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McPake B, Dayal P, Zimmermann J, Williams GA. How can countries respond to the health and care workforce crisis? Insights from international evidence. Int J Health Plann Manage 2024; 39:879-887. [PMID: 38278780 DOI: 10.1002/hpm.3766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/02/2024] [Accepted: 01/06/2024] [Indexed: 01/28/2024] Open
Abstract
Future global health security requires a health and care workforce (HCWF) that can respond effectively to health crises as well as to changing health needs with ageing populations, a rise in chronic conditions and growing inequality. COVID-19 has drawn attention to an impending HCWF crisis with a large projected shortfall in numbers against need. Addressing this requires countries to move beyond a focus on numbers of doctors, nurses and midwives to consider what kinds of healthcare workers can deliver the services needed; are more likely to stay in country, in rural and remote areas, and in health sector jobs; and what support they need to deliver high-quality services. In this paper, which draws on a Policy Brief prepared for the World Health Organization (WHO) Fifth Global Forum on Human Resources for Health, we review the global evidence on best practices in organising, training, deploying, and managing the HCWF to highlight areas for strategic investments. These include (1). Increasing HCWF diversity to improve the skill-mix and provide culturally competent care; (2). Introducing multidisciplinary teams in primary care; (3). Transforming health professional education with greater interprofessional education; (4). Re-thinking employment and deployment systems to address HCWF shortages; (5). Improving HCWF retention by supporting healthcare workers and addressing migration through destination country policies that limit draining resources from countries with greatest need. These approaches are departures from current norms and hold substantial potential for building a sustainable and responsive HCWF.
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Affiliation(s)
- Barbara McPake
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Prarthna Dayal
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Julia Zimmermann
- European Observatory on Health Systems and Policies, London School of Economics and Political Science, London, UK
| | - Gemma A Williams
- European Observatory on Health Systems and Policies, London School of Economics and Political Science, London, UK
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Odedina FT, Pacheco RA, Castro MC. Building healthy populations one community at a time. Nat Med 2023; 29:1601-1604. [PMID: 37464033 DOI: 10.1038/s41591-023-02422-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Affiliation(s)
- Folakemi T Odedina
- Community Outreach and Engagement Office & Programs, Mayo Clinic Comprehensive Cancer Center, Jacksonville, FL, USA.
| | - Rafaela Alves Pacheco
- Federal University of Pernambuco, Caruaru, Pernambuco, Brazil
- SUS Family Health Strategy, Recife, Pernambuco, Brazil
| | - Marcia C Castro
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Rodrigues CB, Thomaz EBAF, Batista RFL, Riggirozzi P, Moreira DSDO, Gonçalves LLM, Lamy ZC. Prenatal care and human rights: Addressing the gap between medical and legal frameworks and the experience of women in Brazil. PLoS One 2023; 18:e0281581. [PMID: 36787329 PMCID: PMC9928028 DOI: 10.1371/journal.pone.0281581] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 01/26/2023] [Indexed: 02/15/2023] Open
Abstract
Access to quality and affordable healthcare is central to the fulfilment of women's reproductive and sexual health needs and rights. For this reason, the World Health Organization declared access to appropriate healthcare services during pregnancy and childbirth a fundamental women's right. Prenatal care is a recognized human right to women's health in Brazil, as declared by the 1988 Constitution and many Brazilian policies. However, implementing the rights to health in Brazil presents a fundamental performance gap between legal rights and their delivery concerning reproductive health. Through extensive fieldwork including focus groups, interviews with women and participate observation in two municipalities in northeastern Brazil, this article addresses these issues and explores women's lived experience of access to and their fulfilment of the right to health regarding prenatal healthcare. We offer and account of the experience of women regarding what they identified as barriers that trample their right to health, that is: a) limited personnel and medical equipment as a perception of neglect; b) timely delivery of services: time matters for perception and experience of rights; c) misinformation as a barrier to the exercise of health rights; and d) socioeconomic barriers. These barriers particularly affect the right of women in rural communities, with lower socioeconomic levels and education, as well as brown and black women, from an intersectionality perspective, who are already at greater health risk and inadequate prenatal care. As such, we argue there is a performance gap between what the normative and legal frameworks encourage the health system to do and what the system actually provides in terms of access, equality, respect and continuity of treatment amongst certain groups in society whose right to health are denied while their health risks increase.
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Affiliation(s)
| | | | | | - Pía Riggirozzi
- Department of Politics and International Relations, University of Southampton, Southampton, United Kingdom
| | | | | | - Zeni Carvalho Lamy
- Department of Public Health and Postgraduate Program in Public Health, Federal University of Maranhão, São Luís, Maranhão, Brazil
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de Andrade L, Kozhumam AS, Rocha TAH, de Almeida DG, da Silva NC, de Souza Queiroz RC, Massago M, Rent S, Facchini LA, da Silva AAM, Staton CA, Vissoci JRN, Thomaz EBAF. Impact of socioeconomic factors and health determinants on preterm birth in Brazil: a register-based study. BMC Pregnancy Childbirth 2022; 22:872. [PMID: 36424529 PMCID: PMC9685869 DOI: 10.1186/s12884-022-05201-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 11/09/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND More than 15 million children are born preterm annually. While preterm survival rates have increased in high-income countries. Low- and middle-income countries, like Brazil, continue to battle high neonatal mortality rates due to a lack of adequate postnatal care. Globally, neonatal mortality is higher for preterm infants compared to those born at term. Our study aims to map and analyze the spatial, socioeconomic, and health coverage determinants related to preterm birth in Brazil in order to understand how spatial variations in demographics and access to primary care may affect preterm birth occurrences. METHODS: Using publicly available national-level data from the Brazilian health system for 2008-2017, we conducted an ecological study to visualize the spatial distributions of preterm birth along with socioeconomic status, the structure of health services, and primary care work process, each consisting of multiple variables reduced via principal component analysis. Regression models were created to determine predictive effects of numeric and spatial variation of these scores on preterm birth rates. RESULTS In Brazil, preterm birth rates increased from 2008-2017, with small and rural municipalities frequently exhibiting higher rates than urban areas. Scores in socioeconomic status and work process were significant predictors of preterm birth rates, without taking into account spatial adjustment, with more positive scores in socioeconomic status predicting higher preterm birth rates (coefficient 0.001145) and higher scores in work process predicting lower preterm birth rates (coefficient -0.002416). Geographically weighted regression showed socioeconomic status to be a more significant predictor in the North, with the work process indicators being most significant in the Northeast. CONCLUSIONS Results support that primary care work process indicators are more significant in estimating preterm birth rates than physical structures available for care. These results emphasize the importance of ensuring the presence of the minimum human resources needed, especially in the most deprived areas of Brazil. The association between social determinants of health and preterm birth rates raises questions regarding the importance of policies dedicated to foster equity in the accessibility of healthcare services, and improve income as protective proxies for preterm birth.
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Affiliation(s)
- Luciano de Andrade
- grid.271762.70000 0001 2116 9989Department of Medicine, State University of Maringa, Block 126, Colombo Avenue, 5790, Parana CEP: 87020-900 Maringa, Brazil
| | - Arthi S. Kozhumam
- grid.26009.3d0000 0004 1936 7961Duke Global Health Institute, Duke University, Durham, NC USA
| | | | - Dante Grapiuna de Almeida
- grid.8430.f0000 0001 2181 4888Federal University of Minas Gerais, Belo Horizonte, Minas Gerais Brazil
| | - Núbia Cristina da Silva
- grid.26009.3d0000 0004 1936 7961Duke Global Health Institute, Duke University, Durham, NC USA
| | | | - Miyoko Massago
- grid.271762.70000 0001 2116 9989Department of Medicine, State University of Maringa, Block 126, Colombo Avenue, 5790, Parana CEP: 87020-900 Maringa, Brazil
| | - Sharla Rent
- grid.26009.3d0000 0004 1936 7961Duke Global Health Institute, Duke University, Durham, NC USA
| | - Luiz Augusto Facchini
- grid.411221.50000 0001 2134 6519Department of Social Medicine, Federal University of Pelotas, Pelotas, Rio Grande Do Sul Brazil
| | | | - Catherine Ann Staton
- grid.26009.3d0000 0004 1936 7961Duke Global Health Institute, Duke University, Durham, NC USA
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Kessler M, Thumé E, Facchini LA, Tomasi E. Prevalence of not receiving a home visit by Community Health Agents in Brazil and associated factors. CIENCIA & SAUDE COLETIVA 2022. [DOI: 10.1590/1413-812320222711.17072021en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Abstract This article aimed to identify the prevalence of not receiving a home visit by a community health agent (CHA) and the factors associated with it. This was a cross-sectional study, conducted with 38,865 health teams and 140,444 users in the entire country, who participated in the external evaluation of the Program of Access and Quality Improvement in Primary Health (PMAQ-AB, in Portuguese) in 2017/2018. The association between not receiving a home visit by a CHA and the characteristics of the towns, teams, and individuals were estimated by the prevalence ratio (PR) with 95% confidence intervals. The prevalence of not receiving a home visit by a CHA was 18.6% and the main causes were: CHA did not visit the home, lack of knowledge of the existence of CHAs in the neighborhood or unit, and no one present at the home when the CHA visited. The probability of receiving a home visit was higher in poorer regions like the Northeast Region of the country; in towns with a smaller population; among older age users with a lower income, users with chronic health conditions, or users who have someone with a physical disability at home. The results showed that there is a need to increase the coverage of CHA visits in the country, considering that their home visits improve equity in health care.
