional do número de médicos nos municípios participantes e os custos do programa, estratificado pelo componente de custo e fonte de financiamento. Métodos. Os dados oficiais da edição de Demografia médica no Brasil de 2013 foram usados para estimar o número de médicos anterior ao PMM. O número de médicos ao final do quarto ciclo de recrutamento do PMM (julho de 2014) foi fornecido pelo Ministério da Saúde. Os componentes de custo foram identificados e calculados de acordo com a legislação e as diretrizes do PMM. Os municípios participantes foram selecionados segundo quatro critérios relacionados à vulnerabilidade. Resultados. O PMM proveu um adicional de 14.462 médicos para áreas remotas bastante vulneráveis em 3.785 municípios (68% do total) e 34 distritos sanitários especiais indígenas. Houve aumento maior do número de médicos nas regiões mais pobres (Norte e Nordeste). O custo anual estimado de US$ 1,1 bilhão cobriu provisões médicas, educação continuada e supervisão/mentoria. O financiamento foi em grande parte centralizado ao nível federal (92,6%). Conclusão. Considera-se que o custo do PMM seja relativamente moderado em rela- ção aos benefícios em potencial à saúde da população. O aumento maior no número de médicos para atender a população mais pobres e vulnerável alcançou a meta de corrigir a má distribuição de profissionais da saúde. A experiência do PMM no Brasil pode subsidiar o debate visando reduzir a escassez de médicos.(AU)

Implementation research: towards universal health coverage with more doctors in Brazil.

OBJECTIVE: To evaluate the implementation of a programme to provide primary care physicians for remote and deprived populations in Brazil. METHODS: The Mais Médicos (More Doctors) programme was launched in July 2013 with public calls to recruit physicians for priority areas. Other strategies were to increase primary care infrastructure investments and to provide more places at medical schools. We conducted a quasi-experimental, before-and-after evaluation of the implementation of the programme in 1708 municipalities with populations living in extreme poverty and in remote border areas. We compared physician density, primary care coverage and avoidable hospitalizations in municipalities enrolled (n = 1450) and not enrolled (n = 258) in the programme. Data extracted from health information systems and Ministry of Health publications were analysed. FINDINGS: By September 2015, 4917 physicians had been added to the 16 524 physicians already in place in municipalities with remote and deprived populations. The number of municipalities with ≥ 1.0 physician per 1000 inhabitants doubled from 163 in 2013 to 348 in 2015. Primary care coverage in enrolled municipalities (based on 3000 inhabitants per primary care team) increased from 77.9% in 2012 to 86.3% in 2015. Avoidable hospitalizations in enrolled municipalities decreased from 44.9% in 2012 to 41.2% in 2015, but remained unchanged in control municipalities. We also documented higher infrastructure investments in enrolled municipalities and an increase in the number of medical school places over the study period. CONCLUSION: Other countries having shortages of physicians could benefit from the lessons of Brazil's programme towards achieving universal right to health.

Implementation research: towards universal health coverage with more doctors in Brazil

Objective: To evaluate the implementation of a programme to provide primary care physicians for remote and deprived populations in Brazil. Methods: The Mais Médicos (More Doctors) programme was launched in July 2013 with public calls to recruit physicians for priority areas. Other strategies were to increase primary care infrastructure investments and to provide more places at medical schools. We conducted a quasi-experimental, before-and-after evaluation of the implementation of the programme in 1708 municipalities with populations living in extreme poverty and in remote border areas. We compared physician density, primary care coverage and avoidable hospitalizations in municipalities enrolled (n = 1450) and not enrolled (n = 258) in the programme. Data extracted from health information systems and Ministry of Health publications were analysed. Findings: By September 2015, 4917 physicians had been added to the 16 524 physicians already in place in municipalities with remote and deprived populations. The number of municipalities with ≥ 1.0 physician per 1000 inhabitants doubled from 163 in 2013 to 348 in 2015. Primary care coverage in enrolled municipalities (based on 3000 inhabitants per primary care team) increased from 77.9% in 2012 to 86.3% in 2015. Avoidable hospitalizations in enrolled municipalities decreased from 44.9% in 2012 to 41.2% in 2015, but remained unchanged in control municipalities. We also documented higher infrastructure investments in enrolled municipalities and an increase in the number of medical school places over the study period. Conclusion: Other countries having shortages of physicians could benefit from the lessons of Brazil’s programme towards achieving universal right to health.

