Challenges facing the More Doctors program (Programa Mais Médicos) in vulnerable and peri-urban areas in Greater Brasilia, Brazil.

BACKGROUND: A shortage of physicians, especially in vulnerable and peri-urban areas, is a global phenomenon that has serious implications for health systems, demanding policies to assure the provision and retention of health workers. The aim of this study was to analyze the strategies employed by the More Doctors Program (Programa Mais Médicos) to provide primary care physicians in vulnerable and peri-urban parts of Greater Brasilia. METHODS: The study used a qualitative approach based on the precepts of social constructivism. Forty-nine semi-structured interviews were conducted: 24 with physicians employed as part of the More Doctors program, five with program medical supervisors, seven with secondary care physicians, twelve with primary care coordinators, and one federal administrator. The interviews occurred between March and September 2019. The transcripts of the interviews were submitted to thematic content analysis. RESULTS: The partnership between the Ministry of Health and local authorities was essential for the provision of doctors-especially foreign doctors, most from Cuba, to assist vulnerable population groups previously without access to the health system. There was a notable presence of doctors with experience working with socioeconomically disadvantaged populations, which was important for gaining a better understanding of the effects of the endemic urban violence in the region. The incentives and other institutional support, such as enhanced salaries, training, and housing, transportation, and food allowances, were factors that helped provide a satisfactory working environment. However, the poor state of the infrastructure at some of the primary care units and limitations of the health service as a whole were factors that hampered the provision of comprehensive care, constituting a cause of dissatisfaction. CONCLUSIONS: More Doctors introduced a range of novel strategies that helped ensure a supply of primary care doctors in vulnerable and peri-urban parts of Greater Brasilia. The inclusion of foreign doctors, most from Cuba, was crucial for the success of the health services provided for the local communities, who subsist in violent and socioeconomically deprived urban areas. However, it became clear that barriers from within the health service itself hampered the physicians' capacity to provide a satisfactory service. As such, what is needed for primary care to be effective is not just the recruitment, training, and deployment of doctors, but also investment in the organization of the whole health system.

Brazil's more doctors programme and infant health outcomes: a longitudinal analysis.

BACKGROUND: Providing sufficient numbers of human resources for health is essential for effective and accessible health services. Between 2013 and 2018, the Brazilian Ministry of Health implemented the Programa Mais Médicos (PMM) (More Doctors Programme) to increase the supply of primary care doctors in underserved areas of the country. This study investigated the association between PMM and infant health outcomes and assessed if heterogeneity in the impact of PMM varied by municipal socio-economic factors and health indicators. METHODS: An ecological longitudinal (panel) study design was employed to analyse data from 5565 Brazilian municipalities over a 12-year period between 2007 and 2018. A differences-in-differences approach was implemented using longitudinal fixed effect regression models to compare infant health outcomes in municipalities receiving a PMM doctor with those that did not receive a PMM doctor. The impact of PMM was assessed on aggregate and in municipality subgroups. RESULTS: On aggregate, the PMM was not significantly associated with changes in infant or neonatal mortality, but the PMM was associated with reductions in infant mortality rate (IMR) (of - 0.21; 95% CI: - 0.38, - 0.03) in municipalities with highest IMR prior to the programme's implementation (where (IMR) > 25.2 infant deaths per 1000 live births). The PMM was also associated with an increase in the proportion of expectant mothers receiving seven or more prenatal care visits but only in municipalities with a lower IMR at baseline and high density of non-PMM doctors and community health workers before the PMM. CONCLUSIONS: The PMM was associated with reduced infant mortality in municipalities with the highest infant mortality rate prior to the programme. This suggests effectiveness of the PMM was limited only to the areas of greatest need. New programmes to improve the equitable provision of human resources for health should employ comprehensive targeting approaches balancing health needs and socio-economic factors to maximize effectiveness.

Indexes to assess feeding practices of children under 2 years old: a systematic review.