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Affiliation(s)
- Marciane Kessler
- Universidade Regional Integrada do Alto Uruguai e das Missões, Brazil; UFPel, Brazil
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Kessler M, Thumé E, Facchini LA, Tomasi E. Prevalência do não recebimento de visita domiciliar pelo Agente Comunitário de Saúde no Brasil e fatores associados. CIENCIA & SAUDE COLETIVA 2022; 27:4253-4263. [DOI: 10.1590/1413-812320222711.17072021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 06/30/2022] [Indexed: 11/22/2022] Open
Abstract
Resumo O objetivo do artigo é identificar a prevalência de não recebimento de visita domiciliar por Agente Comunitário de Saúde (ACS) e os fatores associados. Trata-se de um estudo transversal realizado com 38.865 equipes e 140.444 usuários em todo o território nacional, que participaram da avaliação externa do Programa de Melhoria do Acesso e da Qualidade da Atenção Básica em 2017/2018. A associação de não recebimento de visita domiciliar por ACS e características dos municípios, equipes e indivíduos foi estimada pela razão de prevalência e intervalos de confiança de 95%. A prevalência de não recebimento de visita domiciliar pelo ACS foi de 18,6% e os principais motivos foram: ACS não realiza visita na casa, desconhecimento da existência de ACS no bairro ou unidade, e não tem ninguém em casa para atendê-lo. A probabilidade de receber visita domiciliar foi maior em regiões mais pobres como o Nordeste, em municípios com menor porte populacional, entre usuários com maior idade e menor renda, com condições crônicas de saúde ou que possuem alguém com dificuldade de locomoção no domicílio. Os resultados evidenciam a necessidade de aumento da cobertura de ACS no país, considerando que sua visita domiciliar promove equidade em saúde.
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Affiliation(s)
- Marciane Kessler
- Universidade Regional Integrada do Alto Uruguai e das Missões, Brazil; UFPel, Brazil
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Luz TCB, de Castro AKS, Marques IC, Cota BB, Alves JDC, Law MR. Performance of a pharmaceutical services regionalization strategy policy in Minas Gerais, Brazil: Pre-post analysis from ERAF project. Front Pharmacol 2022; 13:953990. [PMID: 36120343 PMCID: PMC9478725 DOI: 10.3389/fphar.2022.953990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 07/22/2022] [Indexed: 11/13/2022] Open
Abstract
Background: In 2016, the Brazilian state of Minas Gerais (∼20 million people), implemented the ERAF policy (“Regionalization Strategy of Pharmaceutical Services”) in an effort to improve medicine procurement and distribution within primary care. We evaluated the impact of the policy on three main goals: price reductions, volume increases, and expansion of therapeutic options. Methods: We analyzed the procurement data from the Integrated System of Management of Pharmaceutical Services database in 2012 and 2018. We estimated the volume, drug mix, and expenditure indicators for all major therapeutic classes, and, in detail, for cardiovascular and nervous system drugs. We evaluated the expenditure drivers using decomposition analyses. Results: Overall, the expenditure increased by 14.5%, drug mix almost doubled, while the volume decreased by a third. Cardiovascular and neurological system drugs followed similar patterns. Decomposition analyses showed that prices and drug mix had positive effects while the volume had negative effects, resulting in an overall increase in expenditure. Conclusion: Our findings suggest that the ERAF policy cannot be considered effective as it has not fulfilled its intended purposes so far. Strategies to address the identified problems and to build a platform for a more sustainable long-lasting policy should be put in place by the government.
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Affiliation(s)
- Tatiana Chama Borges Luz
- GETESA (Grupo de Estudos Transdisciplinares em Tecnologias em Saúde e Ambiente), René Rachou Institute (IRR), Oswaldo Cruz Foundation (FIOCRUZ), Belo Horizonte, Brazil
- Strathclyde Institute of Pharmacy and Biomedical Sciences (SIPBS), Strathclyde University, Glasgow, United Kingdom
- *Correspondence: Tatiana Chama Borges Luz, ,
| | - Ana Karine Sarvel de Castro
- GETESA (Grupo de Estudos Transdisciplinares em Tecnologias em Saúde e Ambiente), René Rachou Institute (IRR), Oswaldo Cruz Foundation (FIOCRUZ), Belo Horizonte, Brazil
| | - Isabela Cristina Marques
- GETESA (Grupo de Estudos Transdisciplinares em Tecnologias em Saúde e Ambiente), René Rachou Institute (IRR), Oswaldo Cruz Foundation (FIOCRUZ), Belo Horizonte, Brazil
| | - Betania Barros Cota
- GETESA (Grupo de Estudos Transdisciplinares em Tecnologias em Saúde e Ambiente), René Rachou Institute (IRR), Oswaldo Cruz Foundation (FIOCRUZ), Belo Horizonte, Brazil
| | - Jèssica de Castro Alves
- GETESA (Grupo de Estudos Transdisciplinares em Tecnologias em Saúde e Ambiente), René Rachou Institute (IRR), Oswaldo Cruz Foundation (FIOCRUZ), Belo Horizonte, Brazil
| | - Michael Robert Law
- Centre for Health Services and Policy Research, School of Population and Public Health, The University of British Columbia, Vancouver, CO, Canada
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Chueiri PS, Gonçalves MR, Hauser L, Mengue S, Agostinho M, Roman R, Wollmann L, Dilda A, da Silva RAM, Harzheim E. Brazilian Survey on Preventive Actions for the Population With Access to Primary Healthcare: Inefficient Spending in a Country in Economic Crisis. Int J Health Policy Manag 2022; 11:1905-1912. [PMID: 34523857 PMCID: PMC9808240 DOI: 10.34172/ijhpm.2021.94] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 07/24/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Cancer ranks second as a cause of death in Brazil. Although preventive practices are part of the daily routine of primary healthcare (PHC) teams, organized screening programs are lacking. This study aimed to evaluate the adequacy of preventive interventions in the main cancer types, as defined by the Brazilian government. METHODS We analyzed cross-sectional data from a larger project conducted in 2016 with PHC service users and physicians from all over Brazil, interviewed by trained research staff. The sample was stratified by the number of PHC physicians per geographic region, who were eligible for inclusion if they had been working in the same PHC unit for at least one year. Twelve adult patients with at least two encounters were included per participating physician. Only the data from service users were analyzed in this study. We evaluated the questions about preventive practices and calculated the following indicators: coverage, focus, screening errors, and screening ratio. National guidelines and international evidence were used as a comparison parameter. RESULTS The study population consisted of 6160 service users. The data indicate that the recommendations for cervical, breast, and prostate cancer screening and for treatment of tobacco dependence are not adequately followed. Coverage for breast and cervical cancer screening presented an overutilization bias, with rates 50% and 9% above the expected, respectively. The screening focus was also inadequate: 24%, 47%, and 54% of the screening tests for the three cancer types were performed in individuals outside the recommended age range. 31% of smokers were not approached for treatment. CONCLUSION These findings indicate that the Brazilian population has been subjected to inadequate and potentially iatrogenic interventions in PHC. New policies based on stricter criteria of adequacy and increased use of the concept of quaternary prevention may improve the effectiveness and equity of the health system.
