Health equity and COVID-19: global perspectives.

The COVID-19 is disproportionally affecting the poor, minorities and a broad range of vulnerable populations, due to its inequitable spread in areas of dense population and limited mitigation capacity due to high prevalence of chronic conditions or poor access to high quality public health and medical care. Moreover, the collateral effects of the pandemic due to the global economic downturn, and social isolation and movement restriction measures, are unequally affecting those in the lowest power strata of societies. To address the challenges to health equity and describe some of the approaches taken by governments and local organizations, we have compiled 13 country case studies from various regions around the world: China, Brazil, Thailand, Sub Saharan Africa, Nicaragua, Armenia, India, Guatemala, United States of America (USA), Israel, Australia, Colombia, and Belgium. This compilation is by no-means representative or all inclusive, and we encourage researchers to continue advancing global knowledge on COVID-19 health equity related issues, through rigorous research and generation of a strong evidence base of new empirical studies in this field.

Mortality associated with alternative primary healthcare policies: a nationwide microsimulation modelling study in Brazil.

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.

[Evaluation of the impact of the implementation of the new primary health care information system on records of patient care and home visits in Brazil]. / Avaliação do impacto da implantação do novo sistema de informações da atenção primária à saúde nos registros de atendimentos e visitas domiciliares no Brasil.

The replacement of the Primary Care Information System (SIAB, 1998-2015), as of January 2016, by the new Health Information System for Primary Care (SISAB) determined new forms of collecting, processing, and using information, with a possible impact on the records of activities carried out in primary health care in Brazil. This study aimed to evaluate the implementation impact of the new information system on records of physicians' and nurses' patient care and home visits of community health workers (CHW) in Brazil from 2007 to 2019. To this end, a Bayesian structural time-series model approach was used, based on a diffuse state-space regression. From 2016 to 2019, 463.47 million physician care, 210.61 million nursing care, and 1.28 billion CHW visits were recorded. Following the trend recorded before the implementation, 598.86 million, 430.46 million, and 1.5 billion physician and nursing appointments and CHW visits would be expected, respectively. In relative terms, there was a decrease of 25% in physician care, 51% in nursing care, and 15% in CHW visits when compared to the value expected by the Bayesian method. The negative impact on the records of patient care and home visits identified in this study, whether due to difficulties in adapting to the new system or a reduction in improper records, must be investigated so that the challenge of improving the primary care information system can be understood and overcome in a planned way.

A substituição do Sistema de Informação da Atenção Básica (SIAB, 1998-2015), a partir de janeiro de 2016, pelo novo Sistema de Informação em Saúde para a Atenção Básica (SISAB) determinou novas formas de coleta, processamento e uso das informações, com possível impacto nos registros das atividades desenvolvidas na atenção primária à saúde no Brasil. O objetivo deste estudo foi avaliar o impacto da implantação do novo sistema de informação sobre registros de atendimentos de médicos e enfermeiros, e de visitas domiciliares de agentes comunitários de saúde (ACS) brasileiros entre 2007 e 2019. Para tal, utilizou-se uma abordagem bayesiana de modelo estrutural para séries temporais, com base em uma regressão difusa de espaço-estado. Ao longo do período de 2016 a 2019, foram registrados 463,47 milhões de atendimentos médicos, 210,61 milhões de atendimentos de enfermagem e 1,28 bilhão de visitas de ACS. Seguindo a tendência registrada antes da implantação, seriam esperados 598,86 milhões, 430,46 milhões e 1,5 bilhão de atendimentos de médicos, enfermeiros e visitas de ACS, respectivamente. Em termos relativos, houve um decréscimo de 25% nos atendimentos médicos, 51% nos atendimentos de enfermagem e 15% nas visitas de ACS quando comparado com o valor esperado pelo método bayesiano. O impacto negativo no registro de atendimentos e de visitas domiciliares identificado neste estudo, seja por dificuldade de adaptação ao novo sistema, seja por diminuição de registros indevidos, merece ser alvo de investigação para que se possa, de forma planejada, compreender e superar o desafio da melhoria do sistema de informação da atenção primária.

