The Brazilian health system at crossroads: progress, crisis and resilience

Deciphering Trends in Cancer Mortality: A Comprehensive Analysis of Brazilian Data From 1979 to 2021 With Emphasis on Breast and Prostate Cancers

Background

This study examined cancer mortality trends in Brazil from 1979 to 2021, emphasizing breast and prostate cancers.

Methods

Utilizing data from the Brazilian Mortality Information System and the Brazilian Institute of Geography and Statistics, it analyzed cancer deaths nationally and regionally, highlighting gender-specific and regional disparities.

Results

The research finds that cancer death rates have been growing at an average of 12% per year, contrasting with the population growth rate of 2.2%. This trend is more pronounced in the southern and southeastern regions of Brazil. A comparison of cancer mortality rates between Brazil, the USA, and China reveals that while the Brazilian and Chinese rates exhibit slower growth, the US rate shows a continuous decline since the 1990s.

Conclusions

The study adopts a novel approach by focusing on growth rates and employing polynomial interpolation, revealing a deceleration in cancer death growth over the last 15 years across all malignant neoplasms. The study also contextualizes these findings within Brazil's cancer control policies, tracing the evolution of preventive measures and treatment advancements. It highlights the significant role of the National Cancer Institute and the Unified Health System in implementing effective strategies. The decreasing trend in cancer mortality rates in Brazil, despite population growth, illustrates the effectiveness of comprehensive cancer control and prevention measures, underlining their importance in public health policy.

Retrospective analysis of 1,203 cases of referral to a quaternary vascular surgery outpatient clinic within the Unified Health System, São Paulo, Brazil

OBJECTIVE

Through a retrospective analysis of 1,203 cases of referral from primary healthcare units to a specialized quaternary vascular surgical service, the findings of this study revealed a high proportion of inappropriate referrals, which may represent a substantial subutilization of this highly complex service. Consequently, in this study, we aimed to evaluate 1,203 cases of referral to a quaternary vascular surgical service, in São Paulo, Brazil, over a 6-year period, to assess the appropriate need for referral; in addition to the prevalence of surgical indications.

METHODS

In this retrospective analysis, we reviewed the institutional records of participants referred from Basic Healthcare Units to a vascular surgical service inside the Brazilian Unified Health System, between May 2015 and December 2020. Demographic and clinical data were collected. The participants were stratified, as per the reason for referral to the vascular surgical service, previous imaging studies, and surgical treatment indications. Referral appropriateness and complementary examinations were evaluated for each disease cohort. Finally, the prevalence of cases requiring surgical treatment was defined as the outcome measure.

RESULTS

Of the 1,203 referrals evaluated, venous disease was the main reason for referral (53%), followed by peripheral arterial disease (19.4%). A considerable proportion of participants had been referred without complementary imaging or after a long duration of undergoing an examination. Referrals were regarded as inappropriate in 517 (43%) cases. Of these, 32 cases (6.2%) had been referred to the vascular surgical service, as the incorrect specialty. The percentage of referred participants who ultimately underwent surgical treatment was 39.92%. Carotid (18%) and peripheral arterial diseases (18.4%) were correlated with a lower prevalence of surgical treatments.

CONCLUSION

The rate of referral appropriateness to specialized vascular care from primary care settings was low. This may represent a subutilization of quaternary surgical services, with low rates of surgical treatment.

Mental Health Collaborative Care in Brazil and the Economy of Attention: Disclosing Barriers and Therapeutic Negotiations

The introduction of mental health collaborative care (MHCC) is one of the strategies to scale up access to mental health care in primary health care in Brazil. This article investigates an experience of mental health collaborative care in the city of Rio de Janeiro, Brazil. It is a qualitative study involving interviews with physicians and mental health professionals working in primary health care units located in the northern part of the city of Rio de Janeiro, Brazil. The aim is to examine the various strategies and negotiations that primary health care professionals deploy to identify mental distress and plan health care interventions. We discuss the results within the economy of attention framework. We argue that divergences in diagnostic design and therapeutic planning carried out by professionals and users or observed in MHCC meetings illustrate the health-disease-care seeking phenomenon as a negotiated process, entangled in complex interactions. Our results evince that those interactions are not always evident and configure 'what is at stake' in mental suffering. The incorporation of cultural and structural determinants in collaborative care may enable the expansion of mental health initiatives sensitive to local needs and realities.

Concept analysis of health system resilience

BACKGROUND

There are several definitions of resilience in health systems, many of which share some characteristics, but no agreed-upon framework is universally accepted. Here, we review the concept of resilience, identifying its definitions, attributes, antecedents and consequences, and present the findings of a concept analysis of health system resilience.

METHODS

We follow Schwarz-Barcott and Kim's hybrid model, which consists of three phases: theoretical, fieldwork and final analysis. We identified the concept definitions, attributes, antecedents and consequences of health system resilience and constructed an evidence-informed framework on the basis of the findings of this review. We searched PubMed, PsycINFO, CINAHL Complete, EBSCOhost-Academic Search and Premier databases and downloaded identified titles and abstracts on Covidence. We screened 3357 titles and removed duplicate and ineligible records; two reviewers then screened each title, and disagreements were resolved by discussion with the third reviewer. From the 130 eligible manuscripts, we identified the definitions, attributes, antecedents and consequences using a pre-defined data extraction form.

RESULTS

Resilience antecedents are decentralization, available funds, investments and resources, staff environment and motivation, integration and networking and finally, diversification of staff. The attributes are the availability of resources and funds, adaptive capacity, transformative capacity, learning and advocacy and progressive leadership. The consequences of health system resilience are improved health system performance, a balanced governance structure, improved expenditure and financial management of health and maintenance of health services that support universal health coverage (UHC) throughout crises.

CONCLUSION

A resilient health system maintains quality healthcare through times of crisis. During the coronavirus disease 2019 (COVID-19) epidemic, several seemingly robust health systems were strained under the increased demand, and services were disrupted. As such, elements of resilience should be integrated into the functions of a health system to ensure standardized and consistent service quality and delivery. We offer a systematic, evidence-informed method for identifying the attributes of health system resilience, intending to eventually be used to develop a measuring tool to evaluate a country's health system resilience performance.

Undernutrition, and overweight and obesity: the two faces of malnutrition in Brazil, analysis of the Global Burden of Disease, 1990 to 2019

OBJECTIVES

The objective of this study was to analyse the global burden of disease attributable to undernutrition and high body mass index (BMI) in Brazil and its 27 states, as well as its association with the socio-demographic index (SDI) from 1990 to 2019.

STUDY DESIGN

This is an epidemiological time-series study.

METHODS

This study analysed the undernutrition and high BMI estimated by the Global Burden of Disease study conducted from 1990 to 2019 for Brazil and its states, using the following metrics: absolute number of deaths, standardised mortality rate, and disability-adjusted life years (DALYs). This study also analysed the correlation between the percentage variation of mortality rates and SDI.

RESULTS

A decrease in the number of deaths (-75 %), mortality rate (-75.1 %), and DALYS (-72 %) attributable to undernutrition was found in Brazil and in all regions. As regarding the high BMI, an increase in the number of deaths was found (139.6 %); however, the mortality rate (-9.7) and DALYs (-6.4 %) declined in all regions, except in the North and Northeast regions, which showed an increase. A strong correlation was identified between undernutrition and high BMI with SDI.