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Affiliation(s)
| | - Marcelo Rodrigues Gonçalves
- Graduate Program in Epidemiology, TelehealthRS Project, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Lisiane Hauser
- Graduate Program in Epidemiology, TelehealthRS Project, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Sotero Mengue
- Graduate Program in Epidemiology, TelehealthRS Project, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | | | - Rudi Roman
- Graduate Program in Epidemiology, TelehealthRS Project, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Lucas Wollmann
- Community Health Services, Grupo Hospitalar Conceição, Porto Alegre, Brazil
| | - Anna Dilda
- School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | | | - Erno Harzheim
- School of Medicine, Faculdade Israelita de Ciências da Saúde Albert Einstein, São Paulo, Brazil
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Brito GEGD, Forte FDS, Freire JCG, Moreira LB, Paredes SDO, Silva SLAD. Coordination between Primary Care Teams and Family Health Support Units and influence on Primary Care delivery. CIENCIA & SAUDE COLETIVA 2022; 27:2495-2508. [PMID: 35649035 DOI: 10.1590/1413-81232022276.03942021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 11/03/2021] [Indexed: 11/22/2022] Open
Abstract
This article aims to compare the implementation of coordinated actions by family health/primary care (FH/PC) teams and extended family health and primary care units (NASF-ABs) in the Northeast and rest of Brazil, and the influence of implementation on collaborative working. The independent variables were 19 coordinated actions assessed by Module II of the 3rd Cycle of the National Program for Improving Primary Care Access and Quality (PMAQ-AB). The three collaborative working outcomes were "FH/PC team readiness to work jointly with the NASF-AB", "support received by the FH/PC team from the NASF-AB", and "The NASF-AB's contribution to resolving patients" needs. The implementation of coordinated actions by the Northeast and at national level was compared using the two-proportions z-test and the influence of these actions on the outcomes was assessed using hierarchical linear regression models: The Northeast implemented more actions that at national level (p<0.05). The implemented actions that had the most positive influence on the three outcomes were "Case conferences", "Joint development of singular therapy plans for complex cases", "Shared appointments" and "Results monitoring". The Northeast implemented more actions and the implemented actions had a positive influence on collaborative working.
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Affiliation(s)
- Geraldo Eduardo Guedes de Brito
- Programa de Pós-Graduação em Saúde Coletiva, Centro de Ciências da Saúde, Universidade Federal da Paraíba (UFPB). Campus I, Lot. Cidade Universitária. 58051-900 João Pessoa PB Brasil. .,Programa de Pós-Graduação em Saúde Coletiva, Faculdade de Medicina, Departamento de Saúde Coletiva, Universidade Federal de Juiz de Fora. Juiz de Fora MG Brasil
| | | | - Júlio César Guimarães Freire
- Programa de Pós-Graduação em Saúde Coletiva, Centro de Ciências da Saúde, Universidade Federal da Paraíba (UFPB). Campus I, Lot. Cidade Universitária. 58051-900 João Pessoa PB Brasil.
| | - Lorrane Brunelle Moreira
- Programa de Pós-Graduação em Ciências da Reabilitação, Instituto de Ciências da Motricidade, Universidade Federal de Alfenas. Alfenas MG Brasil
| | - Suyene de Oliveira Paredes
- Programa de Pós-Graduação em Saúde Coletiva, Centro de Ciências da Saúde, Universidade Federal da Paraíba (UFPB). Campus I, Lot. Cidade Universitária. 58051-900 João Pessoa PB Brasil.
| | - Silvia Lanziotti Azevedo da Silva
- Programa de Pós-Graduação em Saúde Coletiva, Faculdade de Medicina, Departamento de Saúde Coletiva, Universidade Federal de Juiz de Fora. Juiz de Fora MG Brasil
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Carneiro VCCB, Ribeiro de Oliveira PDT, Rassy Carneiro S, Cardoso Maciel M, Pedroso JDS. Impact of expansion of primary care in child health: a population-based panel study in municipalities in the Brazilian Amazon. BMJ Open 2022; 12:e048897. [PMID: 35246414 PMCID: PMC8900036 DOI: 10.1136/bmjopen-2021-048897] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Considering the expansion of primary care in areas of difficult access in the Brazilian territory in recent decades, the aim of this study to evaluate the effect of the Family Health Strategy (FHS) expansion on hospitalisations due to ambulatory care-sensitive conditions (ACSCs) and mortality in children under 5 years of age in the state of Pará, Brazilian Amazon. METHODS A longitudinal analysis from 2008 to 2017 was conducted for data collected from the SUS's database (DATASUS) using panel regression methods to determine the association between the expansion FHS coverage, ACSC rate, under 5 mortality rate and child mortality rate in municipalities of the state of Pará. RESULTS There was an expansion of 40% of the population coverage of the FHS, in the same period there were 347 468.55 hospitalisations due to ASCSs of children under 5 years of age in the public health network in the state of Pará, which represented a reduction of almost 28% (p value <0001), and significant reduction of almost 57.67% in government hospital expenditures with hospitalisations between 2008 and 2017. In this period, there was also a significant decrease in the mortality rate in children under 5 years of age. CONCLUSIONS Our findings reinforce the importance of the public health protection for the child population and the positive impacts of FHS in the state of Pará, in the Brazilian Amazon. The government actions aimed at reducing regional health disparities and the effort to strengthen primary care can improve health indicators of children and be an important strategy to developing countries.
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Magnago C, Pierantoni CR. Situational analysis and reflections on the introduction of advanced practice nurses in Brazilian primary healthcare. HUMAN RESOURCES FOR HEALTH 2021; 19:90. [PMID: 34294088 PMCID: PMC8296671 DOI: 10.1186/s12960-021-00632-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 07/09/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND The shortage of doctors and their unequal distribution serve as challenges to advancing primary healthcare (PHC) and achieving effective universal healthcare coverage in Brazil. In an effort to use nurses' potential more efficiently, the country is investigating the introduction of the advanced practice nurse (APN) into PHC. This paper presents a situational analysis of the practices of Brazilian nurses based on the following components: regulation, practice, and education. METHODS This is a national multi-method study with triangulated data from a documentary study, a scoping review, and an exploratory study. The regulation component involved the analysis of official normative documents on the regulation of nursing education and nurses' scope of practice. The practice component aimed to identify the practices performed by nurses in Brazilian PHC based on primary studies. The education component intended to identify the practices taught in nursing training based on a survey and interviews with directors of undergraduate nursing programs. RESULTS Federal legislation in Brazil authorizes nursing graduates to perform a set of advanced practices as part of the PHC nurse's daily routine. They can request and interpret complementary tests and prescribe medication. However, in the local context, municipalities define the scope of this assistance based on technical norms or nursing protocols. Furthermore, this study indicates that undergraduate nursing programs do not fully prepare students to adequately execute these tasks. CONCLUSIONS In the context of Brazilian PHC, advanced practices have already been implemented and respond to main healthcare demands. Therefore, it is unnecessary to introduce the APN as a new professional category. Upon detecting deficiencies in the training process, the current education model should undergo reforms that seek to incorporate the skills compatible with the regulated advanced practices and in-service training for practicing nurses. Regarding the introduction of APN along international lines, this article presents recommendations that may support the operationalization of a Brazilian APN model.
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Affiliation(s)
- Carinne Magnago
- Department of Policy, Management and Health, School of Public Health, University of São Paulo (FSP/USP), Av. Dr. Arnaldo, 715, São Paulo, SP, 01246-904, Brazil.
| | - Celia Regina Pierantoni
- Institute of Social Medicine, Rio de Janeiro State University (IMS/Uerj), Rio de Janeiro, Brazil
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Zimmermann IR, Sanchez MN, Frio GS, Alves LC, Pereira CCDA, Lima RTDS, Machado C, Santos LMP, da Silva EN. Trends in COVID-19 case-fatality rates in Brazilian public hospitals: A longitudinal cohort of 398,063 hospital admissions from 1st March to 3rd October 2020. PLoS One 2021; 16:e0254633. [PMID: 34270568 PMCID: PMC8284655 DOI: 10.1371/journal.pone.0254633] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 06/30/2021] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Almost 200,000 deaths from COVID-19 were reported in Brazil in 2020. The case fatality rate of a new infectious disease can vary by different risk factors and over time. We analysed the trends and associated factors of COVID-19 case fatality rates in Brazilian public hospital admissions during the first wave of the pandemic. METHODS A retrospective cohort of all COVID-19-related admissions between epidemiological weeks 10-40 in the Brazilian Public Health System (SUS) was delimited from available reimbursement records. Smoothing time series and survival analyses were conducted to evaluate the trends of hospital case fatality rates (CFR) and the probability of death according to factors such as sex, age, ethnicity, comorbidities, length of stay and ICU use. RESULTS With 398,063 admissions and 86,452 (21.7%) deaths, the overall age-standardized hospital CFR trend decreased throughout the period, varying from 31.8% (95%CI: 31.2 to 32.5%) in week 10 to 18.2% (95%CI: 17.6 to 18.8%) in week 40. This decreasing trend was observed in all sex, age, ethnic groups, length of stay and ICU admissions. Consistently, later admission (from July to September) was an independent protective factor. Patients 80+ year old had a hazard ratio of 8.18 (95% CI: 7.51 to 8.91). Ethnicity, comorbidities, and ICU need were also associated with the death risk. Although also decreasing, the CFR was always around 40-50% in people who needed an ICU admission. CONCLUSIONS The overall hospital CFR of COVID-19 has decreased in Brazilian public hospitals during the first wave of the pandemic in 2020. Nevertheless, during the entire period, the CFR was still very high, suggesting the need for improving COVID-19 hospital care in Brazil.
