Access In Brazil Research Articles

Geographic inequities in hemodialysis access: a call to reassess dialysis facility locations in Brazil.

Patients who travel more than 60 min to undergo hemodialysis may experience higher mortality and lower quality of life. The primary aim of this study was to calculate the travel distance between patient city areas and dialysis facility care locations in Brazil, to highlight barriers and need to optimize access to chronic dialysis. We conducted a retrospective cohort study using claims data from the Brazilian Public Health System's database, focusing on kidney replacement therapy (KRT) by hemodialysis. Our study population comprised all patients undergoing hemodialysis in Brazil between January 2023 and December 2023. For patients from different city areas, we calculated the Haversine distance between the patient city area and the dialysis facility. We evaluated 154,788 patients who received hemodialysis funded by the Brazilian Public Health System. Fifty-nine percent of the patients underwent dialysis in the same city area. Overall, patients traveled a median (IQR) distance of 35.9 [19.5 - 64.2] kilometers to the facilities, 48% traveled more than 40 km, with a maximum traveling distance of 353 km. Notably, the median distance traveled was shortest in the Southeast (27.6 km) and longest in the North (84.3 km). The number of patients that traveled more than 40 km was lower in the Southeast (32%) and higher in the North region (77%). The travel distance to the dialysis facility is an important inequity to KRT access in Brazil. In the South and Southeast, where there is a higher dialysis unit density, patients have greater regional availability of dialysis centers, and shorter traveling distances than in the North, Midwest, and Northeast regions.

Impact of Health Access on Hospitalization of Children and Youth with Cerebral Palsy and Paralytic Syndromes in Brazilian Regions.

In 2021, 28.16% of Brazilians were aged 0-19 years, highlighting the critical need for medical care in diagnosing and treating cerebral palsy (CP). In developing countries, CP prevalence reaches 7/1000 live births, emphasizing the importance of healthcare access, which influences diagnosis and prognosis. This study aimed to analyze the correlation between health infrastructure across different Brazilian regions and its impact on hospitalization and mortality rates among children with CP and other paralytic syndromes. An ecological time-series design was used, analyzing secondary population-based data from DATASUS, covering January 2018 to December 2021. The data included healthcare facilities, physicians, hospitalizations, and deaths for individuals aged 0-19 years, with analysis conducted using Microsoft Excel. The results revealed significant disparities in healthcare infrastructure, particularly in the northern and northeastern regions. A notable correlation was found between healthcare inequalities and hospitalizations and mortality rates, with the northern region showing significant results (p = 0.03 for hospitalizations and p = 0.02 for mortalities). This study underscores significant regional disparities in healthcare access in Brazil, contributing to variations in hospitalization rates for children and adolescents, especially in the northern region.

The European Union and United Kingdom's deforestation-free supply chains regulations: Implications for Brazil

This paper analyses the potential implications of the proposed European Union Deforestation Regulation (EUDR) and the recently adopted United Kingdom (UK) legislation on deforestation-free supply chains (henceforth ‘the legislation’) for different stakeholders in Brazil. These regulations intend to address global commodity-driven deforestation and forest degradation by ensuring that targeted commodities and products placed on (or exported from) markets are of minimal risk of being associated with - in the EU - deforestation and forest degradation or - in the UK - illegal deforestation. The paper examines potential compliance readiness in cattle, cocoa, coffee, palm oil, soybean and tropical timber supply chains in Brazil, indicating specific challenges that may arise. Through the construction of a “Compliance Likelihood Index”, our research provides comparable indications to policymakers on sectors and stakeholders that may need stronger support to meet the requirements, in order to maintain Brazil's access to EU and UK markets. The paper indicates that coffee is the sector with the highest level of incentivization and smallest hurdles for compliance, while the cattle sector may face stronger challenges to rapidly adjust its production system towards a deforestation-free value chain and prove compliance. Results of our analysis also highlight the need for collaboration between the EU/UK and Brazil in order to promote alignment between domestic and demand-side legislations so that they are mutually reinforcing. Results of this exercise, which has a focus on the producer-country view of demand-side legislation, will contribute to discussions on the merits of different approaches to strengthen the governance of deforestation-risk commodity trade.