CONCLUSION

Our study observed a double burden of malnutrition in Brazil, with a reduction in the burden of diseases due to malnutrition in Brazil and variation in the burden due to high BMI according to the socioeconomic status of the region. Public policies are necessary in order to guarantee the human right to a healthy and sustainable diet, together with food and nutrition security and a diminishing of social inequality.

Does unequal economic development contribute to the inequitable distribution of healthcare resources? Evidence from China spanning 2001-2020

BACKGROUND

There is a dearth of research combining geographical big data on medical resource allocation and growth with various statistical data. Given the recent achievements of China in economic development and healthcare, this study takes China as an example to investigate the dynamic geographical distribution patterns of medical resources, utilizing data on healthcare resources from 290 cities in China, as well as economic and population-related data. The study aims to examine the correlation between economic growth and spatial distribution of medical resources, with the ultimate goal of providing evidence for promoting global health equity.

METHODS

The data used in this study was sourced from the China City Statistical Yearbook from 2001 to 2020. Two indicators were employed to measure medical resources: the number of doctors per million population and the number of hospital and clinic beds per million population. We employed dynamic convergence model and fixed-effects model to examine the correlation between economic growth and the spatial distribution of medical resources. Ordinary least squares (OLS) were used to estimate the β values of the samples.

RESULTS

The average GDP for all city samples across all years was 36,019.31 ± 32,029.36, with an average of 2016.31 ± 1104.16 doctors per million people, and an average of 5986.2 ± 6801.67 hospital beds per million people. In the eastern cities, the average GDP for all city samples was 47,672.71 ± 37,850.77, with an average of 2264.58 ± 1288.89 doctors per million people, and an average of 3998.92 ± 1896.49 hospital beds per million people. Cities with initially low medical resources experienced faster growth (all β < 0, P < 0.001). The long-term convergence rate of the geographic distribution of medical resources in China was higher than the short-term convergence rate (|βi + 1| > |βi|, i = 1, 2, 3, …, 9, all β < 0, P < 0.001), and the convergence speed of doctor density exceeded that of bed density (bed: |βi| >doc: |βi|, i = 3, 4, 5, …, 10, P < 0.001). Economic growth significantly affected the convergence speed of medical resources, and this effect was nonlinear (doc: βi < 0, i = 1, 2, 3, …, 9, P < 0.05; bed: βi < 0, i = 1, 2, 3, …, 10, P < 0.01). The heterogeneity between provinces had a notable impact on the convergence of medical resources.

CONCLUSIONS

The experiences of China have provided significant insights for nations worldwide. Governments and institutions in all countries worldwide, should actively undertake measures to actively reduce health inequalities. This includes enhancing healthcare standards in impoverished regions, addressing issues of unequal distribution, and emphasizing the examination of social determinants of health within the domain of public health research.

Managing under austerity: a qualitative study of management-union relations during attempts to cut labour costs in three South African public hospitals

PURPOSE

In this paper, the authors examine the strategies used to reduce labour costs in three public hospitals in South Africa, which were effective and why. In the democratic era, after the revelations of large-scale corruption, the authors ask whether their case studies provide lessons for how public service institutions might re-make themselves, under circumstances of austerity.

DESIGN/METHODOLOGY/APPROACH

A comparative qualitative case study approach, collecting data using a combination of interviews with managers, focus group discussions and interviews with shop stewards and staff was used.

FINDINGS

Management in two hospitals relied on their financial power, divisions between unions and employees' loyalty. They lacked the insight to manage different actors, and their efforts to outsource services and draw on the Extended Public Works Program failed. They failed to support staff when working beyond their scope of practice, reducing employees' willingness to take on extra responsibilities. In the remaining hospital, while previous management had been removed due to protests by the unions, the new CEO provided stability and union-management relations were collaborative. Her legitimate power enabled unions and management to agree on appropriate cost cutting strategies.

ORIGINALITY/VALUE

Finding an appropriate balance between the new reality of reduced financial resources and the needs of staff and patients, requires competent unions and management, transparency and trust to develop legitimate power; managing in an authoritarian manner, without legitimate power, reduces organisational capacity. Ensuring a fair and orderly process to replace ineffective management is key, while South Africa grows cohorts of competent managers and builds managerial experience.

Health insurance status, lifestyle choices and the presence of non-communicable diseases: a systematic review

BACKGROUND

Although health insurance (HI) has effectively mitigated healthcare financial burdens, its contribution to healthy lifestyle choices and the presence of non-communicable diseases (NCDs) is not well established. We aimed to systematically review the existing evidence on the effect of HI on healthy lifestyle choices and NCDs.

METHODS

A systematic review was conducted across PubMed, Medline, Embase, Cochrane Library and CINAHLComplet@EBSCOhost from inception until 30 September 2022, capturing studies that reported the effect of HI on healthy lifestyle and NCDs. A narrative synthesis of the studies was done. The review concluded both longitudinal and cross-sectional studies. A critical appraisal checklist for survey-based studies and the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies were used for the quality assessment.

RESULT

Twenty-four studies met the inclusion criteria. HI was associated with the propensity to engage in physical activities (6/11 studies), consume healthy diets (4/7 studies), not to smoke (5/11 studies) or take alcohol (5/10 studies). Six (of nine) studies showed that HI coverage was associated with a lowered prevalence of NCDs.

CONCLUSION

This evidence suggests that HI is beneficial. More reports showed that it propitiated a healthy lifestyle and was associated with a reduced prevalence of NCDs.

Motivational drivers for health professionals in a large quality improvement collaborative project in Brazil: a qualitative study

BACKGROUND

The success of collaborative quality improvement (QI) projects in healthcare depends on the context and engagement of health teams; however, the factors that modulate teams' motivation to participate in these projects are still unclear. The objective of the current study was to explore the barriers to and facilitators of motivation; the perspective was health professionals in a large project aiming to implement evidence-based infection prevention practices in intensive care units of Brazilian hospitals.

METHODS

This qualitative study was based on content analysis of semistructured in-depth interviews held with health professionals who participated in a collaborative QI project named "Improving patient safety on a large scale in Brazil". In accordance with the principle of saturation, we selected a final sample of 12 hospitals located throughout the five regions of Brazil that have implemented QI; then, we conducted videoconference interviews with 28 health professionals from those hospitals. We encoded the interview data with NVivo software, and the interrelations among the data were assessed with the COM-B model.

RESULTS

The key barriers identified were belief that improvement increases workload, lack of knowledge about quality improvement, resistance to change, minimal involvement of physicians, lack of supplies, lack support from senior managers and work overload. The primary driver of motivation was tangible outcomes, as evidenced by a decrease in infections. Additionally, factors such as the active participation of senior managers, teamwork, learning in practice and understanding the reason for changes played significant roles in fostering motivation.

CONCLUSION

The motivation of health professionals to participate in collaborative QI projects is driven by a variety of barriers and facilitators. The interactions between the senior manager, quality improvement teams, and healthcare professionals generate attitudes that modulate motivation. Thus, these aspects should be considered during the implementation of such projects. Future research could explore the cost-effectiveness of motivational approaches.