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Affiliation(s)
- Ivan Ricardo Zimmermann
- Department of Collective Health, Faculty of Health Sciences, University of Brasilia, Brasilia, Brazil
| | - Mauro Niskier Sanchez
- Department of Collective Health, Faculty of Health Sciences, University of Brasilia, Brasilia, Brazil
| | - Gustavo Saraiva Frio
- Department of Collective Health, Faculty of Health Sciences, University of Brasilia, Brasilia, Brazil
| | - Layana Costa Alves
- Department of Collective Health, Faculty of Health Sciences, University of Brasilia, Brasilia, Brazil
- Institute of Collective Health (ISC) at the Federal University of Bahia, Salvador, Brazil
| | | | | | - Carla Machado
- Department of Preventive and Social Medicine, Faculty of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | | | - Everton Nunes da Silva
- Department of Collective Health, Faculty of Health Sciences, University of Brasilia, Brasilia, Brazil
- Collective Health Course, Faculty of Ceilândia, University of Brasilia, Brasilia, Brazil
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Özçelik EA, Massuda A, Castro MC, Barış E. A Comparative Case Study: Does the Organization of Primary Health Care in Brazil and Turkey Contribute to Reducing Disparities in Access to Care? Health Syst Reform 2021; 7:e1939931. [PMID: 34402403 DOI: 10.1080/23288604.2021.1939931] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Brazil and Turkey are among the few high-middle-income countries that explicitly chose to strengthen their primary health care (PHC) systems as the centerpiece of much broader health system reforms aiming to narrow inequities in access to care. This comparative case study reviews the organization of Brazil and Turkey's PHC systems to derive lessons that can apply to other countries that may consider reforming the organization of PHC systems as a way to address health inequities. The analysis uses the Flagship Framework to investigate how the organization of PHC delivery in Brazil and Turkey can lead to measurable improvements in access to care. It compares (1) the degree of decentralization in PHC service delivery responsibilities, (2) the use of multi-professional PHC teams, and (3) patient impanelment strategies. The comparative analysis offers three important lessons. First, changes in the organization of PHC systems can contribute to observable improvements in the level and distribution of health outcomes, but organizational strategies do not guarantee eliminating disparities in access. Second, PHC systems can operate in health systems with varying degrees of decentralization, but the level of decentralization may influence implementation. Third, relying on multi-professional PHC teams that serve geographically empaneled populations can improve equitable access to care, but course corrections may be needed to address evolving health demands.
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Affiliation(s)
- Ece A Özçelik
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Adriano Massuda
- São Paulo School of Business Administration, Fundação Getulio Vargas, São Paulo, Brazil
| | - Marcia C Castro
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Enis Barış
- Health, Nutrition and Population, World Bank Group, Washington, DC, USA
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Bastos V, Mota R, Guimarães M, Richard Y, Lima AL, Casseb A, Barata GC, Andrade J, Casseb LMN. Challenges of Rabies Surveillance in the Eastern Amazon: The Need of a One Health Approach to Predict Rabies Spillover. Front Public Health 2021; 9:624574. [PMID: 34249829 PMCID: PMC8267869 DOI: 10.3389/fpubh.2021.624574] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 05/21/2021] [Indexed: 11/18/2022] Open
Abstract
Brazil has been promoting essential improvements in health indicators by implementing free-access health programs, which successfully reduced the prevalence of neglected zoonosis in urban areas, such as rabies. Despite constant efforts from the authorities to monitor and control the disease, sylvatic rabies is a current issue in Amazon's communities. The inequalities among Amazon areas challenge the expansion of high-tech services and limit the implementation of active laboratory surveillance to effectively avoid outbreaks in human and non-human hosts, which also reproduces a panorama of vulnerability in risk communities. Because rabies is a preventable disease, the prevalence in the particular context of the Amazon area highlights the failure of surveillance strategies to predict spillovers and indicates the need to adapt the public policies to a “One Health” approach. Therefore, this work assesses the distribution of free care resources and facilities among Pará's regions in the oriental Amazon; and discusses the challenges of implanting One Health in the particular context of the territory. We indicate a much-needed strengthening of the sylvatic and urban surveillance networks to achieve the “Zero by 30” goal, which is inextricable from multilateral efforts to combat the progressive biome's degradation.
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Affiliation(s)
- Victor Bastos
- Federal University of Pará, Institute of Biological Sciences, Belém, Brazil.,Department of Arbovirology and Hemorrhagic Fevers, Evandro Chagas Institute, Ananindeua, Brazil
| | - Roberta Mota
- Federal University of Pará, Institute of Biological Sciences, Belém, Brazil.,Department of Arbovirology and Hemorrhagic Fevers, Evandro Chagas Institute, Ananindeua, Brazil
| | - Mylenna Guimarães
- Department of Arbovirology and Hemorrhagic Fevers, Evandro Chagas Institute, Ananindeua, Brazil
| | - Yuri Richard
- Federal University of Pará, Institute of Biological Sciences, Belém, Brazil
| | - André Luis Lima
- Federal Rural University of the Amazon, Institute of Animal Health and Production, Belém, Brazil
| | - Alexandre Casseb
- Federal Rural University of the Amazon, Institute of Animal Health and Production, Belém, Brazil
| | | | - Jorge Andrade
- Pará State Health Secretary, Health Surveillance Directorate, Belém, Brazil
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15
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Curado DDSP, Gomes DF, Silva TBC, Almeida PHRF, Tavares NUL, Areda CA, da Silva EN. Direct cost of systemic arterial hypertension and its complications in the circulatory system from the perspective of the Brazilian public health system in 2019. PLoS One 2021; 16:e0253063. [PMID: 34111216 PMCID: PMC8191920 DOI: 10.1371/journal.pone.0253063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 05/28/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Systemic arterial hypertension (SAH), a global public health problem and the primary risk factor for cardiovascular diseases, has a significant financial impact on health systems. In Brazil, the prevalence of SAH is 23.7%, which caused 203,000 deaths and 3.9 million DALYs in 2015. OBJECTIVE To estimate the cost of SAH and circulatory system diseases attributable to SAH from the perspective of the Brazilian public health system in 2019. METHODS A prevalence-based cost-of-illness was conducted using a top-down approach. The population attributable risk (PAR) was used to estimate the proportion of circulatory system diseases attributable to SAH. The direct medical costs were obtained from official Ministry of Health of Brazil records and literature parameters, including the three levels of care (primary, secondary, and tertiary). Deterministic univariate analyses were also conducted. RESULTS The total cost of SAH and the proportion of circulatory system diseases attributable to SAH was Int$ 581,135,374.73, varying between Int$ 501,553,022.21 and Int$ 776,183,338.06. In terms only of SAH costs at all healthcare levels (Int$ 493,776,445.89), 97.3% were incurred in primary care, especially for antihypertensive drugs provided free of charge by the Brazilian public health system (Int$ 363,888,540.14). Stroke accounted for the highest cost attributable to SAH and the third highest PAR, representing 47% of the total cost of circulatory diseases attributable to SAH. Prevalence was the parameter that most affected sensitivity analyses, accounting for 36% of all the cost variation. CONCLUSION Our results show that the main Brazilian strategy to combat SAH was implemented in primary care, namely access to free antihypertensive drugs and multiprofessional teams, acting jointly to promote care and prevent and control SAH.
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Affiliation(s)
| | - Dalila Fernandes Gomes
- Graduate Program in Public Health, University of Brasilia, Brasilia, Federal District, Brazil
| | | | | | | | - Camila Alves Areda
- Faculty of Ceilandia, University of Brasilia, Brasilia, Federal District, Brazil
| | - Everton Nunes da Silva
- Graduate Program in Public Health, University of Brasilia, Brasilia, Federal District, Brazil
- Faculty of Ceilandia, University of Brasilia, Brasilia, Federal District, Brazil
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16
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Andrade MV, Coelho AQ, Neto MX, Carvalho LRD, Atun R, Castro MC. Correction: Transition to universal primary health care coverage in Brazil: Analysis of uptake and expansion patterns of Brazil's Family Health Strategy (1998-2012). PLoS One 2021; 16:e0251764. [PMID: 33974650 PMCID: PMC8112692 DOI: 10.1371/journal.pone.0251764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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17
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Campelo Barroso Carneiro VC, Ribeiro de Oliveira PDT, Rassy Carneiro S, Cardoso Maciel M, da Silva Pedroso J. Evidence of the effect of primary care expansion on hospitalizations: Panel analysis of 143 municipalities in the Brazilian Amazon. PLoS One 2021; 16:e0248823. [PMID: 33831030 PMCID: PMC8031449 DOI: 10.1371/journal.pone.0248823] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 03/06/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND The Family Health Strategy (FHS) became consolidated as a primary care model and gatekeeper for the Unified Health System (Sistema Único de Saúde, SUS) in the Brazil and it is considered one of the largest primary health care programmes in the world. Its rapid expansion allowed the SUS to meet the changing health care needs of the population remote localities of Brazilian municipalities. METHODS In the present study, exploratory data analysis was performed using modelling to provide a general overview of the study and to delineate possible structural characteristics of the cross-sectional time-series data. Panel regression methods were used to assess the association between FHS coverage and ambulatory care-sensitive hospitalizations (ACSH rates) in the municipalities of Pará, in the Brazilian Amazon, from 2008 to 2017. RESULTS The results showed strong evidence for the association between FHS coverage and ACSH rates, including reductions of 22% in preventable hospitalizations and 15% in hospital expenses that were directly linked to the 40% increase in FHS population coverage during the evaluated period. This expansion of primary care has mainly benefitted areas that are difficult to access and populations that were previously deprived of health care in the vast Amazon territory. CONCLUSIONS The findings of this study show that the increase of the expansion of primary care reduces the preventable hospitalization and the hospital expenses. This reinforces the need for public protection of the health of populations at risk and the positive impacts of primary care in the Brazilian Amazon.
