Family Health

The Primary Health Care (APS) Strategy in Brazil

Luis Fernando Rolim Sampaio, MD, MPH National Director of Primary Care

Tegucigalpa, Honduras – November, 2006

RIO DE JANEIRO

BRAZIL

An unequal country

Per capita income by municipalities, 2000

Per Capita Income, 2000All municipalities in Brazil

Histogram

Legend

Infant mortality < 1 year by municipality - 2000

Histogram

Legend

Mortality up to one year of age, 2000All municipalities in Brazil

An unequal country that chose a universal,

integrated and publicly financed health system: The construction of the Brazilian Unified Health

System- SUS

Started with the community agents program in 1991

Reinforced by primary care and the creation of the Family Health Program - PSF - in Brazil

in 1993

National efforts for the universalization of access, without out-of-pocket expenses,

for the entire population

The search for compatibility and integration and the creation of health care networks

based on primary care

1 – Definition of the national primary care team and the essential functions to be integrated into the

service network

2 – Definition of the role of responsibilities of each governmental sphere within PHC management

3 – Changes in financing and in the growth in resources budgeted for primary care

4 – Creation of monitoring and evaluation systems

5 – Articulation with training centers

6 – Achievements and creation of a political space for PHC

Six basic points for change in PHC

DEFINITION OF THE NATIONAL PRIMARY CARE TEAM AND ITS ESSENTIAL

FUNCTIONS

What is the primary care team?

It is a team responsible for a territory of 800 to 1,000 families – up to 4,000 people, which includes:

- Generalist physician (or specialist in family medicine)

- Nurse or nursing assistant

- Community health agent

- Odontologist and dental hygienist

- Others – to be defined by the municipalities

Definition of the national primary care team and its essential functions

What does the primary care team do?

They should monitor and evaluate the health situation of the population, provide primary care services, and make referrals to other levels of the system if necessary;

They should understand the social process in their territory, be proactive in the community and have cultural competence;

They should work together on clinical, public health and health promotion activities and on the prevention of health hazards.

Definition of the national primary care team and its essential functions

How does the primary care team work?

Everyone should work 40 hours per week (at the beginning, they would not be able to have another job);

Professionals receive differentiated salaries (the doctor is paid as if working in two or three jobs);

They will not receive anything for the provision of services (they have to work the required hours);

The form of contracting is different in each municipality.

Definition of the national primary care team and its essential functions

What is the community health agent?•They are people that live in the same area where they work;•They should have good knowledge of the community’s problems;•They should be capable of connecting the professional team to the community (cultural competency);•They work with a focus on health promotion and are not disease-oriented;•They are community leaders;•They are essential team members

Definition of the national primary care team and its essential functions

RESPONSIBILITIES OF THE MANAGEMENT

SPHERES IN PRIMARY CARE

Federal Responsibility

Develop the guidelines for national primary health care policy – 2006 strategic areas (women’s health, child health, older adult health, AH/DM, TBC, Hansen, oral health and elimination of child malnutrition)

Co-finance the primary care system

Manage human resource training

Propose mechanisms for the programming, control, regulation and evaluation of primary care

Monitor and evaluate national indicators

State/Provincial Responsibility

Accompany the introduction and implementation of primary care activities in their territory

Regulate inter-municipal relationships

Coordinate the implementation of policies for the qualification of human resources in their territory

Co-finance primary care activities

Support the implementation of strategies for evaluating primary care in their territory.

Municipal Responsibility

Define and implement the primary care model in their territory

Regulate the work contract related to primary care

Maintain the network of basic health units in operation (management and stewardship)

Co-finance primary health care activities

Contribute to national information systems

Evaluate the performance of the primary health care teams under their supervision.

CHANGES IN THE FINANCING AND ALLOCATION OF RESOURCES

FOR PRIMARY CARE

The creation of the Basic Care Ceiling – PAB (Piso de Atenção

Básica, a budget "floor" for basic health care)– a national per capita

for all municipalities

The institution of an incentive for the PSF: an adjustable PAB and

equity incentives (HDI < 0.700 = 50% higher budget)

Financing of Health in the SUS

Responsibility of the three management spheres

Constitutional Amendment 29 - 15% of the municipal budget, 12% of the states’ budgets, in addition to spending by the Federal union, starting in 2000, and increasing each year according to GDP growth.

Federal Budgets transferred from the national fund to municipal funds through the fixed PAB and adjustable PAB – PSF . There will be no destination other than primary health care activities.

0

2,000

4,000

6,000

Adjustable* 651.9 898.9 1,270. 1,662. 2,191. 2,679. 3,248.Fixed 1,562. 1,744. 1,766. 1,902. 2,134. 2,335. 2,470.