OBJECTIVE: To systematically review studies that used indexes to assess feeding practices of children under 2 years. DESIGN: Seven databases were searched with no limit on language or publication date. SETTING: The reviewed studies included thirteen Asian, ten Latin American, four European, four North American, three Oceanian and three African. PARTICIPANTS: Children under 2 years. RESULTS: We analysed thirty-six studies: twenty-two presenting original indexes and fourteen using adapted indexes. Among the original indexes, thirteen assess breast-feeding, fourteen food consumption, ten food groups, and ten other feeding practices. Original indexes were mainly adapted to fit the data available in the study, to update for current nutritional recommendations or to add components not present in the original indexes. Seven studies evaluated the associations between the indexes and nutrient intake or nutritional status. The main limitations cited by the authors were: flaws in the definition of the index components, criteria for cut-off points and weighting of the evaluated index components. CONCLUSIONS: The assessment of feeding practices for young children and its comparison across countries remains a challenge, especially due to the lack of consensus on the construction of indexes and regional differences in dietary recommendations and practices. Lack of validation for some indexes also makes it difficult to choose the most appropriate index for a given objective. Adapting existing indexes is a viable option. We point out relevant recommendations that may contribute to future research. Validation and longitudinal studies in diverse populations are favourable to qualify the assessment of feeding practices in this group.

Direct from the COVID-19 crisis: research and innovation sparks in Brazil.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has spread throughout more than 160 countries, infecting millions of people worldwide. To address this health emergency, countries have organized the flow of production and innovation to reduce the impact on health. This article shows the response of the Brazilian scientific community to meet the urgent needs of the public unified health system [SUS], aiming to guarantee universal access to an estimated population of 211 million. By December 2020, Brazil had recorded more than six million cases and approximately 175,000 deaths. METHODS: We collected data on research, development and innovation projects carried out by 114 public universities (plus Oswaldo Cruz Foundation [Fiocruz] and Butantan Institute), as reported on their websites. Additionally, we examined the studies on COVID-19 approved by the National Comission for Research Ethics, as well as those reported on the Ministry of Education website as of May 15, 2020. RESULTS: The 789 identified projects were classified according to research categories as follows: development and innovation (n = 280), other types of projects (n = 226), epidemiologic research (n = 211), and basic research on disease mechanisms (n = 72). Most proposals focused on the development and innovation of personal protective equipment, medical devices, diagnostic tests, medicines and vaccines, which were rapidly identified as research priorities by the scientific community. Some promising results have been observed from phase III vaccine trials, one of which is conducted in partnership with Oxford University and another of which is performed with Sinovac Biotech. Both trials involve thousands of volunteers in their Brazilian arms and include technology transfer agreements with Fiocruz and the Butantan Institute, respectively. These vaccines proved to be safe and effective and were immediately licensed for emergency use. The provision of doses for the public health system, and vaccination, started on January 17, 2021. CONCLUSIONS: The mobilized Brazilian scientific community has generated comprehensive research, development and innovation proposals to meet the most urgent needs. It is important to emphasize that this response was only possible due to decades of investment in research, development and innovation in Brazil. We need to reinforce and protect the Brazilian science, technology and innovation system from austerity policies that disregard health and knowledge as crucial investments for Brazilian society, in line with the constitutional right of universal health access and universal health coverage.

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.

Impact of the Programa Mais médicos (more doctors Programme) on primary care doctor supply and amenable mortality: quasi-experimental study of 5565 Brazilian municipalities.

