Transcript Slide 1

Family Health
The Primary Health Care (APS)
Strategy in Brazil
Luis Fernando Rolim Sampaio, MD, MPH
National Director of Primary Care
Tegucigalpa, Honduras – November, 2006
RIO DE JANEIRO
BRAZIL
An unequal country
Per capita income by municipalities, 2000
Per Capita Income, 2000
All municipalities in Brazil
Histogram
Legend
Infant mortality < 1 year by municipality - 2000
Mortality up to one year of age, 2000
All municipalities in Brazil
Histogram
Legend
An unequal country that
chose a universal, integrated
and publicly financed health
system: The construction of
the Brazilian Unified Health
System- SUS
Started with the community agents program in 1991
Reinforced by primary care and the creation of the
Family Health Program - PSF - in Brazil in 1993
National efforts for the universalization of access,
without out-of-pocket expenses,
for the entire population
The search for compatibility and integration and
the creation of health care networks
based on primary care
Six basic points for change in PHC
1 – Definition of the national primary care team and the
essential functions to be integrated into the service network
2 – Definition of the role of responsibilities of each
governmental sphere within PHC management
3 – Changes in financing and in the growth in resources
budgeted for primary care
4 – Creation of monitoring and evaluation systems
5 – Articulation with training centers
6 – Achievements and creation of a political space for PHC
DEFINITION OF THE
NATIONAL PRIMARY CARE
TEAM AND ITS ESSENTIAL
FUNCTIONS
Definition of the national primary care team
and its essential functions
What is the primary care team?
It is a team responsible for a territory of 800 to 1,000
families – up to 4,000 people, which includes:
- Generalist physician (or specialist in family medicine)
- Nurse or nursing assistant
- Community health agent
- Odontologist and dental hygienist
- Others – to be defined by the municipalities
Definition of the national primary care team
and its essential functions
What does the primary care team do?
They should monitor and evaluate the health situation of
the population, provide primary care services, and make
referrals to other levels of the system if necessary;
They should understand the social process in their
territory, be proactive in the community and have cultural
competence;
They should work together on clinical, public health and
health promotion activities and on the prevention of
health hazards.
Definition of the national primary care team
and its essential functions
How does the primary care team work?
Everyone should work 40 hours per week (at the
beginning, they would not be able to have another job);
Professionals receive differentiated salaries (the doctor is
paid as if working in two or three jobs);
They will not receive anything for the provision of
services (they have to work the required hours);
The form of contracting is different in each municipality.
Definition of the national primary care team
and its essential functions
What is the community health agent?
•They are people that live in the same area where they work;
•They should have good knowledge of the community’s problems;
•They should be capable of connecting the professional team to the
community (cultural competency);
•They work with a focus on health promotion and are not diseaseoriented;
•They are community leaders;
•They are essential team members
RESPONSIBILITIES OF THE
MANAGEMENT SPHERES IN
PRIMARY CARE
Federal Responsibility
Develop the guidelines for national primary health care policy –
2006 strategic areas (women’s health, child health, older adult
health, AH/DM, TBC, Hansen, oral health and elimination of child
malnutrition)
Co-finance the primary care system
Manage human resource training
Propose mechanisms for the programming, control, regulation
and evaluation of primary care
Monitor and evaluate national indicators
State/Provincial Responsibility
Accompany the introduction and implementation of
primary care activities in their territory
Regulate inter-municipal relationships
Coordinate the implementation of policies for the
qualification of human resources in their territory
Co-finance primary care activities
Support the implementation of strategies for
evaluating primary care in their territory.
Municipal Responsibility
Define and implement the primary care model in their
territory
Regulate the work contract related to primary care
Maintain the network of basic health units in operation
(management and stewardship)
Co-finance primary health care activities
Contribute to national information systems
Evaluate the performance of the primary health care
teams under their supervision.