Twenty-first-century demographic and social inequalities of heat-related deaths in Brazilian urban areas

Population exposure to heat waves (HWs) is increasing worldwide due to climate change, significantly affecting society, including public health. Despite its significant vulnerabilities and limited adaptation resources to rising temperatures, South America, particularly Brazil, lacks research on the health impacts of temperature extremes, especially on the role played by socioeconomic factors in the risk of heat-related illness. Here, we present a comprehensive analysis of the effects of HWs on mortality rates in the 14 most populous urban areas, comprising approximately 35% of the country's population. Excess mortality during HWs was estimated through the observed-to-expected ratio (O/E) for total deaths during the events identified. Moreover, the interplay of intersectionality and vulnerability to heat considering demographics and socioeconomic heterogeneities, using gender, age, race, and educational level as proxies, as well as the leading causes of heat-related excess death, were assessed. A significant increase in the frequency was observed from the 1970s (0-3 HWs year-1) to the 2010s (3-11 HWs year-1), with higher tendencies in the northern, northeastern, and central-western regions. Over the 2000-2018 period, 48,075 (40,448-55,279) excessive deaths were attributed to the growing number of HWs (>20 times the number of landslides-related deaths for the same period). Nevertheless, our event-based surveillance analysis did not detect the HW-mortality nexus, reinforcing that extreme heat events are a neglected disaster in Brazil. Among the leading causes of death, diseases of the circulatory and respiratory systems and neoplasms were the most frequent. Critical regional differences were observed, which can be linked to the sharp North-South inequalities in terms of socioeconomic and health indicators, such as life expectancy. Higher heat-related excess mortality was observed for low-educational level people, blacks and browns, older adults, and females. Such findings highlight that the strengthening of primary health care combined with reducing socioeconomic, racial, and gender inequalities represents a crucial step to reducing heat-related deaths.

A scientometric analysis of fairness in health AI literature

Artificial intelligence (AI) and machine learning are central components of today's medical environment. The fairness of AI, i.e. the ability of AI to be free from bias, has repeatedly come into question. This study investigates the diversity of members of academia whose scholarship poses questions about the fairness of AI. The articles that combine the topics of fairness, artificial intelligence, and medicine were selected from Pubmed, Google Scholar, and Embase using keywords. Eligibility and data extraction from the articles were done manually and cross-checked by another author for accuracy. Articles were selected for further analysis, cleaned, and organized in Microsoft Excel; spatial diagrams were generated using Public Tableau. Additional graphs were generated using Matplotlib and Seaborn. Linear and logistic regressions were conducted using Python to measure the relationship between funding status, number of citations, and the gender demographics of the authorship team. We identified 375 eligible publications, including research and review articles concerning AI and fairness in healthcare. Analysis of the bibliographic data revealed that there is an overrepresentation of authors that are white, male, and are from high-income countries, especially in the roles of first and last author. Additionally, analysis showed that papers whose authors are based in higher-income countries were more likely to be cited more often and published in higher impact journals. These findings highlight the lack of diversity among the authors in the AI fairness community whose work gains the largest readership, potentially compromising the very impartiality that the AI fairness community is working towards.

Maintenance of medium- and high-complexity health services in the context of high patient transition: a time series ecological study of the state of Rio de Janeiro, Brazil

The study addresses the historical disparities in the distribution of the medium- and high-complexity health network and the limits to budget adjustments between the municipality of Rio de Janeiro and its neighboring municipalities of the Metropolitan region 1. An ecological study was conducted with data related to the municipality of Rio de Janeiro, chosen because it has a large assistance network, while located on the borders of vulnerable and underprivileged areas, characterizing a locus that is representative of the situations faced throughout the country. A decrease in the gross values of the programmed quotas in all municipalities of Rio de Janeiro was observed from 2016 onwards. The temporal trend of the programmed quotas remained stable for all municipalities in the Metropolitan Region 1, even with significant increases in the accomplished quotas for neighboring municipalities. The resulting overload in local expenditure prevents the increase of capacity to anticipate fluctuations in demand, both known and unexpected ones, compromising the responsiveness of the health system regarding its regular operation, as well as the ability to adjust to cope with extraordinary events, essential characteristics of resilience.

Developing hospital resilience domains in facing disruption era in Indonesia: a qualitative study

BACKGROUND

The studies of hospital resilience have been of increasing importance during the last decade due to disasters and pandemics. However, studies in developing the domain and indicators of hospital resilience were limited mainly on disaster response. A few studies of hospital resilience focused on how to deal with disruptions such as environmental turbulence, rapid technological changes, and changes in patient preferences. This study aims to develop domains and indicators of hospital resilience in facing the disruption era.

METHODS

This qualitative study focused on exploring the domains and indicators to face disruptions that have been identified in the first exploratory phase of the studies. Key informants included hospital experts from the government, medical practitioners, and academics. A total of 20 key informants were involved in semi-structured interviews which were conducted face-to-face, via telephone and Zoom. Data was analyzed using a grounded theory approach to discover domains for a resilient hospital.

RESULTS

The study identified a number of domains that are fundamental for a hospital to become a resilient in the face of disruption. These include readiness to face digital transformation, effective leadership, and flexibility in managing resources among others. Situation awareness and resilience ethos, implementation of marketing management, networking, and disaster anticipation are found to be equally important. These domains focused on the hospital's ability to deal with specific shocks from different perspectives as the result of changes from disruptions which are inevitable within the organizational business environment.

CONCLUSIONS

The domains identified in the study are able to respond to the limitations of the concept of hospital resilience, which is currently more focused on hospital disaster resilience. They can be used to measure hospital resilience in the context of the volatility, uncertainty, complexity, and ambiguity (VUCA), which are relevant to the context of the Indonesia hospital industry.

Current State of Brazilian Neurosurgery: Evaluation of Burden of Care and Case Volume

BACKGROUND

Low- and middle-income countries (LMICs) bear a heavier burden of neurosurgical diseases than high-income countries. Brazil, a growing middle-income country, holds promise as a health care market. However, there exists a lack of information to characterize the state of neurosurgical practice and access to care in Brazil. This study aimed to characterize neurosurgical practice in Brazil and identify barriers to care.

METHODS

A collaborative survey was developed with Brazilian neurosurgeons and distributed by the Brazilian Society of Neurosurgery. The survey gathered demographic information, practice characteristics, case volume, referral patterns, income sources, and assessed barriers using a Likert scale. Descriptive statistics were employed for data analysis.

RESULTS

One-hundred and forty-nine neurosurgeons participated (response rate: 17.5%), representing various states in Brazil. Neurosurgeons practiced in more than 4 different hospital systems on average, with most consultations and procedures occurring in public hospitals. Common procedures included tumor surgeries, general neurosurgery, spine surgeries, trauma surgeries, and hydrocephalus management. Equipment shortage and systemic issues were identified as major barriers to care.

CONCLUSIONS

Neurosurgical practice in Brazil exhibits diverse age distribution, widespread distribution across states, and involvement in both public and private hospitals. Survey insights shed light on neurosurgical workload and neurosurgical practice characterization. Lack of equipment and inadequate postoperative resources pose significant barriers to care. The findings highlight the need for investments in equipment, critical care facilities, and improved health care system coordination to enhance access to neurosurgical care in Brazil.