La sustitución del Sistema de Información de la Atención Básica (SIAB, 1998-2015), desde enero de 2016, por el nuevo Sistema de Información en Salud para la Atención Básica (SISAB) estableció nuevas maneras para recolectar, procesar y utilizar las informaciones, con posibles impactos en los registros de las actividades desarrolladas en la atención primaria de salud en Brasil. El objetivo de este estudio fue evaluar el impacto de la implantación del nuevo sistema de información sobre los registros de atención de médicos y enfermeros y de visitas domiciliarias de agentes comunitarios de salud (ACS) en Brasil entre 2007 y 2019. Para eso, se utilizó un enfoque bayesiano de modelo estructural para series temporales basadas en una regresión difusa de espacio de estado. Entre los años 2016 y 2019, se registraron 463,47 millones de consultas médicas, 210,61 millones de consultas de enfermería y 1,28 mil millones de visitas de ACS. Siguiendo la tendencia registrada antes de la implantación, se esperarían 598,86 millones, 430,46 millones y 1,5 mil millones de consultas médicas y de enfermería y visitas de ACS respectivamente. En términos relativos, hubo una disminución del 25% en las consultas médicas, del 51% en las consultas de enfermería y del 15% en las visitas de ACS en comparación con el valor esperado por el método bayesiano. El impacto negativo en el registro de consultas y visitas domiciliarias identificado en este estudio, ya sea por dificultades en la adaptación al nuevo sistema o por la disminución de los registros indebidos, merece ser objeto de investigación para que se pueda, de manera planificada, comprender y superar el desafío continuo de mejorar el sistema de información de la atención primaria.

Current and Projected Mortality and Hospitalization Rates Associated With Conditional Cash Transfer, Social Pension, and Primary Health Care Programs in Brazil, 2000-2030.

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 1 462 626 (95% CI, 1 332 128-1 596 924) 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 1 305 359 (95% CI, 1 163 659-1 449 256) deaths and 6 593 224 (95% CI, 5 534 591-7 651 327) 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.

Competencies for Transformational Leadership in Public Health-An International Delphi Consensus Study.

Objectives: This Delphi study intended to develop competencies for transformational leadership in public health, including behavioral descriptions (descriptors) tailored to individuals and their contexts. Methods: The study involved five rounds, including online "e-Delphi" consultations and real-time online workshops with experts from diverse sectors. Relevant competencies were identified through a literature review, and experts rated, ranked, rephrased, and proposed descriptors. The study followed the Guidance on Conducting and REporting DElphi Studies (CREDES) and the COmpeteNcy FramEwoRk Development in Health Professions (CONFERD-HP) reporting guidelines. Results: Our framework comprises ten competencies for transformational public health leadership (each with its descriptors) within four categories, and also describes a four-stage model for developing relevant competencies tailored to different contexts. Conclusion: Educators responsible for curriculum design, particularly those aiming to align curricula with local goals, making leadership education context-specific and -sensitive, may benefit from the proposed framework. Additionally, it can help strengthen links between education and workforce sectors, address competency gaps, and potentially reduce the out-migration of graduates in the health professions.

Evaluating social protection mitigation effects on HIV/AIDS and Tuberculosis through a mathematical modelling study.

The global economic downturn due to the COVID-19 pandemic, war in Ukraine, and worldwide inflation surge may have a profound impact on poverty-related infectious diseases, especially in low-and middle-income countries (LMICs). In this work, we developed mathematical models for HIV/AIDS and Tuberculosis (TB) in Brazil, one of the largest and most unequal LMICs, incorporating poverty rates and temporal dynamics to evaluate and forecast the impact of the increase in poverty due to the economic crisis, and estimate the mitigation effects of alternative poverty-reduction policies on the incidence and mortality from AIDS and TB up to 2030. Three main intervention scenarios were simulated-an economic crisis followed by the implementation of social protection policies with none, moderate, or strong coverage-evaluating the incidence and mortality from AIDS and TB. Without social protection policies to mitigate the impact of the economic crisis, the burden of HIV/AIDS and TB would be significantly larger over the next decade, being responsible in 2030 for an incidence 13% (95% CI 4-31%) and mortality 21% (95% CI 12-34%) higher for HIV/AIDS, and an incidence 16% (95% CI 10-25%) and mortality 22% (95% CI 15-31%) higher for TB, if compared with a scenario of moderate social protection. These differences would be significantly larger if compared with a scenario of strong social protection, resulting in more than 230,000 cases and 34,000 deaths from AIDS and TB averted over the next decade in Brazil. Using a comprehensive approach, that integrated economic forecasting with mathematical and epidemiological models, we were able to show the importance of implementing robust social protection policies to avert a significant increase in incidence and mortality from AIDS and TB during the current global economic downturn.