CHANGES IN THE FINANCING AND
ALLOCATION OF RESOURCES
FOR PRIMARY CARE
The creation of the Basic Care Ceiling –
PAB (Piso de Atenção Básica, a budget
"floor" for basic health care)– a national
per capita for all municipalities
The institution of an incentive for the
PSF: an adjustable PAB and equity
incentives (HDI < 0.700 = 50% higher
budget)
Financing of Health in the SUS
Responsibility of the three management spheres
Constitutional Amendment 29 - 15% of the municipal
budget, 12% of the states’ budgets, in addition to
spending by the Federal union, starting in 2000, and
increasing each year according to GDP growth.
Federal Budgets transferred from the national fund to
municipal funds through the fixed PAB and adjustable
PAB – PSF . There will be no destination other than
primary health care activities.
Evolution of federal budgets
Fixed and adjustable PAB
6 ,0 0 0
4 ,0 0 0
2 ,0 0 0
0
2000
2001
2002
2003
2004
2005 2006*
A djus t a ble *
6 5 1.9
8 9 8 .9 1,2 7 0 . 1,6 6 2 . 2 ,19 1. 2 ,6 7 9 . 3 ,2 4 8 .
F ixe d
1,5 6 2 . 1,7 4 4 . 1,7 6 6 . 1,9 0 2 . 2 ,13 4 . 2 ,3 3 5 . 2 ,4 7 0 .
Per capita distribution of Financial Resources
for Primary Care in reales/inhab/year
BRAZIL – 1998 and 2005
1998
up to 20
from 20 to 40
from 40 to 60
from 60 to 80
more than 80
SOURCE: DATASUS
2005
Family Health Strategy
Evolution of the Introduction of Family Health Teams
- BRAZIL, 1998/2005
0%
1998
1999
2000
2001
2002
2003
2004
2005*
0 to 25% 25 to 50%
50 to 75% 75 to 100%
SOURCE: Primary Care Information System - SIAB
(*)
Agosto/2005.
Family Health Teams (ESF), Community Health Agents (ACS)
and Oral Health Teams (SB)
BRAZIL, SEPTEMBER/2006
No. of Teams – 26,650
No. of Municipalities - 5,087
No. of Agents – 218,121
No. of Municipalities - 5,288
No. of Oral Health Teams – 14,597
No. of Municipalities – 4,189
ESF/ACS/SB
ESF/ACS
ACS
SEM ESF, ACS E ESB
SOURCE: Primary Care Information System - SIAB
Achievements of the Brazilian
PHC strategy
Family Health Program
•PHC on the political agenda of public managers;
•Expansion of access and coverage;
•Academic studies in progress and institutionalization of
evaluation;
•Improvement in selected indicators from 1998-2004, with an
increase in equity;
•User satisfaction;
•Changes in the practices of the health teams;
•Professional qualifications (medical and multi-professional
residencies and specializations in Family Health);
10% growth in coverage – 4.6% decline in infant
mortality (1992-2002);
This study is a longitudinal ecological analysis using panel data from
secondary sources. Analyses controlled for state-level measures of
access to clean water and sanitation, average income, women’s literacy
and fertility, physicians and nurses per 10,000 population, and hospital
beds per 1,000 population. Additional analyses controlled for
immunization coverage and tested interactions between the Family
Health Program and proportionate mortality from diarrhea and acute
respiratory infections.
Setting: 13 years (1990-2002) of data from 27 Brazilian States
Family Health Program in Brazil
Analysis of selected health indicators
1998-2004
Prof. Alice Teles de Carvalho
February 2006
Decrease in gaps
Figure.: Evolution
of cobertura
PSF coverage
in nos
municipalities
Figura
Evolução da
do PSF
municípios
grouped according to the HDI. Brazil, 1998-2005
agrupados segundo IDH. Brasil,1998-2005
90,00
%
70,00
50,00
30,00
10,00
-10,00
1998
1999
Low
Baixo
2000
2001
2002
Intermediate
Intermediário
2003
High
Alto
2004
2005
P roporção
de óbitos
por causas
ma l according
definida sto
Proportion
of infant
deathsinfanti
due to lundefined
causes,
coverage
stratum. Brazil,
1998/2004
se gundo PSF
estrato
de cobertura
do PSF.
