Prenatal care within Brazil's Unified Health System

OBJECTIVE: To assess antenatal care in health care units, so as to obtain a baseline for future evaluation studies. METHODS: A self-applied inquiry was conducted among municipal health managers within a probabilistic stratified random sample of 627 municipalities which, through expansion technique, extended the analysis to 5,507 municipalities. Data was collected from October 2003 to April 2004. The survey appraised information about the priority granted by the managers to each modality of care, as well as data concerning characteristics of the assistance provided and the declared estimate of the demand being covered. The Chi-square test and Student's t-test were performed in order to verify independence among the qualitative variables and mean differences, respectively. RESULTS: Almost half (43.8%; n=2,317) of the municipalities did not attend gestational risk; 81% (n=4,277) and 30.1% (n=1,592) reported that they attend over 75% of the demand for low and high risk antenatal respectively; 30.1% (n=1,592) attend over 75% of the demand for high risk care. Care for low risk (chi2=282,080; P<0.001 n=4,277) and for high risk pregnancies (chi2=267.924; P<0.001 n=5,280) were associated to geographic region, municipality's size and management modality within the Unified Health System. The guarantee of vacancy for labour and birth was also associated to management modality. CONCLUSIONS: There were gaps related to the provision and the quality of antenatal care within the Unified Health System. Municipal based health care extends the provision of antenatal care, but there are inequalities among regions and among municipalities according to demographic size.     

Environmental surveillance in health in Brazil's Unified Health System

The incorporation of environmental surveillance in the field of public health policies is a relatively recent demand in Brazil. One of the major challenges in environmental health surveillance is defining its object and the specificity of its practice. The expanded concept of exposure, treated as a set of complex relations between a society and the environment, and not as a personal attribute, is central to the definition of indicators and should guide the practice of environmental surveillance in the health sector. Among the difficulties encountered in applying this concept within the Brazilian Health System, is the need to restructure health surveillance activities and to form multidisciplinary teams capable of dialoguing with other sectors. Furthermore, information systems capable of aiding in health situation analysis and decision making must be constructed. Taking this into consideration, a review of the object and concepts of environmental health surveillance was undertaken and the challenges with respect to its implementation in the Brazilian Health System were identified.     

Pediatric care in Brazil's Unified Health System: reflections on the role of pediatricians in Family Healthcare Strategy

This essay seeks to contribute to the elucidation of the potential activities of pediatricians in the Family Healthcare Strategy. The origins, types of care and inherent implications to the process of change in the Healthcare Model that are being implemented in the Brazilian Unified Health System (SUS) since the Basic Operational Norms were instituted in 1996 are duly presented.     

Small hospitals and their insertion in Brazil's National Health System (SUS)

This paper analyses small hospitals (less than fifty beds) in Brazil, in terms of their geographical distribution, legal status, types of wards and units, structures and service production. Under a directive published in April 2004, the Ministry of Health contracts and encourages these hospitals to adapt their profiles to the new roles assigned to them in the health system; consequently, data from December 2005 is compared to data from April 2004. Results: Small hospitals represent 62% of Brazil's hospital network, with 18% of current beds. Located mainly in upstate municipalities with less than 300,000 inhabitants, they offer limited complexity and technological density, with a low occupancy rate (32.8%). There are no changes in their production profiles between 2004 and 2006, due to the brief period since the implementation of Brazil's small hospitals policy in 2004, which has not been supported by the corresponding investment plans and human resources policies. This is a strategic hospital segment for providing all-round care in the Brazil's National Health System, due to its nationwide capillarity, endowed with ample potential for providing primary care while ensuring seamless links with other levels of complexity.     