Revolutionizing the Public Health Workforce-A Policy Brief in Retrospect of the World Congress on Public Health Rome 2020.

Background: The COVID-19 pandemic dramatically illustrates the consequences of inadequate prioritization of the Public Health Workforce (PHW). This Policy Brief introduces a Call for Action following the plenary session entitled "Revolutionising the Public Health Workforce (PHW) as Agents of Change" as part of the 2020 World Congress on Public Health. Policy Options and Recommendations: In order to revolutionize the PHW, five long-term key approaches are proposed: 1. Transforming public health competencies through transdisciplinary education and inter-professional training; 2. Revolutionizing educational systems by shifting the public health paradigm; 3. Linking public health education and work opportunities; 4. Overcoming the paradoxical shortage and overproduction of graduates and 5. Developing adaptable, multisectoral agents of change. Conclusion: Public health education of the future requires a paradigm shift towards a holistic understanding of public health, characterized by transdisciplinary education, inter-professional training and a closer integration of academia, health services, and communities.

Assessing the severity of medication administration errors identified in an observational study using a valid and reliable method.

BACKGROUND: Epidemiological data on medication errors severity are scarce. The assessment of the prevalence and severity of medication errors may be limited because of several reasons, including a lack of standardization in the method of identifying medication administration errors and little knowledge about the appropriate assessment tools to measure severity. Thus, in this study, we aim to assess the potential severity of errors identified by direct observation in a teaching hospital. METHODS: We used a validated method for assessing the potential severity of medication administration errors. Responses are scored on a 10-point scale. The 203 errors identified in a previous study were organized per similarity, resulting in 67 errors. This list was assessed by a panel of a physician, a nurse, and two pharmacists. The average score for each of the 67 errors was estimated considering the scores given by the 4 judges. Errors with a severity index < 3, between 3 and 7, and > 7 were considered minor, moderate, and severe, respectively. RESULTS: Professionals classified the potential clinical significance of the errors as minor, moderate, and severe in 8.8% (18/203), 82.8% (168/203), and 8.4% (17/203) of the cases, respectively. Most errors considered potentially serious (41%, 7/17) were technical errors. Most potentially serious errors involved insulin. Regarding the administration route, nine (53%) potentially serious errors involved medications administered intravenously. CONCLUSIONS: Most of the errors were considered as potentially moderated by the expert panel; however, the frequency of potentially serious errors was higher than that in previous studies using the same methodology, which highlights the need for strategies to reduce their occurrence.

Validation of a method to assess the severity of medication administration errors in Brazil.

INTRODUCTION: Medication errors are frequent and have high economic and social impacts; however, some medication errors are more likely to result in harm than others. Therefore, it is critical to determine their severity. Various tools exist to measure and classify the harm associated with medication errors; although, few have been validated internationally. METHODS: We validated an existing method for assessing the potential severity of medication administration errors (MAEs) in Brazil. Thirty healthcare professionals (doctors, nurses and pharmacists) from Brazil were invited to score 50 cases of MAEs as in the original UK study, regarding their potential harm to the patient, on a scale from 0 to 10. Sixteen cases with known harmful outcomes were included to assess the validity of the scoring. To assess test-retest reliability, 10 cases (of the 50) were scored twice. Potential sources of variability in scoring were evaluated, including the occasion on which the scores were given, the scorers, their profession and the interactions among these variables. Data were analysed using generalisability theory. A G coefficient of 0.8 or more was considered reliable, and a Bland-Altman analysis was used to assess test-retest reliability. RESULTS: To obtain a generalisability coefficient of 0.8, a minimum of three judges would need to score each case with their mean score used as an indicator of severity. The method also appeared to be valid, as the judges' assessments were largely in line with the outcomes of the 16 cases with known outcomes. The Bland-Altman analysis showed that the distribution was homogeneous above and below the mean difference for doctors, pharmacists and nurses. CONCLUSION: The results of this study demonstrate the reliability and validity of an existing method of scoring the severity of MAEs for use in the Brazilian health system.

The effects of cash transfer programmes on HIV/AIDS prevention and care outcomes: a systematic review and meta-analysis of intervention studies.