P029 Cystic fibrosis precision treatment – an unequal access in Brazil

Introduction: There have been significant advancements in the treatment of cystic fibrosis (CF), particularly for people who are eligible for CFTR modulators drugs. However, there is an unequal access to these drugs worldwide. Currently, in Brazil, only Ivacaftor is approved in the public health system. The state of Bahia, located in the Northeast of Brazil, presents a highly admixture population. In spite of this the F508del CFTR variant is the most frequently identified in this population.

Protected areas still used to produce Brazil's cattle

AbstractCattle production inside Brazil's protected areas (PAs), including indigenous lands, continues to contaminate Amazonian supply chains more than a decade after efforts to reform the sector were launched with the signing of the zero‐deforestation cattle agreements (CAs). During 2013–2018, nearly 1.1 million cattle head were sold directly from private properties inside PAs to slaughterhouses in Mato Grosso, Pará, and Rondônia states. Another 2.2 million head were linked via indirect suppliers located in PAs. Most of these 3.3 million slaughtered head were originated in to sustainable‐use areas (72%), where cattle ranching may be permitted in certain cases; however, production also occurred in strictly protected units (20%) and indigenous lands (8%), where commercial grazing activities are illegal and prohibited by the CAs. Nearly half of the PA properties linked to cattle transactions from 2013 to 2018 also had deforestation. We estimate that approximately 2.8 million cattle head from properties in PAs were sold to slaughterhouses participating in the CAs (86% of the total cattle from indirect suppliers in PAs). Controlling commercial cattle production inside of PAs is crucial to both ensure Brazil's access to international beef markets and protect critical biodiversity regions in the Amazon rainforest.

Centralized Admissions, Affirmative Action, and Access of Low-Income Students to Higher Education

I analyze how two reforms, introduced to expand college access in Brazil, impacted enrollments of low-SES students. The first policy centralized applications in a nationwide platform (SISU), and the second expanded affirmative action quotas (AA) to a uniform share of 50 percent of vacancies offered by degree. Results show that SISU changes enrollment decisions of high-SES students, crowding out low-SES groups from the least competitive degrees disproportionately. In contrast, AA increases enrollments of low-SES individuals not only mechanically but also through behavioral responses. Finally, their interaction creates a complementary effect, protecting the low-SES groups from the crowding-out of centralization. (JEL I23, I24, I28, O15)

Infrastructure and income inequality: An application to the Brazilian case using hierarchical spatial autoregressive models

AbstractMany scholars have highlighted the role of infrastructure in reducing income inequality. Developing economies present immense regional and income discrepancies, which are correlated with unequally distributed infrastructure in territorial and population terms. In this paper, we assess the effects of infrastructure supply on income inequality and verify whether these effects vary according to the infrastructure sector and its degree of quality and access in Brazil. The analysis is based on spatial hierarchical models. Results allow us to say that infrastructure correlates negatively with income inequality. Hence, policies aimed at improving infrastructure quality and expanding access are crucial for reducing income concentration.