Prognostic Factors and Survival Outcomes of Patients With Early HER2+ Breast Cancer Treated With Trastuzumab in a Brazilian Public Reference Center: A Real-World Study

PURPOSE

Trastuzumab was introduced into the Brazilian public health care service for early breast cancer (BC) in 2012. This study describes the survival outcomes and prognostic factors related to early HER2+ BC treatment in a Brazilian reference cancer center.

PATIENTS AND METHODS

This were a retrospective, single-center, observational study of early HER2+ BC patients treated with trastuzumab in the (neo)adjuvant setting between 2012 and 2018 at Hospital Pérola Byington. Demographic, clinical, disease-free survival (DFS) and overall survival (OS) data were evaluated. Multivariate analysis was performed to assess independent prognostic factors.

RESULTS

One hundred seventy-six and 353 patients treated in the neoadjuvant and adjuvant setting were included, respectively. The 3- and 5-year OS rates were 79% and 56% for the neoadjuvant group and 97% and 92% for the adjuvant group, respectively. Node positivity at diagnosis predicted poor OS for both groups. In the neoadjuvant group, stage III disease at diagnosis, delayed surgery, and lack of pathological complete response (pCR) predicted poor prognosis. The 3- and 5-year DFS rates were 67% and 46% in the neoadjuvant group and 91% and 86% in the adjuvant group, respectively. Histological grade 2, stage III disease at diagnosis, and lack of pCR predicted poor DFS for the neoadjuvant group. For the adjuvant group, node positivity at diagnosis predicted poor DFS.

CONCLUSION

Our results reveal multiple clinical parameters affecting survival outcomes according to the treatment setting. Patients treated with neoadjuvant therapy have a poor prognosis since they present with more advanced disease, indicating the importance of early diagnosis and optimized treatment.

A resilience view on health system resilience: a scoping review of empirical studies and reviews

BACKGROUND

Prompted by recent shocks and stresses to health systems globally, various studies have emerged on health system resilience. Our aim is to describe how health system resilience is operationalised within empirical studies and previous reviews. We compare these to the core conceptualisations and characteristics of resilience in a broader set of domains (specifically, engineering, socio-ecological, organisational and community resilience concepts), and trace the different schools, concepts and applications of resilience across the health literature.

METHODS

We searched the Pubmed database for concepts related to 'resilience' and 'health systems'. Two separate analyses were conducted for included studies: a total of n = 87 empirical studies on health system resilience were characterised according to part of health systems covered, type of threat, resilience phase, resilience paradigm, and approaches to building resilience; and a total of n = 30 reviews received full-text review and characterised according to type of review, resilience concepts identified in the review, and theoretical framework or underlying resilience conceptualisation.

RESULTS

The intersection of health and resilience clearly has gained importance in the academic discourse with most papers published since 2018 in a variety of journals and in response to external threats, or in reference to more frequent hospital crisis management. Most studies focus on either resilience of health systems generally (and thereby responding to an external shock or stress), or on resilience within hospitals (and thereby to regular shocks and operations). Less attention has been given to community-based and primary care, whether formal or informal. While most publications do not make the research paradigm explicit, 'resilience engineering' is the most prominent one, followed by 'community resilience' and 'organisational resilience'. The social-ecological systems roots of resilience find the least application, confirming our findings of the limited application of the concept of transformation in the health resilience literature.

CONCLUSIONS

Our review shows that the field is fragmented, especially in the use of resilience paradigms and approaches from non-health resilience domains, and the health system settings in which these are used. This fragmentation and siloed approach can be problematic given the connections within and between the complex and adaptive health systems, ranging from community actors to local, regional, or national public health organisations to secondary care. Without a comprehensive definition and framework that captures these interdependencies, operationalising, measuring and improving resilience remains challenging.

COVID-19 inpatient mortality in Brazil from 2020 to 2022: a cross-sectional overview study based on secondary data

BACKGROUND

In Brazil, the COVID-19 pandemic found the universal and public Unified Health System (SUS) with problems accumulated over time, due, among other reasons, to low investments, and disparities in resource distribution. The preparedness and response of the healthcare system, involving the SUS and a private sector, was affected by large socioeconomic and healthcare access inequities. This work was aimed at offering an overview of COVID-19 inpatient mortality during the pandemic in Brazil, exploring factors associated with its variations and, specifically, differences across public, private (for-profit) and philanthropic (private non-profit) inpatient healthcare units, providers, and non-providers of services to the SUS.

METHODS

This cross-sectional study used public secondary data. The main data source was the SIVEP-Gripe, which comprises data on severe acute respiratory illness records prospectively collected. We also employed the National Record of Health Establishments, the SUS' Hospitalization Information System and municipalities' data from IBGE. We considered adult COVID-19 hospitalizations registered in SIVEP-Gripe from February 2020 to December 2022 in inpatient healthcare units with a minimum of 100 cases in the period. Data analyses explored the occurrence of inpatient mortality, employing general linear mixed models to identify the effects of patients', health care processes', healthcare units' and municipalities' characteristics on it.

RESULTS

About 70% of the COVID-19 hospitalizations in Brazil were covered by the SUS, which attended the more vulnerable population groups and had worse inpatient mortality. In general, non-SUS private and philanthropic hospitals, mostly reimbursed by healthcare insurance plans accessible for more privileged socioeconomic classes, presented the best outcomes. Southern Brazil had the best performance among the macro-regions. Black and indigenous individuals, residents of lower HDI municipalities, and those hospitalized out of their residence city presented higher odds of inpatient mortality. Moreover, adjusted inpatient mortality rates were higher in the pandemic peak moments and were significantly reduced after COVID-19 vaccination reaching a reasonable coverage, from July 2021.

CONCLUSIONS

COVID-19 exposed socioeconomic and healthcare inequalities and the importance and weaknesses of SUS in Brazil. This work indicates the need to revert the disinvestment in the universal public system, a fundamental policy for reduction of inequities in the country.

Early detection of respiratory disease outbreaks through primary healthcare data

Background

The emergence of coronavirus disease 2019 (COVID-19) in 2020 highlighted the relevance of surveillance systems in detecting early signs of potential outbreaks, thus enabling public health authorities to act before the pathogen becomes widespread. Syndromic digital surveillance through web applications has played a crucial role in monitoring the spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. However, this approach requires expensive infrastructure, which is not available in developing countries. Pre-existing sources of information, such as encounters in primary health care (PHC), can provide valuable data for a syndromic surveillance system. Here we evaluated the utility of PHC data to identify early warning signals of the first COVID-19 outbreak in Bahia-Brazil in 2020.

Methods

We compared the weekly counts of PHC encounters due to respiratory complaints and the number of COVID-19 cases in 2020 in Bahia State - Brazil. We used the data from December 2016 to December 2019 to predict the expected number of encounters in 2020. We analysed data aggregated by geographic regions (n = 34) and included those where historical PHC data was available for at least 70% of the population.

Results

Twenty-one out of 34 regions met the inclusion criteria. We observed that notification of COVID-19 cases was preceded by at least two weeks with an excess of encounters of respiratory complaints in 18/21 (86%) of the regions analysed and four weeks or more in 10/21 (48%) regions.

Conclusions

Digital syndromic surveillance systems based on already established PHC databases may add time to preparedness and response to emerging epidemics.