BACKGROUND: Investing in human resources for health (HRH) is vital for achieving universal health care and the Sustainable Development Goals. The Programa Mais Médicos (PMM) (More Doctors Programme) provided 17,000 doctors, predominantly from Cuba, to work in Brazilian primary care. This study assesses whether PMM doctor allocation to municipalities was consistent with programme criteria and associated impacts on amenable mortality. METHODS: Difference-in-differences regression analysis, exploiting variation in PMM introduction across 5565 municipalities over the period 2008-2017, was employed to examine programme impacts on doctor density and mortality amenable to healthcare. Heterogeneity in effects was explored with respect to doctor allocation criteria and municipal doctor density prior to PMM introduction. RESULTS: After starting in 2013, PMM was associated with an increase in PMM-contracted primary care doctors of 15.1 per 100,000 population. However, largescale substitution of existing primary care doctors resulting in a net increase of only 5.7 per 100,000. Increases in both PMM and total primary care doctors were lower in priority municipalities due to lower allocation of PMM doctors and greater substitution effects. The PMM led to amenable mortality reductions of - 1.06 per 100,000 (95%CI: - 1.78 to - 0.34) annually - with greater benefits in municipalities prioritised for doctor allocation and where doctor density was low before programme implementation. CONCLUSIONS: PMM potential health benefits were undermined due to widespread allocation of doctors to non-priority areas and local substitution effects. Policies seeking to strengthen HRH should develop and implement needs-based criteria for resource allocation.

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.

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.

Ethnic differences in maternal near miss.

PURPOSE: To evaluate the association between ethnic differences and the occurrence of maternal near miss (MNM) in the Amazon and Northeast regions of Brazil. METHODS: This is a secondary analysis of a national cross-sectional study focused on the assessment of care to pregnancy, childbirth, and infants under 1 year of age. Ethnicity was classified as white, black or indigenous. Ethnic distribution by state and region, the proportion of severe maternal complications and related procedures, and the prevalence of MNM and its criteria were calculated for the ethnic groups. Risks for MNM were estimated per sociodemographic characteristics and healthcare received by ethnic group, using prevalence ratios adjusted by all predictors and by the sampling method. RESULTS: 76% of the 16.783 women were black, 20% white and 3.5% indigenous. Around 36% reported any complication related to pregnancy and the most frequent were hemorrhage (27-31%), and infection (7.1-9.0%). The MNM ratio was higher among indigenous (53.1) and black (28.4) than in white women (25.7). For black women, the risks of MNM were lower for private prenatal care and hospital admission for conditions other than hypertension, while higher for cesarean section and peregrination. For indigenous, the risks of MNM were lower for private prenatal care, and higher for a longer time to reach the hospital. For white women, only the low number of prenatal visits increased the risk of MNM. CONCLUSIONS: The occurrence of MNM was higher for indigenous and black than for white women.

[Humanism in the practice of Cuban cooperating physicians in Brazil: narratives of basic health care teamsHumanismo na prática dos médicos colaboradores cubanos no Brasil: narrativas das equipes de atenção básica]. / Humanismo en la práctica de médicos cooperantes cubanos en Brasil: narrativas de equipos de atención básica.

OBJECTIVE: To present the narratives of Brazilian members of family health teams with regard to the humanism perceived in the practice of Cuban physician cooperating in the Mais Médicos program. METHODS: Cross-sectional descriptive case study. A semi-structured interview was applied to Brazilian members of family health teams who had worked from the beginning of the program with Cuban physicians in selected municipalities included in the Mais Médicos program (20% or more of the population in extreme poverty and less than five physicians or a rate of 0.5 physicians per 1, 000 population prior to the program). The data were processed using the content analysis technique. RESULTS: Interviews were held with 30 senior nurses, 28 nursing assistants, one administrative technician, and 19 health agents. The interviewees offered a positive assessment of the work of the Cuban cooperating physicians, emphasizing their responsibility, ethics, and humanism, as well as the high quality of their medical -consultations and their good relations with their peers in basic health care teams. CONCLUSIONS: There were confirmed differences between the patterns of care of the Cuban cooperating physicians in the Mais Médicos program and the physicians who were working before in the studied communities prior to implementation of that program. The differential features of the Cuban physicians most frequently mentioned include their commitment to the population (both in medical consultations and in solving people's problems), their empathy, their respect, and in general, the human values with which they treat patients.