Lessons from the Brazilian radiotherapy expansion plan: A project database study

The Radiotherapy Expansion Plan for Brazil's Unified Health System (PER-SUS) was an innovative program designed by the Ministry of Health in 2012 to provide improvements to the challenging problem of access to radiotherapy in the country. This study sought to analyze the execution and implementation of installations proposed by PER-SUS, and their capacity to address the problems of radiotherapy access in Brazil. From the first release (February 2015) until October 2021, all PER-SUS monthly progress reports were retrospectively analyzed. The beneficiary institutions, project location, project status, project type, dates of the progress on the stages, and reasons for cancellations or possible justifications for changing the status were collected. Brazilian geographic data, health care demands, and cancer incidences were correlated. Finally, we performed an Ishikawa diagram and 5W3H methodology, aiming to better understand the findings and to yield possible ways to improve the access to radiotherapy. After ten years, the PER-SUS project delivered nearly 50% of the planned implementation of radiotherapy equipment. There was a 17% growth in the national number of linear accelerators (LINACS) with PER-SUS, against a 32% increase in cancer incidence in Brazil in the same period. The following points were identified: a high rate of beneficiary exclusions reflecting inappropriate selection or inadequate planning; delays in execution related to bureaucratic obstacles and underestimation of the requirements (logistics/people); early closing of the equipment factory as a result of lack of project prioritization by the Government. Only about 50% of PER-SUS are being carried out. However, delays and exclusions of beneficiaries were observed. The dimension of the need for radiotherapy care in Brazil is greater than considered, and might not be fully attended by PER-SUS. Geographic, epidemiological, logistical, and economic variables could be reevaluated to allow better strategic planning and improvement proposals. PER-SUS could be optimized for the next decade, by involving all stakeholders' participation, alignment, and engagement. In the future, the States and regions with a higher LINAC shortage should be prioritized to improve RT access across the country. Considering the data and the initial project deadline, PER-SUS did not achieve the pre-established goals specified by the Brazilian Government. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Time-to-treatment initiation for cutaneous melanoma reflects disparities in healthcare access in Brazil: a retrospective study

ObjectivesThis study aimed at identifying the sociodemographic and first treatment characteristics affecting time-to-treatment initiation (TTI) of patients with cutaneous melanoma assisted by the Brazilian Unified Health System (SUS). Study designRetrospective observational study using cutaneous melanoma cases recorded in the Brazilian Hospital-Based Cancer Registries (HBCR). MethodsA total of 12,783 cutaneous melanoma cases were included in the analysis. Based on the legislation, TTI in Brazil is 60 days; therefore, the cohort was dichotomized into TTI within 60 days and over. The association among variables was evaluated through the Chi-squared test. Kaplan–Meier method and log-rank hypothesis test were used to determine the probability of initiating treatment within 60 days. Cox proportional hazards regression model was used for multivariate analysis. ResultsMedian TTI was 28 days (95% CI, 25–29). First treatment in SUS provided more than 60 days after diagnosis (34.8%) was associated with females; low level of formal education; living or getting treatment in northern Brazil; being diagnosed in SUS and treated at different healthcare facilities, in addition to starting treatment with radiotherapy or systemic therapy. There were no significant differences in access to health care before and after the enactment of the 60-day law. ConclusionIncreased TTI for cutaneous melanoma is associated with sociodemographic and first treatment characteristics in Brazil; approximately one-third of cases did not have access to first treatment within the period established by law. Receiving the diagnosis and treatment at different healthcare facilities (transitions in care) is the main independent factor associated with TTI longer than 60 days.

Improving medicines access in Brazil through collaboration in the PPRI network

In 2020, Brazil joined Pharmaceutical Pricing and Reimbursement Information (PPRI). PPRI is a network of public authorities responsible for pharmaceutical pricing and reimbursement policies from 50, mainly European, countries. It offers a platform to its members to share information and experiences regarding pricing and reimbursement policies for medicines, and this helps improve access to affordable medicines. Information-sharing is done, among others, through network queries, country reports, meetings and webinars. Contributing to the PPRI network activities, Brazil can benefit from the policy experience of the other countries.

‘O outro’ da pandemia da Covid-19: ageísmo contra pessoas idosas em jornais do Brasil e do Chile

ABSTRACT The emergence of the new coronavirus and the indication of the elderly population as a risk group led to the emergence of speeches, jokes, memes and facts indicative of ageism in social media and mass media. This article aims to analyze the expressions and implications of ageism toward the elderly reported in newspapers in Brazil and Chile in the first year of the COVID-19 pandemic. Documentary study of news from newspapers with the greatest access in Brazil and Chile. Data collection occurred in May 2021. The selection of titles, abstracts and full text was performed by two independently and blinded researchers. The final corpus of 89 news was submitted to thematic analysis supported by the MAXQDA software, whose codification, thematization and interpretation process was based on sociological theories that explain ageism. The expressions of ageism were evidenced through images and attitudes that devalue and depreciate the life of the elderly people, positioning them as ‘the other’ of the pandemic, which has implications for the life, health and work of this population.