The Impact of Time, Region, and Income Level on Stillbirth and Neonatal Mortality in Brazil, 2000-2019

OBJECTIVE

To describe trends in perinatal loss across Brazil, a country that transitioned in 2006 from a lower-middle income to an upper-middle income country, from 2000 to 2019 and analyze the effect of municipal wealth status on perinatal outcomes.

STUDY DESIGN

We conducted an ecological cohort study, based on publicly available data from the Brazilian Ministry of Health's data repository on live births and deaths. The Atlas of Human Development in Brazil was used to associate each region with a World Bank income classification.

RESULTS

The national neonatal mortality rate (NMR) for infants born at ≥22 weeks of gestation decreased from 21.2 in 2000 to 12.4 in 2019. The stillbirth rate (SBR) decreased from 12.0 to 10.2 during this period. For infants born between 22 and 27 weeks of gestation, worsening perinatal outcomes were seen after 2012. In 2019, the median rates of neonatal mortality and stillbirth were both 4 points higher in lower- to middle-income municipalities compared with high-income municipalities (P < .01).

CONCLUSION

Brazil has made significant progress in neonatal mortality and stillbirth from 2000 to 2019, yet inequity in perinatal outcomes remains and is correlated with municipal economic status. Nationally, ongoing improvement is needed for infants <28 weeks of gestation, and closer exploration is needed into why there are increasing rates of negative perinatal outcomes among infants born at 22-27 weeks of gestation after 2012.

Impacts of the infodemic on COVID-19 for Brazilian health professionals

This article aims to analyze the effects of the COVID-19 infodemic from the perspective of Brazilian health workers regarding the patients, measure the impacts of fake news on health professionals, and verify the perception of health multidisciplinary teams regarding the authorities' stance. This cross-sectional study is nested in the research "Health Professionals' Working Conditions in the Brazilian Context of COVID-19". The nationwide non-probability sampling included 15,132 professionals who worked in the COVID-19 frontline in health institutions of 2,200 Brazilian municipalities. Approximately 91% of respondents believed that fake news is an obstacle in fighting the SARS-CoV-2 virus; 76.1% declared they had seen patients who expressed faith in fake news about COVID-19; 29.3% agreed that the health authorities' stance about COVID-19 was consistent and enlightening, and 62.6% disagreed about this. The respondents believe that the COVID-19 infodemic confused patients, impaired adherence to PHC measures, and stirred people's negative behavior vis-à-vis the pandemic. The lack of clarity of the authorities' stance influenced the COVID-19 infodemic process.

An evidence-based primary health care intervention to address domestic violence against women in Brazil: a mixed method evaluation

BACKGROUND

Health systems have a critical role in a multi-sectoral response to domestic violence against women (DVAW). However, the evidence on interventions is skewed towards high income countries, and evidence based interventions are not easily transferred to low-and middle-income countries (LMIC) where significant social, cultural and economic differences exist. We evaluated feasibility and acceptability of implementation of an intervention (HERA-Healthcare Responding to Violence and Abuse) to improve the response to DVAW in two primary health care clinics (PHC) in Brazil.

METHODS

The study design is a mixed method process and outcome evaluation, based on training attendance records, semi-structured interviews (with 13 Primary Health Care (PHC) providers, two clinic directors and two women who disclosed domestic violence), and identification and referral data from the Brazilian Epidemiological Surveillance System (SINAN).

RESULTS

HERA was feasible and acceptable to women and PHC providers, increased providers' readiness to identify DVAW and diversified referrals outside the health system. The training enhanced the confidence and skills of PHC providers to ask directly about violence and respond to women's disclosures using a women centred, gender and human rights perspective. PHC providers felt safe and supported when dealing with DVAW because HERA emphasised clear roles and collective action within the clinical team. A number of challenges affected implementation including: differential managerial support for the Núcleo de Prevenção da Violência (Violence Prevention Nucleus-NPV) relating to the allocation of resources, monitoring progress and giving feedback; a lack of higher level institutional endorsement prioritising DVAW work; staff turnover; a lack of feedback from external support services to PHC clinics regarding DVAW cases; and inconsistent practices regarding documentation of DVAW.

CONCLUSION

Training should be accompanied by system-wide institutional change including active (as opposed to passive) management support, allocation of resources to support roles within the NPV, locally adapted protocols and guidelines, monitoring progress and feedback. Communication and coordination with external support services and documentation systems are crucial and need improvement. DVAW should be prioritised within leadership and governance structures, for example, by including DVAW work as a specific commissioning goal.

Evaluation of Functional and Joint Health and Associated Factors in Adults With Hemophilia From a Developing Country With Government-Backed Efforts to Improve Hemophilia Care

Introduction Hemophilic arthropathy affects people with hemophilia (PwH) and causes joint dysfunction and disability. Brazil has a unique situation and implemented policies to improve health care for PwH. The aim of this study was to evaluate the Functional Independence Score in Hemophilia (FISH), Hemophilia Joint Health Score (HJHS), and associated factors among adult PwH attending a Hemophilia Comprehensive Care Center in Brazil. Methods A post hoc analysis was conducted, including 31 patients who had submitted to a physical evaluation during a previously published cross-sectional study performed from June 2015 to May 2016 at the Brasília Blood Center Foundation, Brazil. Results The mean age was 30.8±9.4 years, and 80.6% had severe hemophilia. FISH was 27.0±3.8, and HJHS 18.0±10.8. The ankle was the most often affected joint (25/31, 80.6%). There were significant correlations between FISH and HJHS scores and the Hemophilia Quality of Life Questionnaire for Adults. Patients with severe hemophilia (P = 0.029) and PwH aged ≥ 30 years (P = 0.049) had lower FISH scores. Monthly household income > 2 Brazilian minimum wages was independently associated with improved HJHS (P = 0.033). The factors simultaneously associated with better HJHS and FISH were age < 30 years (P = 0.021) and monthly household income < 2 minimum wages (P = 0.013). Conclusion FISH and HJHS showed favorable scores despite being performed in a country with unfavorable socioeconomic conditions. In addition to hemophilia severity and age, monthly household income was independently associated with functional and articular state of PwH. The results highlight the importance of the free provision of coagulation factors in Brazil.

Budgeting in Healthcare Systems and Organizations: A Systematic Review

Background

Budgeting is the process resource allocation to produce the best output according to the revenue levels involved. Among the constraints that healthcare organizations, including hospitals, both in the public and private sectors, grapple with is budgetary constraints. Therefore, cost control and resource management should be considered in healthcare organizations under such circumstances.

Methods

We aimed to identify methods of budgeting in healthcare systems and organizations as a systematic review. To extract and analyze the data, a form was designed by the researcher to define budgeting methods proposed in the literature and to identify their strengths, weaknesses, and dimensions. The search was conducted in Google Scholar, Web of science, Pub med and Scopus databases covering the period 1990-2022.

Results

Overall, 33 articles were included in the study for extraction and final analysis. The study results were reported in four main themes: healthcare system budgeting, capital budgeting, global budgeting, and performance-based budgeting.

Conclusion

Each budgeting approach has its own pros and cons and requires meeting certain requirements. These approaches are selected and implemented depending on each country's infrastructure and conditions as well as its organizations. These infrastructures need to be thoroughly examined before implementing any budgeting method, and then a budgeting method should be selected accordingly.