Chronic dependence on mechanical pulmonary ventilation in pediatric care: a necessary debate for Brazil's Unified Health System

People with prolonged dependence on mechanical ventilation require permanent care and the use of equipment that can result in longer term hospital internment. This can lead to difficulty of access for patients with acute injuries, as well as personal difficulties and stress with reduced quality of life for their families or caregivers due to such longer hospital internment. This critical review of publications dealing with dependence on mechanical ventilation among children and adolescents aimed at making information organized in a systematic manner available in order to support discussion on the subject. It should be borne in mind that changes in epidemiological profile and growing technological access determine needs such as intensive therapy hospital beds and complex home care for chronic patients, which still have limits of supply and regulatory restrictions in the Brazilian public health system.     

The organization of regional and integrated healthcare delivery systems: challenges facing Brazil's Unified Health System

This article examines the causes of the segmentation/fragmentation in the healthcare process and the benefits of the constitution of networks set up to rationalize expenditures, optimize resources and ensure care tailored to the needs of the users. Its main purpose is to analyze the current challenges facing Brazil's Unified Health System, in order to promote improved integration between services. Among the challenges, those related to the insufficiency of resources due to low public funding, the training and education processes and their effects on the availability of health professionals to work in the public health system and the difficulties in the decentralization of health services and actions in the context of the Brazilian Federation Pact should be stressed. The paper concludes that, besides the efforts to tackle these challenges, the organization of regionalized networks integrated with the Unified Health System also depends on the improvement of intergovernmental management in the health regions to bolster the agreement on responsibilities among the government areas and the qualification of primary healthcare to coordinate care and ensure its continuity at other levels of the system.     

Survival analysis of dialysis patients in the Brazilian Unified National Health System

The aim of this study was to analyze the survival of patients who initiated renal replacement therapy (RRT) with hemodialysis or peritoneal dialysis in the Brazilian Unified National Health System from 2002 to 2004. This was an observational, prospective, non-concurrent study. The study used the National Database for Renal Replacement Therapies resulting from probabilistic matching of Authorization of High-Complexity Procedures/Outpatient Information System and the Mortality Information System. The study included patients admitted in 2002 and 2003, with 3 months of treatment, and 18 years or older. Of the 31,298 patients, the majority: began RRT with hemodialysis, were male, with mean age 54 years, and living in the Southeast region and in municipalities with a mean HDI of 0.78. Increased risk of death was associated with: female gender, age greater than 55 years, diagnosis of diabetes mellitus, peritoneal dialysis, and not residing in the Southeast region. Residing in cities with higher HDI was associated with lower risk. Adjusted risk was HR = 1.17 in favor of hemodialysis. The results suggest shorter survival for peritoneal dialysis and older patients. It is thus necessary to support policies to better evaluate the RRT modality with studies that further elucidate the findings.     

Community health workers in Brazil's Unified Health System: a framework of their praxis and contributions to patient health behaviors

Community health workers (CHWs) play a pivotal role in primary care, serving as liaisons between community members and medical providers. However, the growing reliance of health care systems worldwide on CHWs has outpaced research explaining their praxis - how they combine indigenous and technical knowledge, overcome challenges and impact patient outcomes. This paper thus articulates the CHW Praxis and Patient Health Behavior Framework. Such a framework is needed to advance research on CHW impact on patient outcomes and to advance CHW training. The project that originated this framework followed community-based participatory research principles. A team of U.S.-Brazil research partners, including CHWs, worked together from conceptualization of the study to dissemination of its findings. The framework is built on an integrated conceptual foundation including learning/teaching and individual behavior theories. The empirical base of the framework comprises in-depth interviews with 30 CHWs in Brazil's Unified Health System, Mesquita, Rio de Janeiro. Data collection for the project which originated this report occurred in 2008-10. Semi-structured questions examined how CHWs used their knowledge/skills; addressed personal and environmental challenges; and how they promoted patient health behaviors. This study advances an explanation of how CHWs use self-identified strategies--i.e., empathic communication and perseverance--to help patients engage in health behaviors. Grounded in our proposed framework, survey measures can be developed and used in predictive models testing the effects of CHW praxis on health behaviors. Training for CHWs can explicitly integrate indigenous and technical knowledge in order for CHWs to overcome contextual challenges and enhance service delivery.     