Protector factors for use of non-prescribed hormones among transwomen in São Paulo, Brazil, 2020

Abstract Despite the Brazilian universal and free of charge public health system, transwomen (TGW) still face barriers to their right to access healthcare, especially transition-related. One of the most common gender- affirmative need is the use of hormones, which is available for free in the health national system. In spite of that, the use of non-prescribed hormones is a reality - rising the risk of complications. The aim of this analysis is to describe the frequency of non-prescribed hormones and assess risk factors among TGW. TransOdara is a cross-sectional study, conducted in São Paulo, Brazil, from December 2019-October 2020, which included TGW>18 years. Participants were recruited from an ongoing cohort study, originally assembled using RDS. A questionnaire collected socio-demographic and behavioral information. Predictor variables for non-prescribed hormone use were assessed using multivariable logistic regression. Brazilian MOH and PAHO supported the study. 403 TGW participants were recruited. The mean age was 34.4 years (SD 9.6). The majority (70%) declared themselves black/parda, while 103 (27%) participants self-reported white and 12 (3.0%) yellow/Indigenous. Most (95%) reported ever having taken hormones, from which 48.8% (197/384) reported presently taking hormones. Among those, 53% (104/196) reported non-prescribed hormone use. Among participants that ever took hormones, mean age for starting was 18.6 years (SD 6.7). In our multivariate model, higher education - high school (p < 0.05) and incomplete college or higher (p < 0.005) - and older age (p < 0.005) were protective factors for non-prescribed hormone use, adjusted by income and ethnicity. Non-prescribed hormones use is high among TGW, even though free access in Brazil's health system. High formal education and being older are protection factors for using hormones out of professional supervision. There is an urgency to review the current policy strategies, aiming to reduce this health risk behavior. Key messages Use of hormones among TGW is high. Majority reported hormonization out of professional supervision in lifetime. High formal education and being older are protective factors for non-prescribed use.

P-29 CLINICAL FEATURES OF PRIMARY BILIARY CHOLANGITIS IN BRAZIL

Little is known about primary biliary cholangitis (PBC) in Latin America, where this disease is thought to be rare. To analyze clinical and biochemical features of Brazilian PBC patients. The Brazilian Cholestasis Study Group multicentre database was reviewed to assess demographics, clinical and laboratory features from PBC patients. 562 patients with PBC were included; 80 (14.2%) had overlapping syndrome with autoimmune hepatitis and were excluded. Most subjects were middle-aged women (95%; mean age 51 ± 11 years) with classical symptoms of pruritus and/or fatigue (65%) and jaundice (22%). Mean time to diagnosis was 2.5 years. Prevalence of antimitochondrial (AMA) and antinuclear antibodies was 82.8% and 72.1%, respectively. Concurrent autoimmune diseases occurred in 18.9%, mainly Hashimoto's thyroiditis and Sjogren syndrome. Celiac disease was diagnosed in 1:80 (1.2%). Osteopenia and osteoporosis were demonstrated in 42% and 26%, respectively. Liver pathology at diagnosis was available for 326 patients (67.6%). One third of them had advanced PBC. After a mean follow-up of 6.2 ± 5.3 years, 32% of the subjects had clinical, laboratory or imaging evidence of cirrhosis. Requirement for liver transplantation and liver-related deaths were reported in 6.6% and 3.2% of the patients, respectively. Hepatocarcinoma was diagnosed in 1.9% of the subjects. A higher predominance of PBC among females, compared to other populations, was observed, while AMA positivity was lower. Concurrent autoimmune, celiac and bone diseases are common and should be adequately screened. Prolonged time to diagnosis and high prevalence of advanced liver disease might reflect difficulties in health care access in Brazil.