Cost-Effectiveness Analysis of Monoclonal Antibodies Associated With Chemotherapy in First-Line Treatment of Metastatic Colorectal Cancer

OBJECTIVES

This study aimed to evaluate the cost-effectiveness of anti-epidermal growth factor receptor (cetuximab and panitumumab) or anti-vascular endothelial growth factor (bevacizumab) monoclonal antibodies associated with conventional chemotherapy (CT) (fluorouracil and leucovorin with irinotecan) as a first-line treatment for unresectable metastatic colorectal cancer.

METHODS

A partitioned survival analysis model was adopted to simulate direct health costs and benefits comparing therapeutic options in a 10 years' time horizon. Model data were extracted from the literature and costs were obtained from Brazilian official government databases. The analysis considered the perspective of the Brazilian Public Health System; costs were measured in local currency (BRL) and benefits in quality-adjusted life-years (QALY). A 5% discount rate was applied to costs and benefits. Alternative willingness-to-pay scenarios, varying from 3 to 5 times the cost-effectiveness threshold established in Brazil, were estimated. The results were presented incremental cost-effectiveness ratio (ICER), and both deterministic and probabilistic sensitivity analyses were performed.

RESULTS

The most cost-effective choice would be the association of CT with panitumumab, with an ICER of $58 330.15/QALY compared with isolated CT. The second-best option was CT with bevacizumab and panitumumab, with an ICER of $71 195.40/QALY compared with panitumumab alone. Although having higher costs, the second-best option was the most effective. Both strategies were cost-effective in part of the Monte Carlo iterations, considering the 3× threshold.

CONCLUSIONS

The therapeutic option CT + panitumumab + bevacizumab represents the most significant effectiveness gain in our study. It is the second-lowest cost-effectiveness, and this option includes monoclonal antibodies association for patients with and without KRAS mutation.

The Level of Knowledge and Attitudes Toward Dementia Among Senior Medical Students in Recife, Brazil

INTRODUCTION

Aging is no longer a phenomenon for society; it has become a reality in all countries, leading to a notable increase in the prevalence of dementia, a common condition among the elderly population. This situation highlights the importance of adequately preparing future healthcare professionals with the necessary knowledge and attitudes to effectively care for dementia patients.

OBJECTIVE

This study aims to describe the knowledge and attitudes toward dementia among fifth- and sixth-year medical students at a prestigious medical school in Recife, Brazil.

MATERIALS AND METHODS

A descriptive, analytical cross-sectional study was conducted in which participants answered questionnaires related to epidemiological and educational data of the involved students, the assessment of the sample's knowledge regarding dementia, and addressing attitude toward a patient with dementia. Data collection took place online, targeting fifth- and sixth-year medical students at the Faculdade Pernambucana de Saúde (FPS).

RESULTS

A total of 111 students participated in the study, with a majority of females (73.9%), most of them in the fifth year of medical school (79.3%). While the majority of the students received training during their undergraduate studies on cognitive changes related to dementia (58.6%), this knowledge was mostly theoretical (64%), and only a few students took extracurricular courses on the subject (7.2%). Regarding the questionnaire evaluating students' knowledge, the overall mean was 6.69 points (on a scale of 0-14). Notably, there was no significant difference in correct answers among the tested areas of epidemiology, diagnosis, and management, with percentages of correct answers of 49.8%, 45.27%, and 52.53%, respectively. As for their attitudes toward dementia, the majority of students responded in a manner consistent with current literature and best practices for managing patients with functional dependence and cognitive changes.

CONCLUSION

The results indicate that despite the notable rise in dementia cases across the world, the study revealed that the participants lacked essential knowledge about dementia. However, most of them demonstrated attitudes aligned with the best practices for managing dementia patients and their families. These data may suggest the need for greater attention in the teaching-learning process on the part of the medical school, as well as the promotion of extracurricular activities on this topic, in addition to enhancing the promotion of practical activities in geriatrics.

Socioeconomic Influences on the Outcomes of Dialysis-Requiring Acute Kidney Injury in Brazil

Introduction

Although research suggests that socioeconomic deprivation is linked to a higher incidence of acute kidney injury (AKI) and worse outcomes in high-income countries, there is limited knowledge about these epidemiologic factors in developing countries. In addition, the impact of medical institution administration (private versus public) on AKI outcomes remains to be determined.

Methods

We studied 15,186 pediatric and adult patients with dialysis-requiring AKI (AKI-D) admitted to private and public hospitals in Rio de Janeiro, Brazil. According to Brazil's demographic census, socioeconomic indicators were derived from patient zip codes. Propensity score matching analysis and a mixed-effect Cox regression were used to assess the impact of socioeconomic indicators and hospital governance on patient survival.

Results

Crude mortality rates were higher in private hospitals than in public hospitals (71.8% vs. 59.5%, P < 0.001) and were associated with significant differences in age (75 years, interquartile range [IQR]: 61-83 vs. 53 years, IQR: 31-66), baseline renal function (prevalence of chronic kidney disease [CKD]: 33.2% vs. 23%, P < 0.001), comorbidities (Charlson score: 2.03 ± 0.87 vs. 1.72 ± 0.75, P < 0.001), and severity of presentation (mechanical ventilation: 76.5% vs. 58% and vasopressors: 72.8% vs. 50.5%, P < 0.001). After adjustments and propensity score matching, we found no effect of different hospital administrations or socioeconomic factors on mortality. Baseline characteristics and the severity of presentation primarily influenced AKI-D prognosis.

Conclusions

Despite significant racial and socioeconomic differences in hospital governance, these indicators had no independent influence on mortality. Future epidemiologic studies should investigate these relevant assumptions to allow healthcare systems to manage this severe syndrome promptly.

Evaluation of massive education in prison health: a perspective of health care for the person deprived of freedom in Brazil

Education, with an emphasis on prison health, has acted as a policy inducing changes in work processes, which the Brazilian National Health System (SUS) has used, and which is present in permanent health education, which promotes health care for people deprived of liberty. This article aims to present an analysis of the impacts of the strategy of massive education on prison health in Brazil from the perspective of health professionals and other actors operating in the Brazilian prison system. The data used in the study come from a questionnaire consisting of 37 questions applied nationwide between March and June 2022. Responses were collected from students who completed the course "Health Care for People Deprived of Freedom" of the learning pathway "Prison System", available in the Virtual Learning Environment of the Brazilian Health System (AVASUS). This course was offered nationally, whose adhesion (enrollment) occurred spontaneously, i.e., the course was not a mandatory. The data collected allowed us to analyze the impacts of massive education on prison health. The study also shows that the search for the course is made by several areas of knowledge, with a higher incidence in the health area, but also in other areas, such as humanities, which also work directly with the guarantee of the rights of people deprived of liberty, which are professionals in the areas of social work, psychology, and education. The analysis based on the data suggests that the massive education mediated by technology through the courses of the learning pathway, besides disseminating knowledge-following the action plan of the 2030 Agenda of the United Nations Educational, Scientific and Cultural Organization (UNESCO)-, are an effective tool to promote resilience in response to prison health and care demands of people deprived of liberty.