Quality of care for ischemic stroke in the Brazilian Unified National Health System

The hospital mortality rate is an outcome measure of care used as an indicator of quality of care for stroke. Computerized tomography is the main imaging method for diagnosing and managing stroke. This study aimed to assess the quality of hospital care for acute ischemic stroke (AIS) in the Brazilian Unified National Health System (SUS), considering the severity of cases and use of computerized tomography. Multivariate analysis was used to adjust the mortality risk, evaluate the use of computerized tomography, and rank the performance of hospitals from April 2006 to December 2007. 16,879 admissions were analyzed, and at least one CT scan was performed in 28.6% of the admissions. The crude mortality rate was 34.3%, and the adjusted rate was 31.2%. Performance of a CT scan showed a protective effect: the adjusted OR was 0.27 for one test and 0.32 for two tests. Under-utilization of computerized tomography is one of the limiting factors for good medical practice in the management of ischemic stroke in the SUS.     

Challenges facing community health workers in Brazil's Family Health Strategy: A qualitative study

Community health worker (CHW) programs are implemented in many low‐ and middle‐income countries such as Brazil to increase access to and quality of care for underserved populations; CHW programs have been found to improve certain indicators of health, but few studies have investigated the daily work of CHWs, their perspectives on what both helps and hinders them from fulfilling their roles, and ways that their effectiveness and job satisfaction could be increased. To examine these questions, we observed clinic visits, CHW home visits, and conducted semistructured interviews with CHWs in 7 primary care centers in Brazil—2 in Salvador, Bahia, and 5 in São Paulo, SP—in which CHWs are incorporated into the work of all primary care health teams. In addition to enhancing communication between the medical system and the community, CHWs consider their key roles to be helping persuade community members to seek medical care and increasing health professionals' awareness of the social conditions affecting their patients' health. Key obstacles that CHWs face include failure to be fully integrated into the primary care team, inability to follow‐up on identified health needs due to limited resources, as well as community members' lack of understanding of their work and undervaluing of preventative medicine. Increased training, better incorporation of CHWs into clinic flow and decision making, and establishing a clear community awareness of the roles and value of CHWs will help increase the motivation and effectiveness of CHWs in Brazil.     

Homeopathy in the Unified National Health System in Brazil: users' representations of homeopathic treatment

Homeopathy was officially introduced in Brazil in 1840 but was only recognized by the Federal Board of Medicine as a medical specialty in 1980. It still has a limited presence in the Unified National Health System (SUS), with only a few homeopathy services in a handful of Brazilian counties. The current study aimed to analyze National Health System users' representations of homeopathy. A case study was conducted in a health unit in Salvador, Bahia State, using a qualitative methodology. Data collection used 112 questionnaires and 19 in-depth interviews with users of homeopathy services. The study results showed that the main motivation for seeking homeopathic treatment was the failure of previous allopathic treatment. The holistic perspective, use of natural medications, longer consultations, and attentive listening to patients appeared as positive characteristics of homeopathy as compared to allopathy. The results point to the potential contribution of alternative therapeutic practices like homeopathy to the Brazilian National Health System.     

Adding physiotherapy practitioners to family health teams and Brazil's National Health System (SUS): challenges in training

This paper presents the role of the physiotherapist in the Family Health Program, particularly with regard to all-round care, analyzing the academic education of physiotherapists in terms of this Program from the standpoint of the players involved, based on an analysis of the Physiotherapy Course at the Tubar?o campus of the Southern Santa Catarina State University (UNISUL). Similar to a case study, a qualitative survey was conducted, interviewing three Family Health Program nurses, three teachers, two interns and the Deputy Coordinator of this course. The data were analyzed through an examination of the contents of the collected responses. The closing remarks of this paper stress that the understanding of the nurses and the students of the role played by the physiotherapist in the Family Health Program is guided by diseases. This indicates a need for better-informed lecturers and coordination on this matter to avoid this repercussion, extending experiences in the Family Health Program built up during the course and preparing practitioners for working in teams providing all-round care.     