Immigration, Disability and Healthcare Access in Brazil

Immigration and refugee status protection are growing phenomena in Brazil and the city of São Paulo is one of the largest hubs in the country for this heterogeneous population. Various studies reveal barriers faced by immigrants and refugees in Brazil to receive quality public healthcare services including linguistic issues, cultural differences, socioeconomic barriers, xenophobia and racism. People with disabilities are another heterogeneous group that encounters barriers in healthcare services in Brazil. Studies reveal that people with disabilities face physical, architectural and ableist attitudinal barriers in healthcare services in the country. This text seeks to highlight the necessity for qualitative research at the intersection of disability, immigration and healthcare in Brazil using international and domestic studies and ethnographic observations of the healthcare experiences of a Bolivian immigrant woman with temporary disabilities and the mother and caregiver of a Bolivian immigrant woman with disabilities in São Paulo, Brazil.

Isomorphic mimicry and the effectiveness of water-sector reforms in Brazil

Despite the efforts of various governments and the different reforms in the water sector related to water and sanitation services (WSS), Brazil continues to experience significant difficulties in achieving universal access, having a long way to go to reach this goal. This article discusses the barriers to WSS universal access in Brazil. By analyzing policies, institutions, and regulation (PIR) and the associated enabling environment, we assert that the leading cause of failure is isomorphic mimicry. We further suggest that only with a better alignment of PIR can adequate incentives be provided for universal and sustainable WSS.

Acesso aos serviços de saúde no Brasil por mulheres transexuais: uma revisão integrativa

O objetivo do estudo foi analisar a produção científica brasileira sobre o acesso aos serviços de saúde por mulheres transexuais na atenção primária do SUS. Trata-se de uma revisão integrativa da literatura, realizada no período de janeiro de 2020 a janeiro de 2021, nas bases de dados Medical Literature Analysis and Retrieval System Online, Scientific Electronic Library Online, Literatura Latino-Americana e do Caribe em Ciências da Saúde, Cumulative Index to Nursing and Allied Health Literature e Banco de Dados em Enfermagem, com recorte temporal de 2013 a 2020 e selecionados a partir da questão norteadora: Como se dá o acesso aos serviços de saúde na atenção primária do SUS por mulheres transexuais? A amostra foi composta por onze artigos. Os estudos apontaram barreiras na implementação das políticas voltadas para a população trans, como, dentre outros entraves, o desrespeito ao nome social dentro das unidades de saúde. Além disso, a concentração da maior parte dos estudos na região Sudeste, prejudica uma visão geral do acesso no Brasil. A produção científica analisada evidenciou as lacunas existentes no acesso e a necessidade de instruir os profissionais de saúde da atenção primária do SUS acerca das necessidades das mulheres trans.

Computational Tool for Sizing and Optimization of Planimetric Geometric Parameters of Inland Navigation Channels and of Port Access in Brazil

The design of an access channel is based on regulations and recommendations from each country after considering natural and vessel-related criteria and characteristics, always focusing on navigation safety. This paper presents a set of criteria and technical parameters necessary for the planimetric dimensioning, in straight and curved sections, of navigation channels for inland waterways and port access channels, using a computational tool developed and called DimChannel (Channel Dimensioning Navigation), based on the recommendations of the World Water Transport Infrastructure Association (PIANC). The DimChannel was supported by the technical criteria present in recommendations of the PIANC, in which the characteristics of the vessels and waterways adopted in the standard are like the characteristics of Brazilian inland navigation. The software was validated through a case study in the lower Tapajós River, Amazon, Brazil. The results obtained showed that DimChannel is a tool of great importance for the planimetric dimensioning of navigation channels.

