Brazilian Universal Health Research Articles

HTA57 Costing for Health Economics Evaluation: The Case of the Brazilian Universal Health System

HTA57 Costing for Health Economics Evaluation: The Case of the Brazilian Universal Health System

'Scorched Earth: The portrait of health in Brazil after the Bolsonaro's administration and the first 100days of the Lula Government in health'.

This article is a rejoinder to the rebuttal letter authored by Jair Bolsonaro's former Minister of Health and Secretary of Primary Care to our initial article, 'From Bolsonaro to Lula: The opportunity to rebuild universal healthcare in Brazil during the government transition,' published in the International Journal of Health Planning and Management. We aim to refute the claims that we consider unsubstantiated and disconnected from reality, while reiterating the risks posed by authoritarian and antidemocratic far-right governments, such as Bolsonarism in Brazil, to the sustainability and resilience of universal health systems. This political threat is gaining momentum across several countries worldwide, thereby endangering the Democratic Rule of Law, institutions, and social policies. Furthermore, we emphasise the significant actions implemented during the first 100days of President Lula's government, which align with the priorities established during the governmental transition process and strengthen the prospects of reconstructing and fortifying the Brazilian universal health system.

HPR90 Sustainability of Biosimilars Medicines Policies in Brazil

the Brazilian Universal Health System (BUHS) enact several policies to reduce access barriers to biological medicines, favoring biosimilars. After seven years since the authorization of the first biosimilars, we investigated the major gaps that hinders a greater participation of these products in the market.

Gestão participativa na Atenção Primária à Saúde: ensaio sobre experiência em território urbano vulnerável

ABSTRACT Participatory management, although instituted in the norms of the constitution of the Brazilian Universal Health System (SUS), still faces challenges to be effective in practice at a local level, especially in complex urban territories, aiming at community strengthening and social participation. This essay aims to present and discuss aspects of a participatory management experience in a vulnerable territory, mediated by Primary Health Care. This experience of health co-management was developed between 2009 and 2013 in Manguinhos, a municipality of Rio de Janeiro. From the managers’ reports and the technical materials produced, the implementation of strategies analyzed were the mobilization to create a local intersectoral management council and those of information, education, and communication in health supported by institutional supporters and by the family health teams. We concluded that democratic managerial and sanitary practices can be developed through social technologies, which value participative and shared management among workers-users-management.

Assessment of the Impact of the Implementation of a Pre-Hospital Ambulance System on Acute Myocardial Infarction Mortality in a Developing Country.

The effective management of patients with acute myocardial infarction (AMI) is time-dependent. To assess the impacts of the implementation of prehospital care on admission rates and mortality associated with AMI. Retrospective, ecological study, which assessed data from the Brazilian Universal Health System, from all 853 municipalities of Minas Gerais, from 2008 to 2016. Excessive skewness of general and in-hospital mortality rates was smoothed using the empirical Bayes method. This study assessed the relationship between Mobile Emergency Care Service (SAMU) in each municipality and the following 3 outcomes: mortality rate due to AMI, AMI in-hospital mortality, and AMI hospitalization rate, using the Poisson hierarchical model. Rates were corrected by age structure and detrended by seasonality and temporal influences. A confidence interval of 95% was adopted. AMI mortality rates decreased throughout the study, on average 2% per year, with seasonal variation. AMI in-hospital mortality also showed a decreasing trend, from 13.81% in 2008 to 11.43% in 2016. SAMU implementation was associated with decreased AMI mortality (odds ratio [OR] = 0.967, 95% confidence interval [CI] 0.936 to 0.998) and AMI in-hospital mortality (OR = 0.914, 95% CI 0.845 to 0.986), with no relation with hospitalizations (OR = 1.003, 95% CI 0.927 to 1.083). SAMU implementation was associated with a modest but significant decrease in AMI in-hospital mortality. This finding reinforces the key role of prehospital care in AMI care and the need for investments on this service to improve clinical outcomes in low- and middle-income countries.

Coronavirus, Capitalism in Crisis and the Perversity of Public Health in Bolsonaro's Brazil.