Brasil 1998/2004
30,00
%
25,00
20,00
15,00
10,00
5,00
0,00
1998
1999
2000
2001
2002
2003
2004
YEARS
ANOS
< 20%
20 |-- 50%
50 |-- 70%
>=70%
Brazil
B rasil
Average
annualanua
decline
in pr
theoporç
proportion
of infant
deaths
due to
undefined
Dec línio
m édio
l da
ão de
óbitos
infa ntil
por
causas
causes,
according
to
PSF
coverage
stratum.
Brazil,
1998/2004
m al de finida s segundo estrat o de c obert ura do PSF. Bras il
1998 /2004
14 ,10
1 5,00
10,38
1 0,00
6,06
%
5,00
2,33
0,00
< 2 0%
20 |-- 50%
50 |-- 70 %
Source: Mortality Information System - SIM and Live Birth Information System - SINASC
>=70 %
Post
infant infantil
mortalitypos
rate,neonatal
accordingsegundo
to
Taxa
de neonatal
mortalidade
PSF coverage stratum. Brazil, 1998/2004
estrato de cobertura do PSF. Brasil 1998/2004
15,00
10,00
5,00
0,00
1998
1999
2000
2001
2002
2003
2004
YEARS
ANOS
< 20%
20 |-- 50%
50 |-- 70%
>=70%
Brazil
Brasil
Decline anual
in the post
infant
mortality rate,
according
to neonatal
Declínio médio
da neonatal
Taxa de
mortalidade
infantil
pósPSF coverage
stratum. Brazil,
1998/2004
segundo estrato
de cobertura
do PSF.
Brasil 1998/2004
0,00
%
-5,00
4,836,418,15-
8,61-
-10,00
< 20%
Source: SIM and SINASC
20 |-- 50%
50 |-- 70%
>=70%
Average annual variation in the Infant mortality rate, according to PSF
coverage stratum in municipalities with a low HDI. Brazil 1998-2003
5.00
4.87-
3.51
3.87
50 |-- 70%
>=70%
1.90
% 0.00
-5.00
< 20%
20 |-- 50%
Proportion
of livevivos
births
mothers
no prenatal
Proporção
de nascidos
detomães
comwith
nenhuma
consulta de
controls,
according
to PSF
coverage do
stratum.
pré-natal,
segundo
de cobertura
PSF. Brasil
Taxas* de
internação
por estratos
desnutrição
em
crianças
de até 1 ano
Brazil,
1998/2004
1998/2004
idade, 2002 a 2005, Brasil e regiões (por 1000)
de
12,00
%
9,00
6,00
Taxas de internação
3,00
0,00
Ano
Brasil
1998
1999
Norte
2000
2001 Sudeste2002
Nordeste
Sul
2003
2004
Centro
Oeste
YEARS
ANOS
2002
2003
2,99
2,52
2,38
2,49
4,21
< 20%
20 |-- decline
50%
50
|-- 70%de nascidos
>=70%
Brasil 2,17
Average
annual
inProporção
the
proportion
of live
births
Declínio
médio
anual da
vivos to
demothers
mães
com
consulta according
de pré-natal,
segundo
estratos
de
with
no nenhuma
prenatal controls,
to PSF
coverage
stratum.
coberturaBrazil,
do PSF.
Brasil, 1998/2004
1998/2004
3,08
2,87
2,40
2,36
4,21
3,18
0,00
2004
2,41
% -10,00
2,67
8,62-
3,01
1,90
1,86-20,00
1,74
< 20%
2,65
11,4315,32-
2005
2,05
2,20
20 |-- 50%
1,62
50 |-- 70%
17,96-
1,60
>=70%
2,15
Homogeneity
of tetravalent
vaccinationvacinal
coverage
in infants
under 1em
year
Homogeneidade
de cobertura
por
tetravalente
of age, according
PSF
coverage
stratum.