OBJETIVO: Apresentar as narrativas dos integrantes brasileiros das equipes de saúde da família sobre o humanismo percebido na prática dos colaboradores cubanos do Programa Mais Médicos. MÉTODOS: Trata-se de um estudo de caso descritivo transversal. Foi realizada uma entrevista semiestruturada com os integrantes brasileiros das equipes de saúde da família que trabalhavam desde o início do programa com médicos cubanos em municípios selecionados cadastrados no Programa Mais Médicos. Estas localidades têm 20% ou mais da população vivendo em situação de extrema pobreza, contando com menos de cinco médicos (taxa de 0,5 médico por 1.000 habitantes) antes do programa. Os dados foram analisados com o uso da técnica de análise de conteúdo. RESULTADOS: Foram entrevistados 30 enfermeiros diplomados, 28 técnicos em enfermagem, 1 técnico administrativo e 19 agentes comunitários de saúde. Os participantes avaliaram de forma positiva o trabalho dos médicos colaboradores cubanos destacando características como responsabilidade, postura ética e humanismo bem como a alta qualidade das consultas médicas e o bom relacionamento com os pares da atenção básica. CONCLUSÕES: Foram constatadas diferenças no padrão de atenção dos médicos colaboradores cubanos do Programa Mais Médicos em relação aos médicos brasileiros que atuavam nas comunidades estudadas antes da implantação do programa. Entre as características distintivas dos médicos cubanos destacadas estão o compromisso com os pacientes, tanto na consulta médica quanto na solução de problemas, a empatia, o respeito e o humanismo em geral com que eles tratam os pacientes.

Prevention of neural tube defects by the fortification of flour with folic acid: a population-based retrospective study in Brazil.

OBJECTIVE: To determine if the fortification of wheat and maize flours with iron and folic acid - which became mandatory in Brazil from June 2004 - is effective in the prevention of neural tube defects. METHODS: Using data from national information systems on births in central, south-eastern and southern Brazil, we determined the prevalence of neural tube defects among live births and stillbirths in a pre-fortification period - i.e. 2001-2004 - and in a post-fortification period - i.e. 2005-2014. We distinguished between anencephaly, encephalocele, meningocele, myelomeningocele and other forms of spina bifida. FINDINGS: There were 8554 neural tube defects for 17,925,729 live births notified between 2001 and 2014. For the same period, 2673 neural tube defects were reported for 194,858 stillbirths. The overall prevalence of neural tube defects fell from 0.79 per 1000 pre-fortification to 0.55 per 1000 post-fortification (prevalence ratio, PR: 1.43; 95% confidence interval, CI: 1.38-1.50). For stillbirths, prevalence fell from 17.74 per 1000 stillbirths pre-fortification to 11.70 per 1000 stillbirths post-fortification. The corresponding values among live births were 0.57 and 0.44, respectively. CONCLUSION: The introduction of the mandatory fortification of flour with iron and folic acid in Brazil was followed by a significant reduction in the prevalence of neural tube defects in our study area.

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.

Protective effect of breastfeeding against overweight can be detected as early as the second year of life: a study of children from one of the most socially-deprived areas of Brazil.