2000 2001 2002 2003 2004 2005 2006*

Evolution of federal budgetsFixed and adjustable PAB

Per capita distribution of Financial Resources for Primary Care in reales/inhab/year

BRAZIL – 1998 and 2005

SOURCE: DATASUS

up to 20from 20 to 40from 40 to 60from 60 to 80more than 80

1998 2005

Family Health Strategy

1998 1999 2000 2001

2003 2004 2005*

0% 0 to 25% 25 to 50% 50 to 75% 75 to 100%(*)

Agosto/2005.

SOURCE: Primary Care Information System - SIAB

20022002

Evolution of the Introduction of Family Health Teams- BRAZIL, 1998/2005

Family Health Teams (ESF), Community Health Agents (ACS) and Oral Health Teams (SB)

BRAZIL, SEPTEMBER/2006

ESF/ACS/SB

ACS

SEM ESF, ACS E ESB

ESF/ACS

No. of Teams – 26,650No. of Municipalities - 5,087

No. of Agents – 218,121No. of Municipalities - 5,288

No. of Oral Health Teams – 14,597No. of Municipalities – 4,189

SOURCE: Primary Care Information System - SIAB

Achievements of the Brazilian PHC strategy

Family Health Program

•PHC on the political agenda of public managers; •Expansion of access and coverage; •Academic studies in progress and institutionalization of evaluation;

•Improvement in selected indicators from 1998-2004, with an increase in equity;

•User satisfaction;

•Changes in the practices of the health teams;•Professional qualifications (medical and multi-professional residencies and specializations in Family Health);

This study is a longitudinal ecological analysis using panel data from secondary sources. Analyses

controlled for state-level measures of access to clean water and sanitation, average income, women’s literacy and fertility, physicians and nurses per 10,000 population, and hospital beds per 1,000 population. Additional analyses controlled for

immunization coverage and tested interactions between the Family Health Program and

proportionate mortality from diarrhea and acute respiratory infections.

Setting: 13 years (1990-2002) of data from 27 Brazilian States

10% growth in coverage – 4.6% decline in infant mortality (1992-2002);

Family Health Program in Brazil

Analysis of selected health indicators 1998-2004

Prof. Alice Teles de CarvalhoFebruary 2006

Figura : Evolução da cobertura do PSF nos municípios agrupados segundo IDH. Brasil,1998-2005

-10,00

10,00

30,00

50,00

70,00

90,00

1998 1999 2000 2001 2002 2003 2004 2005

%

Baixo Intermediário Alto

Decrease in gaps

Low

Figure. Evolution of PSF coverage in municipalities grouped according to the HDI. Brazil, 1998-2005

Intermediate High

Source: Mortality Information System - SIM and Live Birth Information System - SINASC

Proporção de óbitos infanti l por causas mal definidas segundo estrato de cobertura do PSF. Brasil 1998/2004

0,005,00

10,0015,0020,0025,0030,00

1998 1999 2000 2001 2002 2003 2004

ANOS

%

< 20% 20 |-- 50% 50 |-- 70% >=70% Brasil

2,336,06

10,3814,10

0,00

5,00

10,00

15,00

%

< 20% 20 |-- 50% 50 |-- 70% >=70%

Declínio médio anual da proporção de óbitos infantil por causas mal definidas segundo estrato de cobertura do PSF. Brasil

1998/2004

Proportion of infant deaths due to undefined causes, according toPSF coverage stratum. Brazil, 1998/2004

Average annual decline in the proportion of infant deaths due to undefined causes, according to PSF coverage stratum. Brazil, 1998/2004

YEARS

Brazil

Source: SIM and SINASC

Taxa de mortalidade infantil pos neonatal segundo estrato de cobertura do PSF. Brasil 1998/2004

0,00

5,00

10,00

15,00

1998 1999 2000 2001 2002 2003 2004

ANOS

< 20% 20 |-- 50% 50 |-- 70% >=70% Brasil

4,83-6,41-

8,15- 8,61--10,00

-5,00

0,00

%

< 20% 20 |-- 50% 50 |-- 70% >=70%

Declínio médio anual da Taxa de mortalidade infantil pós- neonatal segundo estrato de cobertura do PSF. Brasil 1998/2004

Post neonatal infant mortality rate, according toPSF coverage stratum. Brazil, 1998/2004

YEARS

Decline in the post neonatal infant mortality rate, according toPSF coverage stratum. Brazil, 1998/2004