Determinants of expenditures on dialysis in the Unified National Health System, Brazil, 2000 to 2004

The aim of this study was to compare total outpatient expenditures on hemodialysis and peritoneal dialysis from 2000 to 2004 in patients that began dialysis in 2000 under the Unified National Health System (SUS). A historical cohort was developed, consisting of patients that began dialysis in 2000, identified by probabilistic matching in the database of Authorizations for High-Complexity/High-Cost Procedures (APAC). A multiple linear regression model was used, including individual and clinical attributes and health services supply variables. The cohort included 10,899 patients, 88.5% of whom began hemodialysis and 11.5% peritoneal dialysis. The dialysis modality explains 12% of the variance in expenditures, and patients in peritoneal dialysis showed 20% higher mean annual expenditure. The differences in expenditures are explained according to the State of Brazil and health services supply level. Individual risk variables did not alter the model's explanatory power, while age and diabetes mellitus were significant. The study showed the importance of the National Health System's payment mechanism for explaining differences in expenditures on dialysis treatment in Brazil.     

Analysis of the progressivity of Brazilian Unified National Health System (SUS) financing

This article analyzes the level of progressivity in taxes financing the Brazilian Unified National Health System (SUS). Distribution of the tax burden financing the SUS was calculated using micro-data from the Household Budgets Survey, 2002-2003. The Kakwani index, which shows a tax system's level of progressivity, was calculated. The Kakwani index of public financing was -0.008, and SUS financing was nearly proportional to income. From a social justice perspective this is highly undesirable in a society like Brazil, with a Gini index of 0.57. The system should be clearly progressive in order to counterbalance the country's extreme income concentration.     

A critical analysis of medical specialities and strategies for their integration into the Unified National Health System in Brazil

The implementation of medical specialization in Brasil has been relatively free of constraints. There has thus been a progressive fragmentation of medical work. The so-called root specialities are losing both their strength and clinical problem-solving capacity. Two operational concepts are proposed for achieving better administration of medical responsibilities and the role of medical professionals: 1) field of competence and 2) core competence. General goals are suggested for reforming specialized training and integration of specialists into the Unified National Health System.     

Factors associated with poor self-rated health in elderly users of the Brazilian Unified National Health System

This article reports on prevalence of poor self-rated health and associated factors among elderly users of the Brazilian Unified National Health System (SUS) in Goiania, Goiás State, Brazil. The article is based on a cross-sectional study with a proportional sample of elderly in the nine health districts of Goiania. Data were collected after a pilot study and training of field staff. The measure of association was the prevalence ratio (PR) and respective confidence interval (95%CI). Multivariate analysis was performed using hierarchical Poisson regression. In 403 elderly, prevalence of poor self-rated health was 27.5% (95%CI: 23.2-32.2). The rate was 29.7% in women and 29.1% among seniors aged 60-64 years. Variables associated with poor self-rated health according to multivariate analysis were: less than one year of schooling, lack of physical exercise, use of five or more medications, and recent weight loss. The results showed high prevalence of poor self-rated health and associated factors, including both adverse social conditions and individual health and lifestyle factors.     

Access to hospitalization in Brazilian municipalities in 2000: territorial distribution in the Unified National Health System

This article investigates the effect of external factors on hospitalization patterns in Brazilian municipalities (or counties): supply, spatial configuration, socioeconomic aspects, and political context. Inpatient data from 2000 for individuals 15 years and over and most frequent hospital procedures, obtained from the National Hospital Information System (SIH-SUS), were aggregated by place of residence at the municipal level. Nested generalized additive mixed models were fitted using Bayesian inference. Probability of hospitalization is shown to increase with hospital bed supply and with primary care and local capacity, and to decrease with increasing distances and in larger and wealthier municipalities. Inclusion of random, State, and spatial patterns effects reveals regional differences in the probability of hospitalization and the main factors explaining such different patterns.