Millions of children live in Brazil's semi-arid region, one of the most socially-deprived areas of the country, where undernutrition co-exists with obesity as a consequence of the nutrition transition. There is evidence that childhood obesity predisposes adult obesity and, thus, that obesity should be prevented as early as possible. Some studies have shown that breastfeeding is a protective factor against overweight and obesity while other studies have not found this association. There have been few studies on this association in developing countries and of children below two years of age. The present study aimed to investigate whether children exposed to exclusive breastfeeding for ≥ 6 months showed a lower prevalence of overweight in the second year of life, based on a probability sample of 2,209 children (aged 12 to 24 months). The dependent variable was overweight, defined as weight-for-length z-scores of >2, based on the WHO 2006 standard while the independent variable was exclusive breastfeeding (≥ 6 months). The prevalence ratio (PR) and its 95% CI were estimated using Poisson regression with robust adjustment of variance. After adjusting for potential confounding factors (socioeconomic, demographic and health-related variables), children on exclusive breastfeeding for ≥ 6 months showed a lower prevalence of overweight (5.7% vs 9.1%, PR 0.62, 95% CI 0.45-0.89). It was found that exclusive breastfeeding for six months or more is a protective factor against overweight in children in the second year of life living in the Brazilian semi-arid region.

Maternal near miss among women using the public health system in the Amazon and Northeast regions of Brazil.

OBJECTIVE: To assess the prevalence of pregnancy complications identified as maternal near miss (MNM) and associated factors among women using the public health care system in the Amazon and Northeast regions of Brazil. METHODS: A secondary analysis of a population-based survey conducted in 2010 was performed focusing on women self-reporting maternal complications. The main outcome was MNM, pragmatically defined as intensive care unit admission, eclampsia, hysterectomy, or blood transfusion. In addition, the risk of MNM was estimated for certain sociodemographics and characteristics of care received. Poisson regression was performed, generating adjusted prevalence ratios (PRadj) with 95% confidence intervals (95%CI). RESULTS: A total of 13 044 women (77%) who had given birth during the prior year using the public health system were interviewed. At least one complication was reported by 37.5%, with hemorrhage (28.4%) and infection (8.3%) being the most frequent. The overall MNM ratio was 31.5 per 1 000 live births, higher for the Amazon region than for the Northeast. Factors with a higher risk for developing MNM were: indigenous ethnicity (PRadj 2.77; 95% CI: 1.50-5.14), more than one hour to reach the hospital (PRadj 1.55; 95%CI: 1.06-2.25), being refused by a full hospital and having to find another one (PRadj 1.49; 95%CI: 1.03-2.16), cesarean section (PRadj 2.56; 95%CI: 1.90-3.44), and public prenatal care (PRadj 1.95; 95%CI: 1.06-3.61). CONCLUSIONS: Users of public health system in the Amazon and Northeast regions of Brazil have high MNM rates. Some characteristics of the women and of the care they received represent inequalities associated with higher risk for MNM. Specific actions are required to improve maternal health programs in these expansive areas of the country.

Folic acid intake by pregnant women from Vale do Jequitinhonha, Brazil, and the contribution of fortified foods.

The folate deficiency can result in irreversible health damage, such as the neural tube defects. The aim of this article is to determine the folate intake of pregnant women in Vale do Jequitinhonha, Minas Gerais state, Brazil, one of the poorest regions in the world. A descriptive, cross-sectional study was done in 2013 with 492 pregnant women attending the basic health units run by the public health service (Sistema Único de Saúde, SUS) in 15 municipalities. A standard questionnaire was used to gather the data, which included socioeconomic indicators and a food frequency questionnaire. The data were analyzed and compared statistically based on prevalence ratios and 95% confidence intervals. The prevalence of inadequate folate intake was associated with some socioeconomic factors: it was higher amongst the low income and less educated women, in younger women and those who had fewer meals per day. The prevalence of inadequate folate intake in the diet was 94.7% when the contribution of food fortification was not considered, 49.2% taking into account fortified foods, and 17.1% considering food folate, fortified foods, and supplementation with folic acid. We conclude that fortifying foods with folic acid at the current levels reduces the inadequacy of folate intake in the diet, but not enough to assure safe levels and to meet the nutritional requirements of pregnant women in Brazil.

Prevented cases of neural tube defects and cost savings after folic acid fortification of flour in Brazil.