BACKGROUND: Poverty and social inequality are risk factors for poor health outcomes in patients with HIV/AIDS. In addition to eligibility, cash transfer programmes can be divided into two categories: those with specific requirements (conditional cash transfers [CCTs]) and those without specific requirements (unconditional cash transfers). Common CCT requirements include health care (eg, undergoing an HIV test) and education (eg, children attending school). Trials assessing the effect of cash transfer programmes on HIV/AIDS outcomes have yielded divergent findings. This review aimed to summarise evidence to evaluate the effects of cash transfer programmes on HIV/AIDS prevention and care outcomes. METHODS: For this systematic review and meta-analysis, we searched PubMed, EMBASE, Cochrane Library, LILACS, WHO IRIS, PAHO-IRIS, BDENF, Secretaria Estadual de Saúde SP, Localizador de Informação em Saúde, Coleciona SUS, BINACIS, IBECS, CUMED, SciELO, and Web of Science up to Nov 28, 2022. We included randomised controlled trials (RCTs) that evaluated the effects of cash transfer programmes on HIV incidence, HIV testing, retention in HIV care, and antiretroviral therapy adherence, and conducted risk of bias and quality of evidence assessments using the Cochrane Risk of Bias tool and the Grading of Recommendations, Assessment, Development, and Evaluations approach. A random-effects meta-analysis model was used to combine studies and calculate risk ratios (RRs). Subgroup analyses were performed using conditionality types (ie, school attendance or health care). The protocol was registered with PROSPERO, CRD42021274452. FINDINGS: 16 RCTs, which included 5241 individuals, fulfilled the inclusion criteria. Of these, 13 studies included conditionalities for receiving cash transfer programmes. The results showed that receiving a cash transfer was associated with lowered HIV incidence among individuals who had to meet health-care conditionalities (RR 0·74, 95% CI 0·56-0·98) and with increased retention in HIV care for pregnant women (1·14, 95% CI 1·03-1·27). No significant effect was observed for HIV testing (RR 0·45, 95% CI 0·18-1·12) or antiretroviral therapy adherence (1·13, 0·73-1·75). Lower risk of bias was observed for HIV incidence and having an HIV test. The strength of available evidence can be classified as moderate. INTERPRETATION: Cash transfer programmes have a positive effect on mitigating HIV incidence for individuals who have to meet health-care conditionalities and on increasing retention in HIV care for pregnant women. These results show the potential of cash transfer programmes for HIV prevention and care, especially among people in extreme poverty, and highlight that cash transfer programmes must be considered when developing policies for HIV/AIDS control, as indicated by the UNAIDS 95-95-95 target of the HIV care continuum. FUNDING: National Institute of Allergy and Infectious Diseases, National Institutes of Health, USA.

Evaluation and Forecasting Analysis of the Association of Conditional Cash Transfer With Child Mortality in Latin America, 2000-2030.

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 738 919 (95% CI, 695 641-782 104) 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 153 601 (95% CI, 127 441-180 600) 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.

The effects of social determinants of health on acquired immune deficiency syndrome in a low-income population of Brazil: a retrospective cohort study of 28.3 million individuals.

Background: Social determinants of health (SDH) include factors such as income, education, and race, that could significantly affect the human immunodeficiency virus and acquired immunodeficiency syndrome (HIV/AIDS). Studies on the effects of SDH on HIV/AIDS are limited, and do not yet provide a systematic understanding of how the various SDH act on important indicators of HIV/AIDS progression. We aimed to evaluate the effects of SDH on AIDS morbidity and mortality. Methods: A retrospective cohort of 28.3 million individuals was evaluated over a 9-year period (from 2007 to 2015). Multivariable Poisson regression, with a hierarchical approach, was used to estimate the effects of SDH-at the individual and familial level-on AIDS incidence, mortality, and case-fatality rates. Findings: A total of 28,318,532 individuals, representing the low-income Brazilian population, were assessed, who had a mean age of 36.18 (SD: 16.96) years, 52.69% (14,920,049) were female, 57.52% (15,360,569) were pardos, 34.13% (9,113,222) were white/Asian, 7.77% (2,075,977) were black, and 0.58% (154,146) were indigenous. Specific socioeconomic, household, and geographic factors were significantly associated with AIDS-related outcomes. Less wealth was strongly associated with a higher AIDS incidence (rate ratios-RR: 1.55; 95% confidence interval-CI: 1.43-1.68) and mortality (RR: 1.99; 95% CI: 1.70-2.34). Lower educational attainment was also greatly associated with higher AIDS incidence (RR: 1.46; 95% CI: 1.26-1.68), mortality (RR: 2.76; 95% CI: 1.99-3.82) and case-fatality rates (RR: 2.30; 95% CI: 1.31-4.01). Being black was associated with a higher AIDS incidence (RR: 1.53; 95% CI: 1.45-1.61), mortality (RR: 1.69; 95% CI: 1.57-1.83) and case-fatality rates (RR: 1.16; 95% CI: 1.03-1.32). Overall, also considering the other SDH, individuals experiencing greater levels of socioeconomic deprivation were, by far, more likely to acquire AIDS, and to die from it. Interpretation: In the population studied, SDH related to poverty and social vulnerability are strongly associated with a higher burden of HIV/AIDS, most notably less wealth, illiteracy, and being black. In the absence of relevant social protection policies, the current worldwide increase in poverty and inequalities-due to the consequences of the COVID-19 pandemic, and the effects of war in the Ukraine-could reverse progress made in the fight against HIV/AIDS in low- and middle-income countries (LMIC). Funding: National Institute of Allergy and Infectious Diseases (NAIDS), National Institutes of Health (NIH), US Grant Number: 1R01AI152938.