Computational methods applied to syphilis: where are we, and where are we going?

Syphilis is an infectious disease that can be diagnosed and treated cheaply. Despite being a curable condition, the syphilis rate is increasing worldwide. In this sense, computational methods can analyze data and assist managers in formulating new public policies for preventing and controlling sexually transmitted infections (STIs). Computational techniques can integrate knowledge from experiences and, through an inference mechanism, apply conditions to a database that seeks to explain data behavior. This systematic review analyzed studies that use computational methods to establish or improve syphilis-related aspects. Our review shows the usefulness of computational tools to promote the overall understanding of syphilis, a global problem, to guide public policy and practice, to target better public health interventions such as surveillance and prevention, health service delivery, and the optimal use of diagnostic tools. The review was conducted according to PRISMA 2020 Statement and used several quality criteria to include studies. The publications chosen to compose this review were gathered from Science Direct, Web of Science, Springer, Scopus, ACM Digital Library, and PubMed databases. Then, studies published between 2015 and 2022 were selected. The review identified 1,991 studies. After applying inclusion, exclusion, and study quality assessment criteria, 26 primary studies were included in the final analysis. The results show different computational approaches, including countless Machine Learning algorithmic models, and three sub-areas of application in the context of syphilis: surveillance (61.54%), diagnosis (34.62%), and health policy evaluation (3.85%). These computational approaches are promising and capable of being tools to support syphilis control and surveillance actions.

Perspectives and challenges for mother-to-child transmission of HIV, hepatitis B, and syphilis in Brazil

Background

Eliminating mother-to-child transmission (MTCT) of HIV, hepatitis B, and syphilis is a challenge in Brazil. Many policies have been implemented since 1986, but important gaps remain. This study aimed to describe the trends of MTCT in Brazil and evaluate the gaps and perspectives in this scenario.

Methods

This is a descriptive study conducted with secondary data publicly available in the information systems of the Brazilian Ministry of Health regarding data on HIV, syphilis, and hepatitis B in pregnant women and children from 2011 to 2021.

Results

HIV and hepatitis B have had constant rates over the years in pregnant women, with the detection rates around 2.5/1,000 live birth (LB) and 0.5/1.000LB, respectively. The same did not happen with syphilis, which has shown an increasing line in the last decade. In 2011, the detection rate of syphilis in pregnancy was 4.7/1,000LB, and in 2021 it reached 27.1/1,000LB. Regarding the trends in children, an important decrease was observed in HIV/AIDS (incidence rate from 0.18/1,000 in 2011 to 0.04/1,000 in 2021) and Hepatitis B (incidence rate from 0.9/1,000LB in 2011 to 0.5/1,000LB in 2021). For congenital syphilis, there is a continuous increase, being 3.3/1,000LB in 2011 and 9.9/1,000LB in 2021. Data from the HIV clinical monitoring showed that antiretroviral treatment coverage among pregnant women identified increased slightly between 2011 and 2021, in Brazil, from 92.3% to 94.3%. For syphilis, 82.5% of pregnant women were treated with benzathine penicillin, and 88.7% in 2011. The historical series of hepatitis B vaccination coverage in children has decreased over the years; it was 96% in 2013 and 76% in 2021.

Conclusion

These data show many gaps and some perspectives in the MTCT program in Brazil. The country is close to reaching MTCT HIV elimination, but there are many challenges regarding HBV and syphilis. These data can be used to organize the strategies to improve the Brazilian response to MTCT elimination of HIV, hepatitis B, and syphilis.

Municipality-level measles, mumps, and rubella (MMR) vaccine coverage and deprivation in Brazil: A nationwide ecological study, 2006 to 2020

To better understand the declining rates of routine childhood vaccination in Brazil, we investigated the association between measles, mumps, and rubella (MMR) first dose vaccine coverage and deprivation at the municipality level. Using routinely collected data from 5565 Brazilian municipalities from 2006 to 2020, we investigated the association between municipality-level MMR vaccine first dose coverage (i.e., as a continuous variable and as a percentage of municipalities attaining the 95% target coverage) in relation to quintiles of municipality-level deprivation, measured by the Brazilian Deprivation Index (Índice Brasileiro de Privação, IBP), and geographic regions. From 2006 to 2020, the mean municipality-level MMR vaccine coverage declined across all deprivation quintiles and regions of Brazil, by an average of 1.2% per year. The most deprived quintile of municipalities had higher coverage on average, but also the steepest declines in coverage (i.e., an annual decline of 1.64% versus 0.61% in the least deprived quintile) in the period of 2006-2020, and the largest drop in coverage at the beginning of the COVID-19 pandemic (2019-2020). Across all deprivation quintiles and regions (except for the Southeast region), less than 50% of municipalities in Brazil met the 95% MMR coverage target in 2020.The decrease in MMR first dose vaccine coverage in Brazil is widespread, but steeper declines have been observed in the most deprived municipalities. To promote vaccine equity and prevent future outbreaks, further research is urgently needed to understand the causal mechanisms underlying the observed associations between municipality-level MMR vaccine coverage and deprivation.

Discrepancies in breast cancer's oncological outcomes between public and private institutions in the southeast region of Brazil: a retrospective cohort study

Background

Brazil is a middle-income country with inequalities in its healthcare system. The disparities between public and private services affect the diagnosis and treatment of patients with breast cancer. The aim of this study is to assess whether disease-free survival (DFS) and overall survival (OS) are different in public and private specialized centers.

Patient and methods

A retrospective cohort study with 1,545 breast cancer patients diagnosed from 2003 to 2011 at Barretos Cancer Hospital-BCH (public group, N = 1,408) and InORP Oncoclinicas (private group, N = 137) was conducted. A 1:1 propensity score matching (PSM) analysis was used to adjust the differences between the groups' characteristics (n = 137 in each group).

Results

The median age at diagnosis was 54.4 years. Estimated DFS rates at 1, 5, and 10 years were 96.0%, 71.8%, and 59.6%, respectively, at BCH and 97.8%, 86.9%, and 78%, respectively, at InORP (HR: 2.09; 95% confidence interval [CI], 1.41-3.10; p < 0.0001). Estimated OS rates at 1, 5, and 10 years were 98.1%, 78.5%, and 65.4%, respectively, at BCH and 99.3%, 94.5%, and 91.9%, respectively, at InORP (HR: 3.84; 95% CI, 2.16-6.82; p < 0.0001). After adjustment by PSM, DFS and OS results in 1, 3, and 5 years remained worse in the public service compared to the private service.

Conclusion

Patients treated in a public center have worse DFS and OS after a follow-up period of more than 5 years. These results were corroborated after carrying out the PSM.