Mais Médicos program: provision of medical doctors in rural, remote and socially vulnerable areas of Brazil, 2013-2014.

INTRODUCTION: The Mais Médicos program was introduced in 2013 with the aim of reducing the shortage of doctors in priority regions and diminishing regional inequalities in health. One of the strategies has been to offer 3-year contracts for doctors to work in primary healthcare services in small towns, inland, rural, remote, and socially vulnerable areas. This report describes the program's implementation and the allocation of doctors to these target areas in 2014. METHODS: To describe the provision of doctors in the first year of implementation, we compared the doctor-to-population ratio in the 5570 municipalities of Brazil before and after the program, based on the Federal Board of Medicine database (2013), and the official dataset provided by the Ministry of Health (2014). RESULTS: In its first public call (July 2013) 3511 municipalities joined the Mais Médicos program, requesting a total of 15 460 doctors; although the program prioritizes the recruitment of Brazilians, only 1096 nationals enrolled and were hired, together with 522 foreign doctors. As a consequence, an international cooperation agreement was set in place to recruit Cuban doctors. In 12 months the program recruited 14 462 doctors: 79.0% Cubans, 15.9% Brazilians and 5.1% of other nationalities, covering 93.5% of the doctors demanded; they were assigned to all the 3785 municipalities enrolled. The study reveals a major decrease in the number of municipalities with fewer than 0.1 doctors per thousand inhabitants, which dropped from 374 in 2013 to 95 in 2014 (75% reduction). Of the total, 294 doctors were sent to work in the country's 34 Indigenous Health Districts (100% coverage) and 3390 doctors were deployed in municipalities containing certified rural maroon communities (formed centuries ago by runaway slaves). After 1 year of implementation, the municipalities with maroon communities with less than 0.1 doctors per thousand inhabitants were reduced by 87% in the poorest north region. More than 30% of municipalities with maroon communities in the richest regions had more than 1.0 doctors per thousand inhabitants, whereas in the poorest regions fewer than 7% of municipalities reached that level. CONCLUSIONS: The Mais Médicos program has granted medical assistance to these historically overlooked populations. However, it is important to evaluate the mid- and long-term sustainability of this initiative.

Mais Médicos program: provision of medical doctors in rural, remote and socially vulnerable areas of Brazil, 2013–2014

Introduction: The Mais Médicos program was introduced in 2013 with the aim of reducing the shortage of doctors in priorityregions and diminishing regional inequalities in health. One of the strategies has been to offer 3-year contracts for doctors to work inprimary healthcare services in small towns, inland, rural, remote, and socially vulnerable areas. This report describes the program’simplementation and the allocation of doctors to these target areas in 2014.Methods: To describe the provision of doctors in the first year of implementation, we compared the doctor-to-population ratio inthe 5570 municipalities of Brazil before and after the program, based on the Federal Board of Medicine database (2013), and theofficial dataset provided by the Ministry of Health (2014).Results: In its first public call (July 2013) 3511 municipalities joined the Mais Médicos program, requesting a total of15 460 doctors; although the program prioritizes the recruitment of Brazilians, only 1096 nationals enrolled and were hired,together with 522 foreign doctors. As a consequence, an international cooperation agreement was set in place to recruit Cubandoctors. In 12 months the program recruited 14 462 doctors: 79.0% Cubans, 15.9% Brazilians and 5.1% of other nationalities,covering 93.5% of the doctors demanded; they were assigned to all the 3785 municipalities enrolled...