Evolution of the structure and results of Primary Health Care in Brazil between 2008 and 2019. / Evolução da estrutura e resultados da Atenção Primária à Saúde no Brasil entre 2008 e 2019.

This paper describes the structure and results of Primary Health Care (PHC) in Brazil between 2008 and 2019. The medians of the following variables were calculated: PHC spending per inhabitant covered, PHC coverage, and rates of mortality and hospitalizations due to primary care sensitive conditions (PCSC), in 5,565 Brazilian municipalities stratified according to population size and quintile of the Brazilian Deprivation Index (IBP), and the median trend in the period was analyzed. There was a 12% increase in median PHC spending. PHC coverage expanded, with 3,168 municipalities presenting 100% coverage in 2019, compared to 2,632 in 2008. The median rates of PCSC mortality and hospitalizations increased 0.2% and decreased 44.9%, respectively. PHC spending was lower in municipalities with greater socioeconomic deprivation. The bigger the population and the better the socioeconomic conditions were in the municipalities, the lower the PHC coverage. The greater the socioeconomic deprivation was in the municipalities, the higher the median PCSC mortality rates. This study showed that the evolution of PHC was heterogeneous and is associated both with the population size and with the socioeconomic conditions of the municipalities.

Descreve a evolução da estrutura e resultados da Atenção Primária à Saúde (APS) no Brasil, entre 2008 e 2019. Foram calculadas a mediana de variáveis como: despesa per capita em APS por habitante coberto, cobertura da APS e as taxas de mortalidade e internações por condições sensíveis à atenção primária (CSAP) de 5.565 municípios brasileiros estratificados segundo porte populacional e quintil do Índice Brasileiro de Privação (IBP) e analisada a tendência mediana no período. Houve aumento de 12% na mediana da despesa em APS. A cobertura da APS expandiu, sendo que 3.168 municípios apresentaram 100% de cobertura em 2019, contra 2.632 em 2008. A mediana das taxas de mortalidade e internações por CSAP aumentou 0,2% e diminuiu 44,9% respectivamente. A despesa em APS foi menor nos municípios com maior privação socioeconômica. Quanto maior o porte populacional e melhores as condições socioeconômicas dos municípios, menor a cobertura da APS. Quanto maior a privação socioeconômica dos municípios, maiores foram as medianas das taxas de mortalidade por CSAP. Este estudo demonstrou que a evolução da APS foi heterogênea e está associada tanto ao porte populacional como às condições socioeconômicas dos municípios.

Financing of health and the fiscal dependency of Brazilian municipalities between 2004 and 2019. / Financiamento da saúde e dependência fiscal dos municípios brasileiros entre 2004 e 2019.