Brazil

4.87- 1.903.51 3.87

-5.00

0.00

5.00

%

< 20% 20 |-- 50% 50 |-- 70% >=70%

Average annual variation in the Infant mortality rate, according to PSF coverage stratum in municipalities with a low HDI. Brazil 1998-2003

Taxas* de internação por desnutrição em crianças de até 1 ano de idade, 2002 a 2005, Brasil e regiões (por 1000)

2,151,601,622,201,741,862005

2,652,051,903,012,672,412004

3,182,362,404,212,873,082003

2,172,492,384,212,522,992002

Centro OesteSulSudesteNordeste

Norte BrasilAno

Taxas de internação

Proporção de nascidos vivos de mães com nenhuma consulta de pré-natal, segundo estratos de cobertura do PSF. Brasil

1998/2004

0,00

3,00

6,00

9,00

12,00

1998 1999 2000 2001 2002 2003 2004

ANOS

%

< 20% 20 |-- 50% 50 |-- 70% >=70% Brasil

8,62-11,43-

15,32-17,96-

-20,00

-10,00

0,00

%

< 20% 20 |-- 50% 50 |-- 70% >=70%

Declínio médio anual da Proporção de nascidos vivos de mães com nenhuma consulta de pré-natal, segundo estratos de

cobertura do PSF. Brasil, 1998/2004

Proportion of live births to mothers with no prenatal controls, according to PSF coverage stratum.

Brazil, 1998/2004

Average annual decline in the proportion of live births to motherswith no prenatal controls, according to PSF coverage stratum.

Brazil, 1998/2004

YEARS

Homogeneidade de cobertura vacinal por tetravalente em menores de 1 ano de idade, segundo estrato de cobertura

do PSF. Brasil 1998/2005

30,00

40,00

50,00

60,00

70,00

1998 1999 2000 2001 2002 2003 2004 2005

ANOS

%

< 20% 20 |-- 50% 50 |-- 70% >=70% Brasil

3,89 3,914,94

8,58

0,00

5,00

10,00

%

< 20% 20 |-- 50% 50 |-- 70% >=70%

Aumento médio anual da Homogeneidade de cobertura vacinal por tetravalente em menores de 1 ano de idade, segundo estrato

de cobertura do PSF. Brasil 1998/2005

Homogeneity of tetravalent vaccination coverage in infants under 1 year of age, according to PSF coverage stratum. Brazil, 1998/2005

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

YEARS

67.2

57.4

10.1

60.8

8.1 7.0

63.3

6.1

65.8

4.8 3.6

69.5

2.9

70.9

-1020304050607080

% of children up to 4 monthswith exclusive maternal

breastfeeding

% of children under 1 year whoare malnourished

%

1999 2000 2001 2002 2003 2004 2005

Fonte: Sistema de Inf or mação da Atenção Bási ca - SIAB - Base l impa*Cr iança cujo peso fi cou abaixo do percenti l 3 (curva inf er ior ) da curva de peso por idade do Caderneta de Saúde da Cr iança. **Dados até o o mês 11/ 2005. Sujei to à modifi cações.

Prevalence of exclusive maternal breastfeeding in children up to 4 months of age and protein-caloric malnutrition* in children under 1 year of age,

in areas covered by the Family Health Strategy, Brazil, 1999 - 2005**.

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

Family Health Program and Family Grant (Bolsa Família) –

inter-sectoral action

Hospitalization rates* due to malnutrition in children up to 1 year of age, 2002 to 2005, Brazil

and regions (per 1,000)

0

1

2

3

4

5

2002 2003 2004 2005

BRAZILNortheastNorthSouthSoutheastCentral-West

2.151.601.622.201.741.862005

2.652.051.903.012.672.412004

3.182.362.404.212.873.082003

2.172.492.384.212.522.992002

Central West

South

S. eastN. eastNorth BrazilYear

Hospitalization rates

CHALLENGES

CHALLENGES

Qualification following the growth of Family Health – alliances with universities, organizations;

Search for health care that is integrated (guaranteed referral to other services) and comprehensive (promotion, prevention and care) Financial and political sustainability and commitment to PHC in the health system;

Labor relations of professionals – precarization X worker rights;

Strengthening of the PHC Indicators Pact.

CHALLENGES

Social appreciation for the family doctor and primary care doctor;

Resistance by professional unions and associations to the change;Large cities (violence) and remote places (cultural differences);

Social control and community participation;Evaluation for quality improvement – AMQ and the program for managing results – PROGRAB;

The responsibility and commitment of public managers.

www.saude.gov.br/dab

www.saude.gov.br/atencaobasica

www.saude.gov.br/atencaoprimaria