Solidarity Policy in Defense of Life: A Hope in Brazil’s Pandemic

First paragraphs: The current Brazilian political situation together with the advance of coronavirus (COVID-19) has reinforced inequalities to food access in Brazil, generating uncertainties about satisfying basic human needs. Before the COVID-19 boom, Brazil had already been showing the effects of a long political and economic crisis, largely a result of the 2016 coup, which has led to more than 11% of the population unemployed and more than 40% in informal work. Brazilian President Jair Bolsonaro’s statements have made explicit his denialist policy by prioritizing the economy over life. Bolsonaro’s government has been undoing social security and food security poli­cies through the reform of the social security system, the dismantling of public universities, the shut­down of agrarian reform, the disassembling of food supply policies, and the end of the National Council for Food and Nutrition Security. Bolsonaro starts from an authoritarian policy, based on the neoliberal ideology and fear in which agribusiness and other large private corporations are prioritized rather than strengthening the collective alternatives that could help ensure a healthy diet for the Brazilian population. The COVID-19 pandemic, therefore, adds another societal stress factor, bringing back food insecurity and “the ghost of hunger” in Brazil.

New lung cancer treatments in Brazil, inequalities in patient access between the private and public health systems and differences in market access compared with the USA

ObjectiveTo assess the differences in market access in Brazil and the USA for lung cancer treatment other than chemotherapy, and to assess Brazilian patient access to these drugs comparing the public health care system and private setting. MethodNew lung cancer drugs other than chemotherapy, and approved since 2006, were assessed in the US Food and Drug Administration (FDA) online database. For approvals prior to 2006 we consulted cross-references. We assessed the corresponding Brazilian Health Surveillance Agency (ANVISA) approval dates and indications until 2018. In order to assess patient access, we consulted the online lists in the official organization responsible for the incorporation of new drugs in the Brazilian public health care system and private setting. ResultsThe FDA approved 19 lung cancer drugs, 14 of which were registered in Brazil until 2018. The market access for new lung cancer drugs diverged between Brazil and USA in 23 months however, in the past years probably due to Brazilian changes in law for faster drug approval, it decreased to 12 months or less. The label indications were similar between the FDA and ANVISA in almost 80 % of cases. The ANVISA online database, unlike the FDA database, has scarce information about drug approvals. Around 80 % (11 in 14) of lung cancer drugs approved in Brazil were available in Brazilian private setting and 14 % (2 in 14) in the public health system, divergence might be explained by divergences in regulatory standards for health technology assessment. ConclusionTime to market access for lung cancer drugs varied between the FDA and ANVISA but its difference decreased in the past years. Patient access for cancer drugs can vary among patients attending in the same country and it depends on regulatory standards for health technology assessment.

P1928Global telemedicine initiatives for combating ami

Abstract Background Major disparities exist between developed and developing countries in Acute Myocardial Infarction (AMI) outcomes. Telemedicine has emerged as a powerful, cost-efficient, and scalable tool for population-based AMI management. We propose efficient telemedicine protocols as frontline AMI strategies for resource-constrained developing countries. Purpose To create a global template of using telemedicine protocols for treating AMI. Methods A hub and spoke strategy was utilized for Latin America Telemedicine Infarct Network (LATIN) to expand access in Brazil, Colombia, Mexico, and Argentina. Small clinics and primary care health centers in remote areas were strategically connected with 24/7 primary PCI facilities. Experts at 4 remote sites provided urgent EKG diagnosis and tele-consultation that triggered ambulance dispatch and implementation of standardized AMI protocols. Results 784,947 patients were screened for AMI at 350 LATIN centers (Brazil 143, Colombia 118, Mexico 82, Argentina 7). With this expanded geographic reach, 8,448 (1.08%) patients were diagnosed with STEMI and 3,911 (46.3%) urgently reperfused, including 3,049 (78%) with Primary PCI. Time to Telemedicine Diagnosis (TTD) was 3 min, tele-accuracy 98.9%, D2B 51 min, and in-hospital mortality 5.2%. Major reasons for non-treatment were insurance denials, lack of ICU beds and chest pain >12 hours. Conclusions LATIN demonstrates the feasibility of a population-based and telemedicine guided AMI strategy that can hugely expand access. Telemedicine has important public health implications as a global approach to AMI care in developing countries.