This article describes the evolution of municipal financing of the Unified Health System, from 2004 to 2019, considering revenues and expenses from own and non-own sources, analyzes fiscal redistribution, according to population size and average household income, and compares this evolution in two periods, characterized as economic growth (2004-2014) and recession (2015-2019). The study was based on data from the Information System on Public Health Budgets. There was real growth in municipal spending on health from 2004 to 2014 (156.3%), with a drop between 2014 and 2015, followed by a recovery between 2015 and 2019. During the recession period, there was an overall increase in the fiscal dependence of municipalities, indicated by the increase in non-own revenues, even with the decrease in the Federal Government participation in transfers. The growth of own health expenses was lower among municipalities with lower household income, while for non-own expenses it was higher in municipalities with a smaller population size. In short, the results indicate a process of increasing municipal spending on health, as well as the increased fiscal dependence of municipalities to fund health, intensified after the 2015 crisis, which especially affected small and lower income municipalities.

Este artigo descreve a evolução do financiamento municipal do Sistema Único de Saúde, de 2004 a 2019, considerando receitas e despesas de fontes próprias e não-próprias, analisa a redistribuição fiscal, de acordo com o porte populacional e a renda média domiciliar, e compara essa evolução em dois períodos, caracterizados como de crescimento econômico (2004-2014) e de recessão (2015-2019). O estudo se baseou em dados do Sistema de Informações sobre Orçamentos Públicos em Saúde. Constatou-se crescimento real dos gastos municipais em saúde de 2004 a 2014 (156,3%), com queda entre 2014 e 2015, seguida de recuperação até 2019. Na recessão, detectou-se aumento global da dependência fiscal dos municípios, indicada pelo aumento de receitas não-próprias, mesmo com a diminuição da participação da União nas transferências. O crescimento das despesas próprias em saúde foi menor entre os municípios de menor renda domiciliar, enquanto para as despesas não-próprias foi maior nos municípios de menor porte populacional. Em suma, indica-se um processo de incremento dos gastos municipais em saúde, assim como o aumento da dependência fiscal para custeio da saúde, intensificado após a crise de 2015, que atingiu especialmente os municípios de pequeno porte e de menor renda domiciliar.

The global failure of facing the pandemic.

The COVID-19 pandemic outbreak in late 2019 has had social, political, and economic consequences worldwide. However, its emergence was not a surprise. In 2015, a Panel organised by the World Health Organization highlighted the importance of learning about the crisis caused by the Ebola epidemic. In 1992, the Committee on Emerging Microbial Threats to Health of the US Institute of Medicine warned of the possibility of an emerging global microbial threat. In this text, we point out five arguments that reveal the global failure in facing the pandemic: (1) deficiency in the global alert system and the fragility of the International Health Regulations (IHR-2005), (2) problems of the international response to the pandemic, related to global health governance, (3) the dispersed global adoption of the elimination strategy (zero Covid) widely seen as a policy of restriction of freedom instead as a strategy of inequities reduction, (4) fragile control of the disease with a narrow reading of the associated problems, and (5) global setbacks in achieving the Sustainable Development Goals in the context of ongoing neoliberal national policies. Finally, we argue that overcoming the weaknesses discussed requires strengthening health systems in all their components and expanding social welfare policies.[Figure: see text].

Validation of a method to assess the severity of medication administration errors in Brazil: a study protocol.

BACKGROUND: Medication errors are frequent and have a high economic and social impact and is critical to know their severity. A variety of tools exist to measure and classify the harms associated with medication errors, but few are internationally validated. DESIGN AND METHODS: It was decided to validate a method proposed by Dean and Barber for assessment of the potential severity of medication administration errors. A number of thirty health care professionals (doctors, nurses and pharmacists) from Brazil will receive an invitation to take part by scoring 50 cases of medication errors gathered from an original UK study regarding their potential harm to the patient on scale 0 to 10. Sixteen cases with known actual harm outcomes will be used to assess the validity of their scoring. By looking at 10 errors (out of the 50 cases) scored twice, reliability shall be assessed; and potential sources of variability in scoring will be evaluated depending on the severity of each of error case, the occasion when the scores were given, the scorer, their profession, and interactions among these variables. Generalizability theory will be used for analysing data. Expected impact of the study for public health: This study was submitted to the evaluation of the Research Ethics Committee of the Complexo Hospitalar Universitário Professor Edgard Santos and approved under no. 3.102.570/2019. This is the first validation of this method for use in Brazil, and will allow researchers to conduct more standardised evaluations of interventions to reduce the impact of medication errors.

Incorporating social determinants of health into the mathematical modeling of HIV/AIDS.