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Affiliation(s)
| | | | - Saul Rassy Carneiro
- João de Barros Barreto University Hospital, Federal University of Pará, Belém, Pará, Brazil
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Özçelik EA, Massuda A, McConnell M, Castro MC. Assessing the performance of beneficiary targeting in Brazil's More Doctors Programme. Health Policy Plan 2021; 36:149-161. [PMID: 33448298 PMCID: PMC7996646 DOI: 10.1093/heapol/czaa137] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2020] [Indexed: 12/30/2022] Open
Abstract
Many countries employ strategies that rest on the use of an explicitly defined set of criteria to identify underserved communities. Yet, we know relatively little about the performance of community-level targeting in large-scale health programmes. To address this gap, we examine the performance of community targeting in the More Doctors Programme (MDP). Our analysis covers all 5570 municipalities in the period between 2013 and 2017 using publicly available data. We first calculate the rate at which vulnerable municipalities enrolled in the MDP. Next, we consider two types of mistargeting: (1) proportion of vulnerable municipalities that did not have any MDP physicians (i.e. under-coverage municipalities) and (2) proportion of MDP enrolees that did not fit the vulnerability criteria (i.e. non-target municipalities). We found that almost 70% of vulnerable municipalities received at least one MDP physician between 2013 and 2017; whereas non-target municipalities constituted 33% of beneficiaries. Targeting performance improved over time. Non-target municipalities had the highest levels of socioeconomic development and greater physician availability. The poverty rate among under-coverage municipalities was almost six times that in non-target municipalities. Under-coverage municipalities had the lowest primary care physician availability. They were also smaller and more sparsely populated. We also found small differences in the political party alignments of mayors and the President between under-coverage and non-target municipalities. Our results suggest that using community-level targeting approaches in large-scale health programmes is a complex process. Programmes using these approaches may face substantial challenges in beneficiary targeting. Our results highlight that policymakers who consider using these approaches should carefully study various municipal characteristics that may influence the implementation process, including the level of socioeconomic development, health supply factors, population characteristics and political party alignments.
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Affiliation(s)
- Ece A Özçelik
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA
| | - Adriano Massuda
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA
- Department of Administration, São Paulo School of Business Administration, Fundação Getulio Vargas, Avenue Nove de Julho, 2029, São Paulo 01313-902, Brazil
| | - Margaret McConnell
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA
| | - Marcia C Castro
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA
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Massuda A. Primary health care financing changes in the Brazilian Health System: advance ou setback? CIENCIA & SAUDE COLETIVA 2021; 25:1181-1188. [PMID: 32321001 DOI: 10.1590/1413-81232020254.01022020] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2024] Open
Abstract
In 2019, the Brazilian government launched a new Primary Health Care (PHC) policy for the Unified Health System (SUS). Called "PrevineBrasil", the policy changed the PHC funding for municipalities. Instead of inhabitants and Family Health Strategy (ESF) teams, intergovernmental transfers are calculated from the number of people registered in PHC services and the results achieved in a selected group of indicators. The changes will have a set of impacts for the SUS and the health of the population, which must be observed and monitored. In this paper, possible effects of the new policy are discussed from a brief context analysis of global trends in health systems financing and health services' remuneration models, as well as on the advances, challenges, and threats to PHC and the SUS. Based on the analysis, the new policy seems to have a restrictive purpose, which should limit universality, increase distortions in financing and induce the focus of PHC actions on the SUS, contributing to the reversal of historic achievements in reducing health inequalities in Brazil.
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Affiliation(s)
- Adriano Massuda
- Fundação Getúlio Vargas, Escola de Administração do Estado de São Paulo, Av. 9 de Julho 2029/11º/FGVsaude, Bela Vista. 01313-902 São Paulo SP Brasil.
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20
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Figueiredo AM, McKinley DW, Massuda A, Azevedo GD. Evaluating medical education regulation changes in Brazil: workforce impact. HUMAN RESOURCES FOR HEALTH 2021; 19:33. [PMID: 33726741 PMCID: PMC7967964 DOI: 10.1186/s12960-021-00580-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 03/03/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND Shortages and inequitable distribution of physicians is an obstacle to move towards Universal Health Coverage, especially in low-income and middle-income countries. In Brazil, expansion of medical school enrollment, curricula changes and recruitment programs were established to increase the number of physicians in underserved areas. This study seeks to analyze the impact of these measures in reduce inequities in access to medical education and physicians' distribution. METHODS This is an observational study that analyzes changes in the number of undergraduate medical places and number of physicians per inhabitants in different areas in Brazil between the years 2010 and 2018. Data regarding the number of undergraduate medical places, number and the practice location of physicians were obtained in public databases. Municipalities with less than 20,000 inhabitants were considered underserved areas. Data regarding access to antenatal visits were analyzed as a proxy for impact in access to healthcare. RESULTS From 2010 to 2018, 19,519 new medical undergraduate places were created which represents an increase of 120.2%. The increase in the number of physicians engaged in the workforce throughout the period was 113,702 physicians, 74,771 of these physicians in the Unified Health System. The greatest increase in the physicians per 1000 inhabitants ratio in the municipalities with the smallest population, the lowest Gross Domestic Product per capita and in those located in the states with the lowest concentration of physicians occurred in the 2013-2015 period. Increase in physician supply improved access to antenatal care. CONCLUSIONS There was an expansion in the number of undergraduate medical places and medical workforce in all groups of municipalities assessed in Brazil. Medical undergraduate places expansion in the federal public schools was more efficient to reduce regional inequities in access to medical education than private sector expansion. The recruitment component of More Doctors for Brazil Program demonstrated effectiveness to increase the number of physicians in underserved areas. Our results indicate the importance of public policies to face inequities in access to medical education and physician shortages and the necessity of continuous assessment during the period of implementation, especially in the context of political and economic changes.
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Affiliation(s)
- Alexandre Medeiros Figueiredo
- Health Sciences Postgraduate Program, Universidade Federal do Rio Grande do Norte, Natal, Brazil.
- Department of Health Promotion, Federal University of Paraíba, Campus I, Jardim Universitário, S/N, Castelo Branco, João Pessoa, PB, Brazil.
| | | | - Adriano Massuda
- School of Business Administration, Fundação Getulio Vargas (FGV EAESP), Av. 9 de julho, 2029, Bela Vista, São Paulo, SP, 01313-902, Brazil
| | - George Dantas Azevedo
- Multicampi School of Medical Sciences, Federal University of Rio Grande do Norte, Av. Cel. Martiniano, 541, Caicó, RN, 59300-000, Brazil
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Ferreira Freitas R, Santos Brant Rocha J, Ives Santos L, de Carvalho Braule Pinto AL, Rodrigues Moreira MH, Piana Santos Lima de Oliveira F, Marques MS, Souza Guerra Júnior GE, de Oliveira Silva Guerra KD, Araújo Drummond AM, Villas Boas Spelta JV, Ananias Meira Trovão C, Schmidt França D, Borges Oliveira L, Prates Caldeira A, Silveira Vasconcelos D’Angelo MF. Validity and precision of the International Physical Activity Questionnaire for climacteric women using computational intelligence techniques. PLoS One 2021; 16:e0245240. [PMID: 33444409 PMCID: PMC7808655 DOI: 10.1371/journal.pone.0245240] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 12/23/2020] [Indexed: 11/19/2022] Open
Abstract
This study aimed to evaluate the validity and precision of the International Physical Activity Questionnaire (IPAQ) for climacteric women using computational intelligence techniques. The instrument was applied to 873 women aged between 40 and 65 years. Considering the proposal to regroup the set of data related to the level of physical activity of climacteric women using the IPAQ, we used 2 algorithms: Kohonen and k-means, and, to evaluate the validity of these clusters, 3 indexes were used: Silhouette, PBM and Dunn. The questionnaire was tested for validity (factor analysis) and precision (Cronbach's alpha). The Random Forests technique was used to assess the importance of the variables that make up the IPAQ. To classify these variables, we used 3 algorithms: Suport Vector Machine, Artificial Neural Network and Decision Tree. The results of the tests to evaluate the clusters suggested that what is recommended for IPAQ, when applied to climacteric women, is to categorize the results into two groups. The factor analysis resulted in three factors, with factor 1 being composed of variables 3 to 6; factor 2 for variables 7 and 8; and factor 3 for variables 1 and 2. Regarding the reliability estimate, the results of the standardized Cronbach's alpha test showed values between 0.63 to 0.85, being considered acceptable for the construction of the construct. In the test of importance of the variables that make up the instrument, the results showed that variables 1 and 8 presented a lesser degree of importance and by the analysis of Accuracy, Recall, Precision and area under the ROC curve, there was no variation when the results were analyzed with all IPAQ variables but variables 1 and 8. Through this analysis, we concluded that the IPAQ, short version, has adequate measurement properties for the investigated population.