Anencephaly, encephalocele, and spina bifida are congenital neural tube defects and are the main causes of neonatal morbidity and mortality and impose a heavy economic burden on health systems. This study to estimates the direct costs of neural tube defects from the perspective of the Brazilian Ministry of Health, and the prevented cases and cost savings during the period in which mandatory folic acid fortification was in effect in the country (2010-2019). It is a top-down cost-of-illness oriented study based on the prevalence of the disorders in Brazil. Data were collected from the Brazilian Ministry of Health's outpatient and hospital information system databases. The direct cost was estimated from the total patient-years, allocated by age and type of disorder. Prevented cases and cost savings were determined by the difference in the prevalence of the disorders in the pre- and post-fortification periods based on the total number of births and the sum of outpatient and hospital costs during the period. The total cost of outpatient and hospital services for these disorders totaled R$ 92,530,810.63 (Int$ 40,565,896.81) in 10 years; spina bifida accounted for 84.92% of the total cost. Hospital costs were expressive of all three disorders in the first year of the patient's life. Between 2010 and 2019, mandatory folic acid fortification prevented 3,499 live births with neural tube defects and resulted in R$ 20,381,586.40 (Int$ 8,935,373.25) in hospital and outpatient cost savings. Flour fortification has proved to be a valuable strategy in preventing pregnancies with neural tube defects. Since its implementation, there has been a 30% decrease in the prevalence of neural tube defects and a 22.81% decrease associated in hospital and outpatient costs.

Research on chronic noncommunicable diseases in Brazil: meeting the challenges of epidemiologic transition.

In Brazil, chronic noncommunicable diseases (CNCDs) are the leading cause of death and a major contributor to the national disease burden. This article describes CNCD research funded by the Ministry of Health Department of Science and Technology (DECIT) to support the production and dissemination of scientific evidence for the national health system, in accordance with the National Agenda of Priorities in Health Research, and within the context of Brazil's epidemiologic transition. Data were obtained from Ministry of Health database management systems. CNCD-related projects financed by DECIT from 2002 to 2009 were analyzed by research theme (cancer, obesity, hypertension, diabetes, cardiovascular diseases, CNCDs in general, and CNCD risk factors) and geographic region. In terms of funding and number of projects, the most-supported research theme was cancer, and the most-supported region was the Southeast. Project type varied widely, ranging from basic scientific studies to highly technological research and development. Results obtained included epidemiologic profiles and surveillance, cost, and quality-of-life data.

Mortality in children under five years old in Brazil: evolution from 2017 to 2020 and the influence of COVID-19 in 2020.

OBJECTIVE: To analyse the mortality trends in children under five years old in Brazil from 2017 to 2020 and the influence of COVID-19 in 2020. METHODS: A retrospective study employing secondary data from the Brazilian Mortality Information System. Deaths according to cause were extracted and disaggregated into early, late, postneonatal, and 1 to 4-year-old periods. Corrected mortality rates per 1,000 live births and relative risk ratio for the cause of death were calculated. RESULTS: There were 34,070 deaths, being 417 (1.2%) from COVID-19 in 2020. COVID-19 mortality was 0.17 per 1000 live births, reaching 0.006 in the early neonatal period, 0.007 in the late neonatal, 0.09 in the postneonatal, and 0.06 in 1 to 4-year-old. Mortality decreased mostly for some diseases that originated in the perinatal period, congenital anomalies, diseases of the respiratory system and external causes, in this order. In 2020, the highest rate was in the early neonatal period, with a fall from 7.2 to 6.5, followed by the postneonatal (3.9 to 3.4) and late neonatal (2.3 to 2.1). Among children aged 1 to 4-year-old, external causes had the highest proportional rate, and diseases of the respiratory system showed the highest decline. CONCLUSION: The mortality rate declined from 2017 to 2020, and this variation was higher in the early neonatal period. The risk of death from COVID-19 was 14 times higher in the postneonatal period and 10 times higher in children aged 1 to 4 year-old compared to the early neonatal period.