Currently, it is estimated that 37.6 million people are living with the HIV/AIDS virus worldwide, placing HIV/AIDS among the ten leading causes of death, mostly among low- and lower-middle-income countries. Despite the effective intervention in the prevention and treatment, this reduction did not occur equally among populations, subpopulations and geographic regions. This difference in the occurrence of the disease is associated with the social determinants of health (SDH), which could affect the transmission and maintenance of HIV. With the recognition of the importance of SDH in HIV transmission, the development of mathematical models that incorporate these determinants could increase the accuracy and robustness of the modeling. This article aims to propose a theoretical and conceptual way of including SDH in the mathematical modeling of HIV/AIDS. The theoretical mathematical model with the Social Determinants of Health has been developed in stages. For the selection of SDH that were incorporated into the model, a narrative literature review was conducted. Secondly, we proposed an extended model in which the population (N) is divided into Susceptible (S), HIV-positive (I), Individual with AIDS (A) and individual under treatment (T). Each SDH had a different approach to embedding in the model. We performed a calibration and validation of the model. A total of 31 SDH were obtained in the review, divided into four groups: Individual Factors, Socioeconomic Factors, Social Participation, and Health Services. In the end, four determinants were selected for incorporation into the model: Education, Poverty, Use of Drugs and Alcohol abuse, and Condoms Use. the section "Numerical simulation" to simulate the influence of the poverty rate on the AIDS incidence and mortality rates. We used a Brazilian dataset of new AIDS cases and deaths, which is publicly available. We calibrated the model using a multiobjective genetic algorithm for the years 2003 to 2019. To forecast from 2020 to 2035, we assumed two lines of poverty rate representing (i) a scenario of increasing and (ii) a scenario of decreasing. To avoid overfitting, we fixed some parameters and estimated the remaining. The equations presented with the chosen SDH exemplify some approaches that we can adopt when thinking about modeling social effects on the occurrence of HIV. The model was able to capture the influence of the employment/poverty on the HIV/AIDS incidence and mortality rates, evidencing the importance of SDOH in the occurrence of diseases. The recognition of the importance of including the SDH in the modeling and studies on HIV/AIDS is evident, due to its complexity and multicausality. Models that do not take into account in their structure, will probably miss a great part of the real trends, especially in periods, as the current on, of economic crisis and strong socioeconomic changes.

Evaluating the impact of social determinants, conditional cash transfers and primary health care on HIV/AIDS: Study protocol of a retrospective and forecasting approach based on the data integration with a cohort of 100 million Brazilians.

BACKGROUND: Despite the great progress made over the last decades, stronger structural interventions are needed to end the HIV/AIDS pandemic in Low and Middle-Income Countries (LMIC). Brazil is one of the largest and data-richest LMIC, with rapidly changing socioeconomic characteristics and an important HIV/AIDS burden. Over the last two decades Brazil has also implemented the world's largest Conditional Cash Transfer programs, the Bolsa Familia Program (BFP), and one of the most consolidated Primary Health Care (PHC) interventions, the Family Health Strategy (FHS). OBJECTIVE: We will evaluate the effects of socioeconomic determinants, BFP exposure and FHS coverage on HIV/AIDS incidence, treatment adherence, hospitalizations, case fatality, and mortality using unprecedently large aggregate and individual-level longitudinal data. Moreover, we will integrate the retrospective datasets and estimated parameters with comprehensive forecasting models to project HIV/AIDS incidence, prevalence and mortality scenarios up to 2030 according to future socioeconomic conditions and alternative policy implementations. METHODS AND ANALYSIS: We will combine individual-level data from all national HIV/AIDS registries with large-scale databases, including the "100 Million Brazilian Cohort", over a 19-year period (2000-2018). Several approaches will be used for the retrospective quasi-experimental impact evaluations, such as Regression Discontinuity Design (RDD), Random Administrative Delays (RAD) and Propensity Score Matching (PSM), combined with multivariable Poisson regressions for cohort analyses. Moreover, we will explore in depth lagged and long-term effects of changes in living conditions and in exposures to BFP and FHS. We will also investigate the effects of the interventions in a wide range of subpopulations. Finally, we will integrate such retrospective analyses with microsimulation, compartmental and agent-based models to forecast future HIV/AIDS scenarios. CONCLUSION: The unprecedented datasets, analyzed through state-of-the-art quasi-experimental methods and innovative mathematical models will provide essential evidences to the understanding and control of HIV/AIDS epidemic in LMICs such as Brazil.