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Affiliation(s)
| | - Josiane Santos Brant Rocha
- State University of Montes Claros, Montes Claros, Minas Gerais, Brazil
- Fipmoc University Center, Montes Claros, Minas Gerais, Brazil
| | | | | | | | | | - Maria Suzana Marques
- State University of Montes Claros, Montes Claros, Minas Gerais, Brazil
- Fipmoc University Center, Montes Claros, Minas Gerais, Brazil
| | | | | | | | | | | | - Dorothéa Schmidt França
- State University of Montes Claros, Montes Claros, Minas Gerais, Brazil
- Fipmoc University Center, Montes Claros, Minas Gerais, Brazil
| | - Lanuza Borges Oliveira
- State University of Montes Claros, Montes Claros, Minas Gerais, Brazil
- Fipmoc University Center, Montes Claros, Minas Gerais, Brazil
| | - Antônio Prates Caldeira
- State University of Montes Claros, Montes Claros, Minas Gerais, Brazil
- Fipmoc University Center, Montes Claros, Minas Gerais, Brazil
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Soares GH, Ortiz-Rosa E, Alves CP, Paz D, An KS, Pereira AC, Biazevic MGH, Frias AC, Michel-Crosato E. Factors associated with utilisation of dental services by the elders from São Paulo, Brazil. Gerodontology 2020; 38:216-227. [PMID: 33354806 DOI: 10.1111/ger.12519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 11/30/2020] [Accepted: 12/06/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Population ageing in Brazil is rapid and is likely to place additional pressure over the Brazilian public health system. OBJECTIVE This study aims to examine the factors associated with utilisation of dental services in the previous year among a representative sample of older adults from São Paulo, Brazil. METHODS The sample included 5951 older adults who participated in the SBSP-15 study, an epidemiological survey conducted in 2015 in the State of São Paulo, Brazil. The outcome "utilisation of dental services" was defined as having visited a dentist in the previous year. Chi-square tests were employed in the bivariate analyses and Poisson regressions with robust variance in the multilevel analysis. RESULTS Only 30.5% of the participants had their last dental appointment within the previous year. Number of teeth and dental pain presented the strongest effects on the investigated outcome. Education, income, age, ethnicity, living alone, higher Family Health Strategy coverage and the Metropolitan area were associated with having visited a dentist in the previous year. Older adults who rated their oral health as positive did not report treatment need nor prosthodontic need, presented negative oral health-related quality of life, had their last dental appointment in the public health system and sought treatment due to pain or extraction also were more likely to report the utilisation of dental services in the previous year. CONCLUSION Regional, sociodemographic and subjective factors are associated with utilisation of dental services in the previous year among the elders from the State of São Paulo, Brazil.
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Affiliation(s)
- Gustavo Hermes Soares
- Forensic Dentistry and Community Health Department, Dentistry School, University of São Paulo, São Paulo, Brazil
| | - Ezequiel Ortiz-Rosa
- Forensic Dentistry and Community Health Department, Dentistry School, University of São Paulo, São Paulo, Brazil
| | - Caroline Paula Alves
- Forensic Dentistry and Community Health Department, Dentistry School, University of São Paulo, São Paulo, Brazil
| | | | - Ki Sung An
- Forensic Dentistry and Community Health Department, Dentistry School, University of São Paulo, São Paulo, Brazil
| | - Antonio Carlos Pereira
- Community Dentistry Department, Piracicaba Dental School, University of Campinas, São Paulo, Brazil
| | - Maria Gabriela Haye Biazevic
- Forensic Dentistry and Community Health Department, Dentistry School, University of São Paulo, São Paulo, Brazil
| | - Antônio Carlos Frias
- Forensic Dentistry and Community Health Department, Dentistry School, University of São Paulo, São Paulo, Brazil
| | - Edgard Michel-Crosato
- Forensic Dentistry and Community Health Department, Dentistry School, University of São Paulo, São Paulo, Brazil
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Özçelik EA, Massuda A, McConnell M, Castro MC. Impact of Brazil's More Doctors Program on hospitalizations for primary care sensitive cardiovascular conditions. SSM Popul Health 2020; 12:100695. [PMID: 33319027 PMCID: PMC7725939 DOI: 10.1016/j.ssmph.2020.100695] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 11/11/2020] [Accepted: 11/12/2020] [Indexed: 11/18/2022] Open
Abstract
Globally, cardiovascular diseases are the leading cause of disease burden and death. Timely and appropriate provision of primary care may lead to sizeable reductions in hospitalizations for a range of chronic and acute health conditions. In this paper, we study the impact of Brazil's More Doctors Program (MDP) on hospitalizations due to cerebrovascular disease and hypertension. We exploit the geographic variation in the uptake of the MPD and combine coarsened exact matching and difference-in-difference methods to construct valid counterfactual estimates. We use data from the Hospital Information System in Unified Health System, the MDP administrative records, the Brazilian Regulatory Agency, the Ministry of Health, and the Brazilian Institute of Geography and Statistics, covering the years from 2009 to 2017. Our analysis resulted in estimated coefficients of -1.47 (95%CI: -4.04,1.10) for hospitalizations for cerebrovascular disease and -1.20 (95%CI: -5.50,3.11) for hypertension, suggesting an inverse relationship between the MDP and hospitalizations. For cerebrovascular disease, the estimated MDP coefficient was -0.50 (95%CI: -2.94,1.95) in the year of program introduction, -5.21 (95%CI: -9.43,-0.99) and -8.21 (95%CI: -13.68,-2.75) in its third and fourth year of implementation, respectively. Our results further suggest that the beneficial impact of MDP on hospitalizations due to cerebrovascular disease became discernable in urban municipalities starting from the fourth year of implementation. We found no evidence that the MDP led to reductions in hospitalizations due to hypertension. Our results highlight that increased investment in resources devoted to primary care led to improvements in hospitalizations for selected cardiovascular conditions. However, it took time for the beneficial effects of the MDP to become discernable and the Program did not guarantee declines in hospitalizations for all cardiovascular conditions, suggesting that further improvements may be needed to enhance the beneficial impact of the MDP on the level and distribution of population health in Brazil.
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Affiliation(s)
- Ece A. Özçelik
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, 02115, USA
| | - Adriano Massuda
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, 02115, USA
- São Paulo School of Business Administration, Fundação Getulio Vargas, São Paulo, Brazil
| | - Margaret McConnell
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, 02115, USA
| | - Marcia C. Castro
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, 02115, USA
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Moreira CB, Dahinten VS, Howard AF, Fernandes AFC, Schirmer J. Factors related to mammography adherence among women in Brazil: A scoping review. Nurs Open 2020; 8:2035-2049. [PMID: 34388860 PMCID: PMC8363398 DOI: 10.1002/nop2.706] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 09/30/2020] [Accepted: 11/04/2020] [Indexed: 01/24/2023] Open
Abstract
AIM To explore and synthesize the literature on factors related to mammography screening adherence among women in Brazil. DESIGN A scoping review. METHODS We searched 11 databases for studies published between 2006-January 2020. All identified articles were screened, and data were extracted from eligible studies. We used the UK Government Social Research Service weight of evidence appraisal tool to appraise the quality of the included study. RESULTS From a total of 1,384 identified articles, 22 were retained. All included studies used quantitative, non-experimental methods and all but two studies used cross-sectional data. Quality of evidence varied across studies. We identified 41 factors that were investigated across the set of studies. Demographic and socio-economic factors were the most commonly investigated, with older age, urban residence, living in the southeast of Brazil, higher level of education, higher income and private health insurance most consistently associated with mammography adherence.