This article aims to discuss the meaning of the coronavirus crisis as an integral part of the totality of the capitalist crisis and its implication in the health area of Brazilian capitalism, in which the rise of ultraliberal and neofascist policies is witnessed by the Bolsonaro government. To this end, we opted for a historical-dialectical materialist analysis of the situation experienced between the global beginning of the pandemic until the month of May 2020 in Brazil. The article is structured in 2 parts: The first discusses the problem of agrifood systems in the context of capitalism in crisis and its effects on the spread of diseases such as the coronavirus, and the second discusses the neglect of the Bolsonaro government in facing the COVID-19 pandemic and the Brazilian universal health system. Evidence shows that the Bolsonaro government has led to more deaths and more of the barbarism of capitalism. The scenario after the pandemic will be one of a country with a more or less intense capitalist crisis depending on the resistance of workers in the defense of public health and lives.

Admission of dentist in Brazilian Universal Health System (SUS): a priority agenda for the strengthening of Smiling Brazil.

This article aims at: i) describing and analyzing the expansion of dental care in the Unified Health System (SUS); ii) Identifying and analyzing the characteristics of hiring dentists' in the public service; iii) characterizing public vacancies, their duties and remuneration. In this descriptive case study, databases of the Ministry of Health were consulted and public tender notices. The findings indicate that 48% of the dentists enrolled in the National Registry of Health Establishments (CNES) perform care in the SUS, in 13 years there was an increase of 118% of the municipalities with oral health teams (eSB) implanted. The population coverage estimated by eSB increased by 10.46% between the years 2007 and 2015. The main mechanism for joining the Dental Specialties Centers (CEO) was the public tender. Primary care salaries ranged from 1.05 to 12.67 Brazilian minimum wages, to 40-hour weekly jobs, and to CEOs from 3.35 to 7.05. It is concluded that, among other measures, the planning of HRH strategies is necessary. The continuity of successes regulatory measures of labor contracts and support to local managers enter the agenda of priority actions of oral health policy.

Institutional strategies as a mechanism to rationalize the negative effects of the judicialization of access to medicine in Brazil

BackgroundRecently, the Executive Branch and Judiciary in Brazil increased spending due to larger numbers of lawsuits that forced the State to provide health goods and services. This phenomenon, known as health judicialization, has created challenges and required the Executive Branch and Judiciary to create institutional strategies such as technical chambers and departments to reduce the social, economic and political distortions caused by this phenomenon. This study aims to evaluate the effects of two institutional strategies deployed by a Brazilian municipality in order to cope with the economic, social and political distortions caused by the phenomenon of health judicialization regarding access to medicines.MethodsA longitudinal study was carried out in a capital in the Central-West Region of Brazil. A sample of 511 lawsuits was analyzed. The variables were placed into three groups: the sociodemographic characteristics and the plaintiffs’ disease, the characteristics of the claimed medical products and the institutional strategies. To analyze the effect of the interventions on the total cost of the medicines in the lawsuits, bivariate and multivariate linear regressions with variance were performed. For the categorical outcomes, Poisson regressions were performed with robust variance, using a significance level of 5%.ResultsA reduction in the costs of medicines in the lawsuits and of the requests for medicines within the SUS formulary was verified after the deployment of the Department of Assessment of Nonstandardized Medicines (DAMNP) and the Technical Chamber of Health Assessment (CATS); an increase in processed prescriptions from the Brazilian Universal Health System was observed after the deployment of the CATS; and an increase in medicines outside the SUS formulary without a therapeutic alternative was verified after the CATS.ConclusionThe institutional strategies deployed were important tools to reduce the high costs of the medicines in the lawsuits. In addition, they represented a step forward for the State, provided a benefit to society and indicated a potential path for the health and justice systems of other countries that also face problems caused by the judicialization of health.

P5520Evaluation of the impact of the implementation of a pre-hospital ambulance system on acute myocardial infarction mortality in a developing country

