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.

Vigilöncia de óbitos infantis em sistemas locais de saúde: avaliaçào da autópsia verbal e das informaçôes de agentes de saúde / Surveillance of infant deaths in local health systems: assessment of verbal autopsies and of information collected by community health agents

Conhecer os eventos vitais de uma populaçao e de fundamental importancia para combater a morbimortalidade e melhorar as condicoes de vida. Contudo, no Brasil, os sistemas de informacao de saude tem-se mostrado ineficientes. No presente estudo, realizado em tres municipios do Estado do Ceara (Quixada, Icapui e Jucas), com boa cobertura de servicos de atencao primaria a saude, foram investigados, atraves de um instrumento epidemiologico denominado autopsia verbal, 215 obitos de criancas menores de 1 ano de idade, representando 90 por cento do total dos obitos em 1993 e 1994. Foram averiguadas as caracteristicas socioeconomicas, cuidados e higiene, estado nutricional, o processo de doenca, assistencia e morte, a causa basica do obito e o funcionamento do sistema de informacao sobre mortalidade e do sistema de informacao de agentes de saude. Segundo a autopsia verbal, 39 por cento dos obitos tiveram como causa basica a diarreia, seguida da prematuridade (17 por cento) e infeccao respiratoria aguda (10 por cento); 49 por cento das criancas morreram no domicilio, embora 79 por cento das familias tenham procurado os servicos de saude no decorrer da doenca fatal, sugerindo uma baixa efetividade na identificacao e no tratamento de lactentes com doencas graves. Em 84 por cento dos casos, a familia procurou a rezadeira. Os agentes de saude foram procurados em 29 por cento dos casos, embora tenham notificado 78 por cento dos obitos investigados. A concordancia estatistica entre diagnostico dos agentes de saude para a causa basica do obito e autopsia verbal foi boa para a diarreia, regular para outras causas, e fraca para a infeccao respiratoria aguda. A incorporacao da autopsia verbal a rotina dos servicos de atencao primaria a saude do Estado propiciaria informacoes valiosas para as equipes locais de saude e geraria uma consciencia critica que favorece a reducao da mortalidade infantil