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Affiliation(s)
- Camila Brasil Moreira
- School of Nursing, Federal University of São Paulo, São Paulo, Brazil.,School of Nursing, University of British Columbia, Vancouver, BC, Canada
| | - V Susan Dahinten
- School of Nursing, University of British Columbia, Vancouver, BC, Canada
| | - A Fuchsia Howard
- School of Nursing, University of British Columbia, Vancouver, BC, Canada
| | | | - Janine Schirmer
- School of Nursing, Federal University of São Paulo, São Paulo, Brazil
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Abdominal obesity and association with sociodemographic, behavioral and clinical data in climacteric women assisted in primary care. PLoS One 2020; 15:e0237336. [PMID: 32790774 PMCID: PMC7425907 DOI: 10.1371/journal.pone.0237336] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 07/23/2020] [Indexed: 12/02/2022] Open
Abstract
This study aims to investigate the prevalence and factors associated with abdominal obesity in climacteric women assisted at Family Health Strategy units of the city of Montes Claros, State of Minas Gerais, Brazil. It is a cross-sectional analytical study. The women were selected by probabilistic sampling from August 2014 to August 2015. A questionnaire containing information referring to sociodemographic and economic characteristics, behavioral characteristics and clinical data was used. To estimate abdominal obesity, the measure of circumference ≥ 88 cm was considered. To analyze the association between abdominal obesity and the independent variables, a bivariate analysis was performed by means of Pearson’s chi-square test (p≤0.25). Subsequently, a multiple Poisson regression analysis with robust variance was performed, through which prevalence ratios with level of significance of 5% (p<0.05) were obtained. A total of 805 women were evaluated, aged 40 to 65 years, and the prevalence of women with abdominal obesity was 62.4%. The mean and median of abdominal circumference were 93.0 cm. The associated variables were being sedentary (PR = 1.44) or irregularly active (PR = 1.39), presenting altered total cholesterol (PR = 1.21), and being hypertensive (PR = 1.31). The abdominal obesity in climacteric women was associated with physical inactivity, total cholesterol and arterial hypertension. The measurement of abdominal circumference must be valued and adopted in the routine of professionals who work in Primary Care.
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Ben ÂJ, Neyeloff JL, de Souza CF, Rosses APO, de Araujo AL, Szortika A, Locatelli F, de Carvalho G, Neumann CR. Cost-utility Analysis of Opportunistic and Systematic Diabetic Retinopathy Screening Strategies from the Perspective of the Brazilian Public Healthcare System. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2020; 18:57-68. [PMID: 31674001 PMCID: PMC6978298 DOI: 10.1007/s40258-019-00528-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
OBJECTIVE To perform a cost-utility analysis of diabetic retinopathy (DR) screening strategies from the perspective of the Brazilian Public Healthcare System. METHODS A model-based economic evaluation was performed to estimate the incremental costs per quality-adjusted life-year (QALY) gained between three DR screening strategies: (1) the opportunistic ophthalmology referral-based (usual practice), (2) the systematic ophthalmology referral-based, and (3) the systematic teleophthalmology-based. The target population included individuals with type 2 diabetes (T2D) aged 40 years, without retinopathy, followed over a 40-year time horizon. A Markov model was developed with five health states and a 1-year cycle. Model parameters were based on literature and country databases. One-way and probabilistic sensitivity analyses were performed to assess model parameters' uncertainty. WHO willingness-to-pay (WHO-WTP) thresholds were used as reference (i.e. one and three times the Brazilian per capita Gross Domestic Product of R$32747 in 2018). RESULTS Compared to usual practice, the systematic teleophthalmology-based screening was associated with an incremental cost of R$21445/QALY gained ($9792/QALY gained). The systematic ophthalmology referral-based screening was more expensive (incremental costs = R$4) and less effective (incremental QALY = -0.012) compared to the systematic teleophthalmology-based screening. The probability of systematic teleophthalmology-based screening being cost-effective compared to usual practice was 0.46 and 0.67 at the minimum and the maximum WHO-WTP thresholds, respectively. CONCLUSION Systematic teleophthalmology-based DR screening for the Brazilian population with T2D would be considered very cost effective compared to the opportunistic ophthalmology referral-based screening according to the WHO-WTP threshold. However, there is still a considerable amount of uncertainty around the results.
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Affiliation(s)
- Ângela J Ben
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
| | | | - Camila F de Souza
- Faculty of Medicine, Universidade do Vale do Taquari, Lajeado, Brazil
| | - Ana Paula O Rosses
- Department of Social Medicine, Federal University of Pelotas, Pelotas, Brazil
| | - Aline L de Araujo
- Telessaúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Adriana Szortika
- Ophthalmology Service, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Franciele Locatelli
- Postgraduate Program in Epidemiology, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Gabriela de Carvalho
- Postgraduate Program in Epidemiology, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Cristina R Neumann
- Postgraduate Program in Epidemiology, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
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Tasca R, Massuda A, Carvalho WM, Buchweitz C, Harzheim E. [Recommendations to strengthen primary health care in BrazilRecomendaciones para el fortalecimiento de la atención primaria de salud en Brasil]. Rev Panam Salud Publica 2020; 44:e4. [PMID: 31911800 PMCID: PMC6943881 DOI: 10.26633/rpsp.2020.4] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 07/02/2019] [Indexed: 12/16/2022] Open
Abstract
Objective To formulate strategic recommendations to strengthen primary health care (PHC) in Brazil's Unified Health System (SUS) based on expert consultation. Method The present qualitative study, developed from March to August, 2018, included administration of an open questionnaire followed by consensus building among 20 participants representing the five Brazilian regions, selected using the criterion of recognized professional expertise in the field of PHC. Participants answered an online questionnaire created by the authors. The findings were systematized as recommendations, which were submitted for priority ranking by the expert group using a one-round Delphi technique. The final recommendations were discussed in a face-to-face workshop. Results Of 20 experts, 18 answered the open questionnaire, generating 84 themes for analysis, which were systematized into 44 proposals. Evaluation of these proposals resulted in 20 recommendations, emphasizing expansion of the Family Health Strategy (FHS); enhanced access to PHC; training of professionals for multidisciplinary work in the PHC setting; allocation of technologies to ensure PHC resolvability; improvement of regulation/coordination of services to strengthen a foundational role of PHC in the SUS; human resources, provision of professionals, and support/stimulus for teams; production and dissemination of knowledge; transparency in PHC initiatives; and mediating role of PHC in the healthcare system. Conclusions The findings support the FHS as the best model to ensure a strong PHC in the SUS, combined with policies that prioritize essential PHC attributes, especially through innovation in care, management, and communication technologies.
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Affiliation(s)
- Renato Tasca
- Organização Pan-Americana da Saúde (OPAS) Organização Pan-Americana da Saúde (OPAS) BrasíliaDF Brasil Organização Pan-Americana da Saúde (OPAS), Brasília (DF), Brasil
| | - Adriano Massuda
- Harvard T.H. Chan School of Public Health Departamento de Saúde Global e Populações BostonMA Estados Unidos da América Harvard T.H. Chan School of Public Health, Departamento de Saúde Global e Populações, Boston (MA), Estados Unidos da América
| | - Wellington Mendes Carvalho
- Organização Pan-Americana da Saúde (OPAS) Organização Pan-Americana da Saúde (OPAS) BrasíliaDF Brasil Organização Pan-Americana da Saúde (OPAS), Brasília (DF), Brasil
| | - Claudia Buchweitz
- Consultora independente Consultora independente Porto AlegreRS Brasil Consultora independente, Porto Alegre (RS), Brasil
| | - Erno Harzheim
- Universidade Federal do Rio Grande do Sul (UFRGS) Programa de Pós-Graduação em Epidemiologia Porto AlegreRS Brasil Universidade Federal do Rio Grande do Sul (UFRGS), Programa de Pós-Graduação em Epidemiologia, Porto Alegre (RS), Brasil
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Montenegro L, Velasque L, LeGrand S, Whetten K, de Mattos Russo Rafael R, Malta M. Public Health, HIV Care and Prevention, Human Rights and Democracy at a Crossroad in Brazil. AIDS Behav 2020; 24:1-4. [PMID: 30903450 PMCID: PMC6755066 DOI: 10.1007/s10461-019-02470-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
On January 2019, Brazil's new far-right president Jair Bolsonaro was sworn into office. Bolsonaro's administration supports downsizing the Brazilian Unified Health System (SUS), while increasing the size of the private health sector. The new administration might leave millions of Brazilians without medical care, including hundreds of thousands of people living with HIV/AIDS. Bolsonaro's administration, allied with a highly conservative Congress and sharp decreases in federal funding for public health, education and research, could jeopardize key health and human rights strategies focused on women, LGBTQ + individuals, Indigenous populations, and people living with HIV/AIDS.