Abstract Background Acute myocardial infarction (AMI) remains a leading cause of morbidity and mortality worldwide. The effective management of patients with AMI is directly linked to time, and approximately one-half of the deaths attributed to AMI occur from cardiac arrest in the out-of-hospital setting, reinforcing the importance of the prehospital care. Contemporary data remain particularly lacking about the use of prehospital care in the setting of AMI, particularly from the more generalizable perspective of a community-based investigation, as well as information about the hospital outcomes of patients transported by ambulance. Purpose To assess the impact the implementation of a nationwide ambulance service (Serviço de Atendimento Médico de Urgência, SAMU) on AMI mortality and number of hospitalizations, in the state of Minas Gerais, Brazil. Methods Retrospective, ecological study, which assessed data from the Brazilian Universal Health System (SUS), from all 853 municipalities of Minas Gerais, from 2008 to 2016. SAMU implementation dates were obtained from the state government and SAMU local coordinators. Data on the population of each municipality was obtained from Instituto Brasileiro de Geografia e Estatística (IBGE), the Brazilian official demographic institute. Excessive skewness of general and in-hospital mortality rates were smoothed using the Empirical Bayes method The relationship between SAMU care in each municipality and the mortality due to AMI in the general population, in-hospital mortality and number of hospitalizations for AMI was assessed using the Poisson hierarchical model, and the analyzed rates were corrected by the age structure and detrended by seasonal influences. Results AMI mortality rates showed a decreasing tendency throughout the study, on average 2% per year, and seasonal variation, being higher during winter months. Age-corrected AMI in-hospital mortality also showed a decreasing trend, from 13.81% in 2008 to 11.43% in 2016. SAMU implementation was associated with decreased AMI mortality (odds ratio [OR]=0.967, 95% confidence interval [CI] 0.936–0.998) and AMI in-hospital mortality (OR=0.914, 95% CI 0.845–0.986) with no relation with the number of hospitalizations (OR 1.003, 95% CI 0.927–1.083). There was no seasonal variation in the number of AMI hospitalizations. Conclusion SAMU implementation was related to a modest but significant decrease in AMI in-hospital mortality. This finding reinforces the main role of prehospital care in AMI care and reinforces the need for investment in improving the service throughout the country.

Global technological transformations and asymmetries: development strategy and structural challenges for the Unified Health System.

This paper articulates contemporary themes of the development agenda as global phenomena that affect the dissemination and direction of health technical progress, subjecting the sustainability of the Unified Health System (SUS). The evaluation of the external dependence of the Brazilian Health Economic Industrial Complex, the bibliographical review of the literature on economic complexity and its data on Latin America and Brazil and the collection and evaluation of statistical data from the World Intellectual Property Organization and the National Institute of Industrial Property enable us to build an overview of increasing economic and power asymmetries that reiteratesthis centre-periphery pattern in multiple themes and geographical scales. This perspective consolidates the endogenous link between national development patterns and structural possibilities and boundaries for the setting of a Brazilian universal health system. Confronting global technological asymmetries is part of a strategic agenda that conditionsthe advancingof the Unified Health Systemtowards its founding principles of universality, comprehensiveness and equity.

PP50 Microcosting With Time-Driven Activity-Based Costing Applied On Brazilian HTA System: ECMO Case Study

Introduction:Extracorporeal circulatory membrane oxygenation (ECMO) is a technology that allows recovery of adults in cardiorespiratory failure with encouraging results, but is not available in the Brazilian universal public health system (SUS) due to high implementation costs. Time-driven activity based costing (TDABC) is applied to measure processes in an economic perspective by identifying opportunities to make processes more efficient through the reduction of resources used in each activity. The literature has explored the use of TDABC to measure costs related with clinical procedures and technologies in microcosting studies, identifying opportunities to improve the process by making it more efficient. This research measures the real costs to implement ECMO in Brazil to compare with the current public reimbursement system.Methods:This study applied TDABC using data from 6 patients to measure costs of ECMO intervention considering the public perspective in Brazil. In sequence, standard price payed by SUS was used to estimate the current reimbursement amount received by the hospital for ECMO procedure. Cost variable analysis was conducted to understand when and how patients receiving ECMO are using hospital resources. Cost data were collected from an academic public hospital using an average of 18 months (2016–2017) for the department costs.Results:The real average cost was USD 128,923. Most significant resource costs was medical staff, particularly for the three survivor patients, and the ECMO equipment presented the second highest cost. ECMO activities were separated into: before implantation of ECMO, period using ECMO, intensive care post-ECMO and rehabilitation, being the period where ECMO is the most expensive, particularly in nurse and physician costs. The SUS average was USD 31,437, which shows a difference of USD 97,485 between the real ECMO cost and the public reimbursement in Brazil.Conclusions:A critical element of the propagation of ECMO in Brazil and its reimbursement by public health system is the high cost and out-of-date standard payments by the Ministry of Health. Effort to implement a trustworthy method to guide decisions of SUS for the adoption and financing new technologies is essential to contribute to the optimization of public health policies in a country with a universal health system and limited resources dedicated to health sectors.

Legal access to medications: a threat to Brazil\u2019s public health system?

