Transcript Slide 1

Community Health Workers: the PHC
backbone in Brazil
Raphael Aguiar
Community Care Workers Symposium
“Exploring Alternatives”
Johannesburg, 20th,30th April and 1st May 2010
Basic Facts about Brazil
• 53% of South America
• Population:190,000,000
• States: 26 + 1 Federal
District
• Municipalities: 5,563
• 40% of the population in
metropolitan areas
• Multiple Contexts
Brazilian National Health System
 Health as a political issue and a universal right
(since 1988)
 The National Health System benchmarks are:
 Universality
 Equity
 Comprehensiveness
 Decentralization
 Empowerment and social accountability
OUR MAIN HEALTH ISSUES:
• Chronic
diseases: Hypertension, diabetes...
• Cancer
• External Injuries (Violence, car accidents etc)
• Social
inequalities
Some information about HIV/AIDS in Brazil
• HIV prevalence in the 15 to 49 age group in 2008: 0.61%
(females: 0.41%, and males: 0.82%)
• Mother‐to‐child transmission rate: 8.5% (2004)
• AIDS incidence rate: 18.2 per 100,000 inhabitants (2008)
• AIDS mortality coefficient: 6.1 per 100,000 inhabitants
(2008)
Source:
http://data.unaids.org/pub/Report/2010/brazil_2010_country_progress_report_en.pdf
Some governamental actions regarding
HIV/AIDS:
• 466.5 million condoms were distributed in 2009;
• 2.06 million female condoms were distributed in 2009;
• 2.17 million units of lubricant gel were distributed in
2009;
• Massive campaigns on radio, newspapers and TV;
• Some general counselling activities usually take place in
PHC facilities.
Source:
http://data.unaids.org/pub/Report/2010/brazil_2010_country_progress_report_en.pdf
Basic facts about Brazilian
Community Health Agents
 The modern community health agent came up in
1991, in a poor Brazilian state (Ceará)
 Objectives: to reduce infant mortality and to provide
some income to local families
 Their work (based on simple actions) decreased
infant mortality up to 30% in some areas
 This outcome contributed to their definitive insertion
in the National Health System as a national cadre
Basic facts about Brazilian
Community Health Agents
 Their success stimulated the expansion of the
CHA's program in other states;
 In 1994 the “Familiy Health” program (a kind of
upgrade) was launched based on those outcomes;
 Since then, CHA's have been steadily incorporated
to Family Health teams. In 2002, the profession
was recognized by a federal law
 This law establishes minimum requirements for
becoming a CHA as well as their scope of practice
Basic facts about Brazilian Family
Health Teams
a) They are usually composed by:
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A physician ;
A registered nurse
1-2 nursing assistants
4-6 CHA’s
 Many teams have also a dentist and 1-2 dentistry
technicians (Oral health team)
b) Each team is responsible for delivering health care to
about 4,000 citizens
Basic facts about Brazilian Family
Health Teams
c) Each PHC facility may have1-4 Family Health Teams
depending on its size and population.
d) Since 2006 many Family Health Teams are being
assisted by a multidisciplinary health team
(physioterapists, psychologists, nutritionists etc)
Number of CHA's in Brazil – 1994 / 2009
Number of FH teams in Brazil – 1994 / 2009
PHC rate coverage
% of the population covered by health family teams – Brazil, 1998 –2009
1998
2004
0%
0 a 25%
2002
2000
25 a 50%
FONTE: SIAB - Sistema de Informação da Atenção Básica
2000
2006
50 a 75%
75 a 100%
2009
PHC scenario in Brazil (2009)
As of March 2010...
There were 236,399 CHA’s
and
30,782 Family Health Teams in Brazil
There are only 86 municipalities with CHA’s and no
Family Health Teams
PHC plays a major role in social equity (BLUMENTHAL, 1995;
SHI et al., 2003; STARFIELD et al., 2005)
In Brazil, Family Health Teams
use to be first implemented
in most vulnerable areas.
What are the requirements to become a CHA?
As of 2009, a Brazilian CHA must:
a) Have at least 18 years old;
b) Have concluded primary school;
c) Have leadership skills and awareness of their reality;
d) Live in the area they will serve by the time of selection;
e) Be trained after being hired.
CHA Training
• Before professionalization: in-service supervision and
short term courses offered by regional joint initiatives
composed by universities and regional health schools;
• After professionalization (2002):
-They are trained mainly by the Technical Schools of the
National Health System;
-Once they are hired they receive:
- Introductory Training (80 hours);
- CHW Training Course (400 hours) - financed
by the MoH
CHA Training
• The CHW Training Course is part of a complete
professionalizing course (1200 working hours) offered
by technical schools of National Health System;
• Although it is not mandatory, concluding this course
is highly desirable;
• However, there are no incentives to conclude it.
• Since 2005, 127,701 CHW have conclude the
mandatory part
CHA Recruitment and supervision
• Municipalities are in charge of selecting and hiring
CHA as well as the entire Family Health Team
• Their activities are supervised by the professionals
with higher education (physicians and nurses).
Scope of practices
a) General actions aiming disease prevention and health
promotion, including counseling activities (major role in
treatment adherence as well as in “translating”medical
Recommendations);
b) Monthly visits to user's houses to follow up and assess
risk situations;
c) Fulfillment of questionnaires for social and demographic
Analysis;
Scope of practices
d) Fulfillment of records regarding births, deaths, illnesses and
other relevant situations (only for planning purposes)
e) Promotion of social accountability and citizens' participation
on health policies;
f) Engagement in local, intersectoral actions
Important: a Brazilian CHA is not
allowed to perform any direct
Procedures in patients
Evidences of effectiveness
Observation: all the studies take into
consideration the entire PHC team
rather than only CHA’s.
Evidences of effectiveness
Chronic diseases
Evidences of effectiveness
General decrease in Hospital
admissions in Brazil (2000/2005)
a) By conditions which may be influenced by
PHC: 15,8%
b) By conditions which are not influenced by
PHC: 10,1%
(Alfradique et al., 2009)
Evidences of effectiveness
Hypertension Control:
A comparison before and after the
establishment of a FH team in a health
facility has shown that 56% of its
patients with hypertension had their
BP controlled in six months (Lemos et
al., 2006)
Evidences of effectiveness
Hospital admissions by stroke (per 100,000, more than 40
yrs) according to PHC coverage rate - 1998-2004.
(Ministry of Health, 2006)
Evidences of effectiveness
Decrease in hospital admissions by stroke (per 100,000,
more than 40 yrs) according to PHC coverage rate - 19982003.
(Ministry of Health, 2006)
Evidences of effectiveness
a) Home care for elders in need:
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In conventional units: 2,9%
In FHT units: 13,3% (p<0,05) (Facchini et al, 2006)
b)
Consultancies for adults with
hypertension in the last 6 months:
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In conventional units: 31,4%
In FHT units: 46,5% (p<0,05) (Facchini et al, 2006)
Evidences of effectiveness
c) Consultancies for elders with hypertension
in the last 6 months:
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In conventional units: 34,9%
In FHT units: 52,6% (p<0,05) (Facchini et al, 2006)
Evidences of effectiveness
d) Consultancies for adults with Diabetes Mellitus
in the last 6 months:
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In conventional units: 39,3%
In FHT units: 57,6% (p<0,05) (Facchini et al, 2006)
e)
Consultancies for elders with Diabetes Mellitus
in the last 6 months:
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In conventional units: 38,8%
In FHT units: 52,7% (p<0,05) (Facchini et al, 2006)
Thank you