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Affiliation(s)
- Luiz Montenegro
- Department of Epidemiology and Quantitative Methods in Health, Sergio Arouca National School of Public Health (DEMQS-ENSP), FIOCRUZ, Rio de Janeiro, Brazil
| | - Luciane Velasque
- Federal University of Rio de Janeiro State (UNIRIO), Rio de Janeiro, Brazil
| | - Sara LeGrand
- Center for Health Policy and Inequalities Research, Duke Global Health Institute, Durham, NC, USA
| | - Kathryn Whetten
- Center for Health Policy and Inequalities Research, Duke Global Health Institute, Durham, NC, USA
| | - Ricardo de Mattos Russo Rafael
- Federal University of Rio de Janeiro State (UNIRIO), Rio de Janeiro, Brazil
- Public Health Nursing Department, Rio de Janeiro State University (UERJ), Rio de Janeiro, Brazil
| | - Monica Malta
- Division of Equity, Gender and Population, Department of Psychiatry, University of Toronto, Toronto, Canada.
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, Canada.
- Social Science Department, Sergio Arouca National School of Public Health (DCS/ENSP), FIOCRUZ, Rio de Janeiro, Brazil.
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Marques MS, Ferreira Freitas R, Araújo Veloso Popoff D, Piana Santos Lima de Oliveira F, Rodrigues Moreira MH, Araújo Drummond AM, Schmidt França D, Nogueira dos Santos LA, de Siqueira e Rocha ME, Brant Rocha JP, Brant Rocha MC, Santos Figueiredo Brito MF, Prates Caldeira A, Maria Borborema FA, Santos VM, Santos Brant Rocha J. Health conditions associated with overweight in climacteric women. PLoS One 2019; 14:e0218497. [PMID: 31830047 PMCID: PMC6907811 DOI: 10.1371/journal.pone.0218497] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 11/18/2019] [Indexed: 01/01/2023] Open
Abstract
This study aims to investigate the association between health conditions and overweight in climacteric women assisted by primary care professionals. It is a cross-sectional study conducted with 874 women from 40 to 65 years of age, selected by probabilistic sampling between August 2014 and August 2015. In addition to the outcome variable, overweight and obesity, other variables such as sociodemographic, reproductive, clinical, eating and behavioural factors were evaluated. Descriptive analyses of the variables investigated were performed to determine their frequency distributions. Then, bivariate analyses were performed through Poisson regression. For the multivariate analyses, hierarchical Poisson regression was used to identify factors associated with overweight and obesity in the climacteric period. The prevalence of overweight and obesity was 74%. Attending public school (PR: 1.30-95% CI 1.14-1.50), less schooling (PR: 1.11-95% CI 1.01-1.23), gout (PR: 1.18-95% CI 1.16-1.44), kidney disease (PR: 1.18-95% CI 1.05-1.32), metabolic syndrome (MS) (PR: 1.19-95% CI 1.05-1.34) and fat intake (PR: 1.12-95% CI 1.02-1.23) were considered risk factors for overweight. Having the first birth after 18 years of age (PR: 0.89-95% CI 0.82 to 0.97) was shown to be a protective factor for overweight and obesity. The presence of overweight and obesity is associated with sociodemographic, reproductive, clinical and eating habits.
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Affiliation(s)
- Maria Suzana Marques
- State University of Montes Claros, Montes Claros, Minas Gerais, Brazil
- Fipmoc University Center (UNIFIPMoc), Montes Claros, Minas Gerais, Brazil
| | | | - Daniela Araújo Veloso Popoff
- State University of Montes Claros, Montes Claros, Minas Gerais, Brazil
- Fipmoc University Center (UNIFIPMoc), Montes Claros, Minas Gerais, Brazil
| | | | | | | | | | - Luís Antônio Nogueira dos Santos
- State University of Montes Claros, Montes Claros, Minas Gerais, Brazil
- Fipmoc University Center (UNIFIPMoc), Montes Claros, Minas Gerais, Brazil
| | | | | | | | | | - Antônio Prates Caldeira
- State University of Montes Claros, Montes Claros, Minas Gerais, Brazil
- Fipmoc University Center (UNIFIPMoc), Montes Claros, Minas Gerais, Brazil
| | | | | | - Josiane Santos Brant Rocha
- State University of Montes Claros, Montes Claros, Minas Gerais, Brazil
- Fipmoc University Center (UNIFIPMoc), Montes Claros, Minas Gerais, Brazil
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Castro MC, Massuda A, Almeida G, Menezes-Filho NA, Andrade MV, de Souza Noronha KVM, Rocha R, Macinko J, Hone T, Tasca R, Giovanella L, Malik AM, Werneck H, Fachini LA, Atun R. Brazil's unified health system: the first 30 years and prospects for the future. Lancet 2019; 394:345-356. [PMID: 31303318 DOI: 10.1016/s0140-6736(19)31243-7] [Citation(s) in RCA: 368] [Impact Index Per Article: 73.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 04/18/2019] [Accepted: 05/10/2019] [Indexed: 12/28/2022]
Abstract
In 1988, the Brazilian Constitution defined health as a universal right and a state responsibility. Progress towards universal health coverage in Brazil has been achieved through a unified health system (Sistema Único de Saúde [SUS]), created in 1990. With successes and setbacks in the implementation of health programmes and the organisation of its health system, Brazil has achieved nearly universal access to health-care services for the population. The trajectory of the development and expansion of the SUS offers valuable lessons on how to scale universal health coverage in a highly unequal country with relatively low resources allocated to health-care services by the government compared with that in middle-income and high-income countries. Analysis of the past 30 years since the inception of the SUS shows that innovations extend beyond the development of new models of care and highlights the importance of establishing political, legal, organisational, and management-related structures, with clearly defined roles for both the federal and local governments in the governance, planning, financing, and provision of health-care services. The expansion of the SUS has allowed Brazil to rapidly address the changing health needs of the population, with dramatic upscaling of health service coverage in just three decades. However, despite its successes, analysis of future scenarios suggests the urgent need to address lingering geographical inequalities, insufficient funding, and suboptimal private sector-public sector collaboration. Fiscal policies implemented in 2016 ushered in austerity measures that, alongside the new environmental, educational, and health policies of the Brazilian government, could reverse the hard-earned achievements of the SUS and threaten its sustainability and ability to fulfil its constitutional mandate of providing health care for all.
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Affiliation(s)
- Marcia C Castro
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Adriano Massuda
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Collective Health, Health Sciences Sector, Federal University of Paraná, Curitiba, Brazil
| | - Gisele Almeida
- Health Systems and Services Unit, Pan American Health Organization/Regional Office of the World Health Organization, Washington, DC, USA
| | - Naercio Aquino Menezes-Filho
- Center for Public Policy, Insper, São Paulo, Brazil; Department of Economics, University of São Paulo, São Paulo, Brazil
| | - Monica Viegas Andrade
- Center for Development and Regional Planning, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | | | - Rudi Rocha
- São Paulo School of Business Administration, Fundação Getulio Vargas, São Paulo, Brazil
| | - James Macinko
- UCLA Fielding School of Public Health, Center for Health Sciences, University of California Los Angeles, Los Angeles, CA, USA
| | - Thomas Hone
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Renato Tasca
- Health Systems and Services Unit, Pan American Health Organization, Brasília, Brazil
| | - Ligia Giovanella
- Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Ana Maria Malik
- São Paulo School of Business Administration, Fundação Getulio Vargas, São Paulo, Brazil
| | - Heitor Werneck
- Agência Nacional de Saúde Suplementar, Rio de Janeiro, Brazil
| | - Luiz Augusto Fachini
- Center for Epidemiological Research, Universidade Federal de Pelotas, Pelotas, Brazil
| | - Rifat Atun
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA.
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Abstract
Resumo Buscou-se avaliar os limites da Estratégia Saúde da Família (ESF) a partir do cotidiano de trabalho de seus profissionais. Neste estudo qualitativo, realizaram-se entrevistas individuais semiestruturadas com 16 profissionais da equipe de Saúde da Família de um município da região metropolitana de Salvador, Bahia. O exame dos dados utilizou a análise de conteúdo proposta por Bardin e os referenciais da Política Nacional de Atenção Básica e da Política Nacional de Humanização para Atenção Básica. Identificaram-se duas categorias: a atenção básica (AB) do Sistema Único de Saúde (SUS) e a cogestão e humanização na AB. Na primeira categoria, evidenciou-se o contexto atual que permeia a AB, caracterizando os desafios que se apresentam no cotidiano de trabalho dos profissionais da ESF e as dificuldades encontradas para mudar o modelo de atenção à saúde. Na segunda categoria, destacaram-se as condições concretas em que se realizam as práticas no cotidiano de trabalho, indo de encontro aos pressupostos da humanização. Os problemas apresentados evidenciam descaracterização da AB, contradizem os preceitos da ESF e revelam dificuldades na proposta de reorientação do modelo de saúde.
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