BackgroundIn Brazil, health is fundamental human right guaranteed by the Constitution of 1988, which created the Brazilian Universal Health System (Sistema Único de Saúde - SUS). The SUS provides medications for outpatient care via policy of pharmaceutical assistance (PA) programmes. Despite the advances in PA policies which include the improvement in access to medications, there has been a significant increase in lawsuits related to health products and services. This study aimed to characterize the medication processes filed between 2010 and 2014 against the Secretary of State for Health of São Paulo (State Health Department of São Paulo - SES/SP), in Brazil, following PA policies.MethodsThis descriptive study used secondary data on medication lawsuits filed against the SES/SP between 2010 and 2014. The data source was the S-Codes computerized system.ResultsIn the period evaluated, the number of lawsuits filed concerning health-related products increased approximately 63%; requests for medications were predominant. Approximately 30% of the medications involved in court proceedings were supplied via PA programmes. With regard to medications supplied via specialized component, 81.3% were prescribed in disagreement with the protocols published by the Ministry of Health. Insulin glargine was the most requested medication (6.3%), followed by insulin aspart (3.3%). Because there is no scientific evidence that either of these medicines is superior for the treatment of diabetes, neither of them has been incorporated into the SUS by the National Commission for Technology Incorporation. The judicial data showed that most of the lawsuits involved normal proceedings (i.e., individual demands), were filed by private lawyers, and named the State of São Paulo as the sole defendant, demonstrating the individual nature of these claims.The data indicate inequality in the distribution between the number of cases and lawyers and the number of lawsuits and prescribers, evidencing the concentration of lawyers and physicians in filing lawsuits.ConclusionThe judicialization of health in the State of São Paulo with the characteristics presented herein is a threat to the SUS.

Epidemiologic and Economic Aspects Related to Hemodialysis and Kidney Transplantation in Santa Catarina in the Period of 2012–2013

Chronic kidney disease (CKD) is a worldwide public health problem and is expressed by increasing amounts of patients on renal replacement therapy (RRT), with significant economic and social impacts. The aim of this work was to analyze socioeconomic and mortality aspects of CKD patients in Santa Catarina (SC), Brazil. This was an ecologic study with the population of SC's CKD patients, who used RRT or underwent renal transplantation (RT) from 2012 to 2013. Data were obtained through electronic access to the information systems of the Brazilian Universal Health System, tabulated, and analyzed in the Statcalc software. The predominant therapy was hemodialysis (HD)-1-3 times per week-accounting for 97.62% of all procedures and 97.48% of the costs. RT from deceased donor (DD) was the most performed, with a frequency of 79.11%, and it was also responsible for the largest cost (81.78%). Mortality among patients in HD was higher in men (57.84%), and in the age group of 60-79 years (P< .0001). Among RT patients, mortality was also prevalent among men (75%) and in the age group of 50-64 years (P< .057). Men, as well as older age groups, presented more prevalent mortality in HD and in RT. The costs of RRT were higher in HD and in RT from deceased donors and associated with its high prevalence.

A saúde pública brasileira no contexto da crise do Estado ou do capitalismo?

Este artigo tem como objetivo analisar a tendência da saúde publica universal brasileira no contexto da crise estrutural do capitalismo, articulando os interesses do capital e do Estado, sem que seja possível se referir à uma crise do Estado Moderno. Para tanto, o artigo está organizado em duas partes. A primeira parte busca analisar a natureza da crise, identificando tendências do desenvolvimento do capitalismo, principalmente nas últimas décadas do século XX e na primeira década do século XXI, com destaque para a lei marxiana da queda tendencial da taxa de lucro e a dominância do capital portador de juros. A segunda parte discute os impactos dessa crise ao direito universal da saúde no Brasil, especialmente, a partir dos anos 1990, confirmando as incertezas do financiamento do SUS e o crescente movimento de apropriação do capital sobre os recursos das políticas sociais de direitos, as da seguridade social, especialmente a saúde. Por fim, são apresentadas as considerações finais, incluindo algumas propostas para enfrentar esse quadro de instabilidade e subfinanciamento desse sistema de saúde.

Integralidade e acessibilidade no cuidado à criança portadora de paralisia cerebral

Objetivo: Conhecer como as crianças portadoras de paralisia cerebral, decorrente de asfixia perinatal grave, recebem os princípios da integralidade e da acessibilidade do Sistema Único de Saúde. Métodos: A investigação contemplou uma metodologia descritiva, exploratória com abordagem qualitativa. Participaram do estudo seis famílias de crianças portadoras de paralisia cerebral decorrente de asfixia perinatal grave. A coleta dos dados foi realizada através de entrevista semi-estruturada, no domicílio dos sujeitos, na cidade do Rio Grande - RS. Resultados: A análise dos dados revelou as dificuldades encontradas pelas famílias em relação aos princípios da integralidade dos serviços e ações de saúde e acessibilidade além de evidenciar as lacunas no que concerne ao ideal da assistência prestada pela atenção básica e a realidade a que são expostos. Conclusão: A inacessibilidade da assistência não se restringe ao nível da atenção básica, mas estende-se a todas as esferas de atenção, não contemplando a referência e contra-referência.