Covid-19: temporal evolution and immunization in the three epidemiological waves, Brazil, 2020-2022.

OBJECTIVE: Describe the temporal evolution of morbimortality due to Covid-19 and vaccination coverage during the health emergency in Brazil. METHODS: Number of cases and deaths due to Covid-19 were extracted from the public panel of the Brazilian Ministry of Health, according to epidemiological week (EW) and geographic region. Data on vaccines and variants were obtained, respectively, from the Information System of the National Immunization Program and the Genomic Surveillance System of SARS-CoV-2. RESULTS: Three peaks of deaths characterized the evolution of the Covid-19 pandemic: in EW 30 of 2020, in the EW 14 of 2021 and in the EW six of 2022; three case waves, starting in the North and Northeast regions, with higher rates in the third wave, mainly in the South region. Vaccination started in the epidemiological week three of 2021, rapidly reaching most of the population, particularly in the Southeast and South regions, coinciding with a reduction exclusively in the mortality rate in the third wave. Only from the beginning of the second wave, when Gama was the dominant variant, 146,718 genomes were sequenced. From the last EW of 2021, with vaccination coverage already approaching 70%, the Omicron variant caused an avalanche of cases, but with fewer deaths. CONCLUSIONS: We noticed the presence of three waves of Covid-19, as well as the effect of immunization on the reduction of mortality in the second and third waves, attributed to the Delta and Omicron variants, respectively. However, the reduction of morbidity, which peaked in the third wave during the domination of the Omicron variant, remained the same. The national and centralized command of the pandemic confrontation did not occur; thus, public administrators took the lead in their territories. The overwhelming effect of the pandemic could have been minimized, if there had been a coordinated participation of three spheres of the Brazilian Unified Health System administration, in the joint governance of the pandemic fight.

Development of an Index to Assess COVID-19 Hospital Care Installed Capacity in the 450 Brazilian Health Regions.

OBJECTIVE: The article seeks to assess the Brazilian health system ability to respond to the challenges imposed by the coronavirus disease 2019 (COVID-19) pandemic by measuring the capacity of Brazilian hospitals to care for COVID-19 cases in the 450 Health Regions of the country during the year 2020. Hospital capacity refers to the availability of hospital beds, equipment, and human resources. METHODS: We used longitudinal data from the National Register of Health Facilities (CNES) regarding the availability of resources necessary to care for patients with COVID-19 in inpatient facilities (public or private) from January to December 2020. Among the assessed resources are health professionals (certified nursing assistants, nurses, physical therapists, and doctors), hospital beds (clinical, intermediate care, and intensive care units), and medical equipment (computed tomography scanners, defibrillators, electrocardiograph monitors, ventilators, and resuscitators). In addition to conducting a descriptive analysis of absolute and relative data (per 10,000 users), a synthetic indicator named Installed Capacity Index (ICI) was calculated using the multivariate principal component analysis technique to assess hospital capacity. The indicator was further stratified into value ranges to understand its evolution. RESULTS: There was an increase in all selected indicators between January and December 2020. It was possible to observe differences between the Northeast and North regions and the other regions of the country; most Health Regions presented low ICI. The ICI increased between the beginning and the end of 2020, but this evolution differed among Health Regions. The average increase in the ICI was more evident in the groups that already had considerably high baseline capacity in January 2020. CONCLUSIONS: It was possible to identify inequalities in the hospital capacity to care for patients affected by COVID -19 in the Health Regions of Brazil, with a concentration of low index values in the Northeast and North of the country. As the indicator increased throughout the year 2020, inequalities were also observed. The information here provided may be used by health authorities, providers, and managers in planning and adjusting for future COVID-19 care and in dimensioning the adequate supply of hospital beds, health-care professionals, and devices in Health Regions to reduce associated morbidity and mortality. We recommend that the ICI continue to be calculated in the coming months of the pandemic to monitor the capacity in the country's Health Regions.