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Family Health The Primary Health Care (APS) Strategy in Brazil

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

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Family Health The Primary Health Care (APS) Strategy in Brazil

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  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

  2. RIO DE JANEIRO

  3. BRAZIL An unequal country

  4. Per capita income by municipalities, 2000 Per Capita Income, 2000 All municipalities in Brazil Histogram Legend

  5. Infant mortality < 1 year by municipality - 2000 Mortality up to one year of age, 2000 All municipalities in Brazil Histogram Legend

  6. An unequal country that chose a universal, integrated and publicly financed health system: The construction of the Brazilian Unified Health System- SUS

  7. 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

  8. 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

  9. DEFINITION OF THE NATIONAL PRIMARY CARE TEAM AND ITS ESSENTIAL FUNCTIONS

  10. 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

  11. 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.

  12. 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.

  13. 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 disease-oriented; • They are community leaders; • They are essential team members

  14. RESPONSIBILITIES OF THE MANAGEMENT SPHERES IN PRIMARY CARE

  15. 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

  16. 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.

  17. 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.

  18. CHANGES IN THE FINANCING AND ALLOCATION OF RESOURCES FOR PRIMARY CARE

  19. 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)

  20. 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.

  21. Evolution of federal budgets Fixed and adjustable PAB

  22. Per capita distribution of Financial Resources for Primary Care in reales/inhab/year BRAZIL – 1998 and 2005 1998 2005 up to 20 from 20 to 40 from 40 to 60 from 60 to 80 more than 80 SOURCE: DATASUS

  23. Family Health Strategy

  24. 1998 1999 2000 2001 2003 2004 2005* Evolution of the Introduction of Family Health Teams - BRAZIL, 1998/2005 (*) Agosto/2005. 0% 0 to 25% 25 to 50% 50 to 75% 75 to 100% SOURCE: Primary Care Information System - SIAB

  25. 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

  26. Achievements of the Brazilian PHC strategy • Family Health Program

  27. 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);

  28. 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

  29. Family Health Program in Brazil • Analysis of selected health indicators 1998-2004 • Prof. Alice Teles de Carvalho • February 2006

  30. Decrease in gaps Figure. Evolution of PSF coverage in municipalities grouped according to the HDI. Brazil, 1998-2005 Low Intermediate High

  31. Proportion of infant deaths due to undefined causes, according to PSF coverage stratum. Brazil, 1998/2004 YEARS Brazil Average annual decline in the proportion of infant deaths due to undefined causes, according to PSF coverage stratum. Brazil, 1998/2004 Source: Mortality Information System - SIM and Live Birth Information System - SINASC

  32. Post neonatal infant mortality rate, according to PSF coverage stratum. Brazil, 1998/2004 YEARS Brazil Decline in the post neonatal infant mortality rate, according to PSF coverage stratum. Brazil, 1998/2004 Source: SIM and SINASC

  33. Taxas de internação Ano Brasil Norte Nordeste Sudeste Sul Centro Oeste 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 Proportion of live births to mothers with no prenatal controls, according to PSF coverage stratum. Brazil, 1998/2004 Taxas* de internação por desnutrição em crianças de até 1 ano de idade, 2002 a 2005, Brasil e regiões (por 1000) YEARS Average annual decline in the proportion of live births to mothers with no prenatal controls, according to PSF coverage stratum. Brazil, 1998/2004

  34. Homogeneity of tetravalent vaccination coverage in infants under 1 year of age, according to PSF coverage stratum. Brazil, 1998/2005 YEARS Average annual increase in the homogeneity of tetravalent vaccination coverage in infants under 1 year of age, according to PSF coverage stratum. Brazil, 1998/2005

  35. Source: Primary Care Information System - SIAB - Clean database * Child whose weight remained under percentile 3 (inferior curve) on the weight-for- age curve of the Child Care Card. **Data through 11/2005. Subject to modifications.

  36. Family Health Program and Family Grant (Bolsa Família) – inter-sectoral action

  37. Hospitalization rates Year 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 Hospitalization rates* due to malnutrition in children up to 1 year of age, 2002 to 2005, Brazil and regions (per 1,000)

  38. CHALLENGES

  39. 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.

  40. CHALLENGES Social appreciation for the family doctor and primary care doctor; Resistance by professionalunions 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.

  41. www.saude.gov.br/dab www.saude.gov.br/atencaobasica www.saude.gov.br/atencaoprimaria

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