INEQUITABLE DISTRIBUTION OF HEALTH RESOURCES IN BRAZIL: AN ANALYSIS OF NATIONAL PRIORITY SETTING

The purpose of this paper is to describe the national priority setting process for the public health system in Brazil, evaluating the process using the ethical framework Accountability for Reasonableness, and equity considerations highlighted in the 2008 WHO Commission on Social Determinants of Health. We searched the Brazilian Ministry of Health website for documents that described priority setting within the Brazilian Universal Health Care System (SUS). The National Health Conference (CNS) has been defined by the Ministry of Health as the democratic priority setting forum for SUS. The most recent such conference (13th CNS, 2007) is the subject of this paper. Our analysis suggests that the process of priority setting within SUS has not yet achieved the ethical standards of legitimacy and fairness, and that inequitable distribution of decision making power under- represents users in poor areas. The unmet need for hospital care for children in Brazil, which reflects a remarkable inequality of opportunity for human development, may be a product of poor priority setting processes and inequity in representation.

Relação docente-discente em Enfermagem e problemas na formação para o Sistema Único de Saúde

OBJETIVO: Investigar o processo ensino-aprendizado em uma Instituição de Ensino Superior da Região Norte do Brasil, com relação ao modelo pedagógico e a formação do enfermeiro para o Sistema Único de Saúde/ Programa de Saúde da Família (SUS/PSF). METODOS: Grupo focal e entrevistas individuais semi-estruturadas, com seis discentes do último período do curso investigado, analisadas através do marco teórico freireano e literatura do SUS/PSF, por hermenêutica dialética. RESULTADOS: Verticalidade na relação entre docentes e discentes, com falta de autonomia e silenciamento dos alunos, além de falta de articulação entre ensino e a prática do SUS/PSF. CONCLUSÃO: Há necessidade de reorientação do ensino em Enfermagem no curso investigado.

O olhar dos estudantes sobre sua formação profissional para o Sistema Único de Saúde

OBJETIVO: Apresentar e discutir resultados de consulta feita aos estudantes da área da saúde da Universidade Federal de Santa Catarina, sobre aspectos de sua formação relacionados ao Sistema Único de Saúde (SUS) e participação popular e seu entendimento sobre a Carta dos Direitos dos Usuários da Saúde, discutido com os participantes da pesquisa supra-citada. MÉTODOS: Como método foi aplicado questionário estruturado, complementar à coleta de dados qualitativos, a 145 estudantes de graduação de cursos da saúde. RESULTADOS: O resultados apontam mudanças no perfil dos estudantes nos cursos adequados às diretrizes curriculares. Destacam interesse em trabalhar no SUS, mas a remuneração é fator impeditivo; percebem os usuários como pessoas de poucos recursos financeiros; desconhecem os princípios da Carta, concordam com a humanização. CONCLUSÕES: sugerem que a participação popular e controle social são pouco valorizados pelos estudantes e considerados como fragilidade na formação.

Búsqueda de un Nuevo Perfil para el Farmacéutico: la Readaptación de los Currículos en Cursos de Farmacia

This study describes and analyses the pharmacist majoring reorientation’s trajectory in Brazil. A qualitative evaluation was used to adequate the Pharmacy course curriculum and the teachinglearning strategies applied at the Centro Universitario Franciscano, UNIFRA-Brazil. In Brazil, the disease-centered assistentialist medicine model has been abandoned in favor of an integrated model that is concerned with actions to enhance health’s prevention and people’s quality of life. This necessarily requires substantial changes in the profile of health care professionals and better support for the Brazilian Universal Health Care System (Sistema Unico de Saude-SUS). The analysis of the results shows that the various actions of reorientation of the university formation can promote the academic professional qualification of ethical and more humanitarian pharmacists, with critical and reflexive profile, who will be able to work in all levels of health care, with a solid scientific and intellectual basis.

Universal Hearing Health Care: Brazil

Universal Hearing Health Care: Brazil