Brazil,de
1998/2005
menores
de 1 anotode
idade,
segundo
estrato
cobertura
do PSF. Brasil 1998/2005
70,00
%
60,00
50,00
40,00
30,00
1998
1999
2000
2001
2002
2003
2004
YEARS
ANOS
< 20%
20 |-- 50%
50 |-- 70%
>=70%
Brasil
Average annual
increase
theHomogeneidade
homogeneity of tetravalent
vaccination
coverage
Aumento
médio
anualinda
de cobertura
vacinal
por
tetravalente
emofmenores
de 1toano
idade,
segundo
estrato
in infants
under 1 year
age, according
PSFde
coverage
stratum.
Brazil,
1998/2005
de cobertura do PSF.
Brasil 1998/2005
8,58
10,00
%
5,00
3,89
3,91
4,94
0,00
< 20%
20 |-- 50%
50 |-- 70%
>=70%
2005
Prevalence of exclusive m aternal breastfeeding in children up to 4 m onths of age
and protein-caloric m alnutrition* in children under 1 year of age,
in areas covered by the Fam ily Health Strategy, Brazil, 1999 - 2005**.
%
80
65.8 67.2 69.5
70
60
57.4 60.8
70.9
63.3
50
40
30
20
10 . 1
10
8.1
7.0
6.1
4.8
3.6
2.9
% of children up to 4 m onths
w ith exclusive m aternal
breastfeeding
1999
2000
2001
% of children under 1 year w ho
are m alnourished
2002
2003
2004
F o n t e : S i sPrimary
t e m a d e I Care
n f o r m aInformation
ç ã o d a A t e n ç ãSystem
o B á s i c a -- SIAB
S I A B - -B Clean
a s e l i m pdatabase
a
Source:
* C r i a n ç a c u j o p e s o f i c o u a b a i x o d o p e r c e n t i l 3 ( c u r v a i n f e r i o r ) d a c u r v a d e p e s o p o r i d a d e d o C a d e r n e t a d e Sa ú d e d a C r i a n ç a .
** *Child
whose weight remained under percentile 3 (inferior curve) on the weight-forD a d o s a t é o o mê s 1 1 / 2 0 0 5 . Su j e i t o à mo d i f i c a ç õ e s .
age curve of the Child Care Card.
**Data through 11/2005. Subject to modifications.
2005
Family Health Program and Family
Grant (Bolsa Família) –
inter-sectoral action
Hospitalization rates* due to malnutrition in children up to 1
year of age, 2002 to 2005, Brazil and regions (per 1,000)
Year
Hospitalization rates
Brazil
North
N. east
S. east
South
Central West
2002
2.99
2.52
4.21
2.38
2.49
2.17
2003
3.08
2.87
4.21
2.40
2.36
3.18
2004
2.41
2.67
3.01
1.90
2.05
2.65
2005
1.86
1.74
2.20
1.62
1.60
2.15
5
4
BRAZIL
Northe as t
3
North
South
2
Southe as t
Ce ntral-We s t
1
0
2002
2003
2004
2005
CHALLENGES
CHALLENGES
Qualification following the growth of Family Health –
alliances with universities, organizations;
Search for health care that is integrated (guaranteed referral
to other services) and comprehensive (promotion, prevention
and care)
Financial and political sustainability and commitment to PHC
in the health system;
Labor relations of professionals – precarization X worker
rights;
Strengthening of the PHC Indicators Pact.
CHALLENGES
Social appreciation for the family doctor and primary care
doctor;
Resistance by professional unions and associations to the
change;
Large cities (violence) and remote places (cultural
differences);
Social control and community participation;
Evaluation for quality improvement – AMQ and the program
for managing results – PROGRAB;
The responsibility and commitment of public managers.
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