Role of community pharmacy and pharmacists in self-care in Brazil

Global healthcare systems, including the National Health System in Brazil - one of the largest public models in the world -, continue to evolve, as well as populations' health needs, currently shaped on individuals feeling a greater desire to manage their own health. Self-care practices are part of several public policies and clinical guidelines in Brazil including the National Policy on Complementary and Integrative Practices, the National AIDS Control Program, the National Policy for Women's Health, and the Guidelines for Care of People with Chronic Diseases. There are over 100,700 community pharmacies, in the country (89.2% privately owned) employing 234,300 pharmacists, representing an important delivery point for self-care, as they are the first point of access to care for most patients. Self-medication is a common practice in Brazil (prevalence rates of self-medication ranging from 16.1% to 35.0%), especially with non-prescription/over-the-counter medicinal products (65.0%). In fact, these products represent over 25% of volume marketed of medicines, summing revenues of USD 1.9 billion per year. Studies demonstrated a positive budget impact as important savings for the National Health System due to reductions of unnecessary medical appointments and loss of working days. In addition to minor ailments management, other self-care services provided by community pharmacies that are frequently sought by Brazilian citizens (20-25% of cases) are smoking cessation and weight management (costs per service ranging from around USD 5.00-12.00). However, pharmacy services are not yet as fully integrated in Brazil to the same extent as in other countries. Barriers such as standardization of processes (from services' design, implementation, and evaluation in practice), pharmacist remuneration for the provision of services and the amount to be charged for the service are still a matter of controversy. For more rapid and sustainable advances in these practices, communication among various stakeholders, professional practice and healthcare regulations, standardization of services and financing of self-care (both publicly and privately) are urgently needed. This paper provides an overview of some self-care services provided by community pharmacies in Brazil and call attention to the ongoing challenges to move the National Health system forward.

Socioeconomic inequities in specialized health services use following COVID-19 in individuals from Southern Brazil

BACKGROUND

Evidence on inequalities in the health services use is important for public policy formulation, even more so in a pandemic context. The aim of this study was to evaluate socioeconomic inequities in the specialized health use services according to health insurance and income, following COVID-19 in individuals residing in Southern Brazil.

METHODS

This was a cross-sectional telephone survey with individuals aged 18 years or older diagnosed with symptomatic COVID-19 using the RT-PCR test between December 2020 and March 2021. Questions were asked about attendance at a health care facility following COVID-19, the facilities used, health insurance and income. Inequalities were assessed by the following measures: Slope Index of Inequality (SII) and Concentration Index (CIX). Adjusted analyses were performed using Poisson regression with robust variance adjustment using the Stata 16.1 statistical package.

RESULTS

2,919 people (76.4% of those eligible) were interviewed. Of these, 24.7% (95%CI 23.2; 36.3) used at least one specialized health service and 20.3% (95%CI 18.9; 21.8) had at least one consultation with specialist doctors after diagnosis of COVID-19. Individuals with health insurance were more likely to use specialized services. The probability of using specialized services was up to three times higher among the richest compared to the poorest.

CONCLUSIONS

There are socioeconomic inequalities in the specialized services use by individuals following COVID-19 in the far south of Brazil. It is necessary to reduce the difficulty in accessing and using specialized services and to extrapolate the logic that purchasing power transposes health needs. The strengthening of the public health system is essential to guarantee the population's right to health.

Suicide risk classification with machine learning techniques in a large Brazilian community sample

Even though suicide is a relatively preventable poor outcome, its prediction remains an elusive task. The main goal of this study was to develop machine learning classifiers to identify increased suicide risk in Brazilians with common mental disorders. With the use of clinical and sociodemographic baseline data (n = 4039 adult participants) from a large Brazilian community sample, we developed several models (Elastic Net, Random Forests, Naïve Bayes, and ensemble) for the classification of increased suicide risk among individuals with common mental disorders. 1120 participants (27.7%) presented increased suicide risk. The Random Forests model achieved the best AUC ROC (0.814), followed by Naive Bayes (0.798) and Elastic Net (0.773). Sensitivity varied from 0.922 (Naive Bayes) to 0.630 (Random Forests), while specificity varied from 0.792 (Random Forests) to 0.473 (Naive Bayes). The ensemble model presented an AUC ROC of 0.811, sensitivity of 0.899, and specificity of 0.510. Features representing depression symptoms were the most relevant for the classification of increased suicide risk. Some of our models presented good performance metrics in the classification of increased suicide risk in the investigated sample, which can provide the means to early preventive interventions.

How are Brazilian university students coping with the COVID-19 pandemic? Results of an online survey on psychosocial well-being, perceived burdens, and attitudes toward social distancing and vaccination

BACKGROUND

The COVID-19 pandemic caused significant disruption to education systems worldwide, increasing pre-existing concerns regarding university students' mental health. Brazil was among the countries most affected by COVID-19 cases and deaths and was considered a pandemic epicenter. This study aimed to investigate Brazilian university students' mental health status and perceived burdens during the COVID-19 pandemic.

MATERIAL AND METHODS

From November 2021 to March 2022, a cross-sectional and anonymous online survey was conducted among students of a Brazilian federal university. Mental health status (depressive symptoms, alcohol and drug consumption) and social and emotional aspects in the pandemic context (social support, perceived stress, loneliness, resilience, and self-efficacy) were assessed with standardized measures. Students' attitudes toward the COVID-19 pandemic and vaccination and perceived burdens of the pandemic were also investigated.

RESULTS

A total of N = 2,437 students completed the online survey. The PHQ-9 mean sum score was 12.85 (SD = 7.40), while n = 1,488 (61.10%) participants reported a sum score of 10 or more, indicating clinically relevant depressive symptoms. Further, n = 808 (33.1%) of the total sample reported suicidal thoughts. Levels of depressive symptoms, perceived stress, and loneliness were higher among undergraduate/bachelor students than doctoral students. Almost all participants (97.3%) reported being fully vaccinated against COVID-19. Multiple regression analyses showed that being single, having an income decreased during the pandemic, having a previous mental illness, having a chronic somatic condition, not finding positive aspects in the pandemic, lower self-efficacy, lower social support, lower resilience, and higher experienced loneliness were significantly associated with higher levels of depression.

CONCLUSIONS

The study showed high levels of depressive symptoms and suicidal ideation among Federal University of Parana students. Therefore, health care providers and universities need to recognize and address mental health issues; psychosocial policies must be enhanced to mitigate the impact of the pandemic on students' mental health and wellbeing.

Temporal Trend, Causes, and Timing of Neonatal Mortality of Moderate and Late Preterm Infants in São Paulo State, Brazil: A Population-Based Study

Moderate and late preterm newborns comprise around 85% of live births < 37 weeks gestation. Data on their neonatal mortality in middle-income countries is limited. This study aims to analyze the temporal trend, causes and timing of neonatal mortality of infants with 320/7–366/7 weeks gestation without congenital anomalies from 2004–2015 in the population of São Paulo State, Brazil. A database was built by deterministic linkage of birth and death certificates. Causes of death were classified by ICD-10 codes. Among 7,317,611 live births in the period, there were 545,606 infants with 320/7–366/7 weeks gestation without congenital anomalies, and 5782 of them died between 0 and 27 days. The neonatal mortality rate decreased from 16.4 in 2004 to 7.6 per thousand live births in 2015 (7.47% annual decrease by Prais–Winsten model). Perinatal asphyxia, respiratory disorders and infections were responsible, respectively, for 14%, 27% and 44% of the 5782 deaths. Median time to death was 24, 53 and 168 h, respectively, for perinatal asphyxia, respiratory disorders, and infections. Bottlenecks in perinatal health care are probably associated with the results that indicate the need for policies to reduce preventable neonatal deaths of moderate and late preterm infants in the most developed state of Brazil.

Participatory surveillance for COVID-19 trends detection in Brazil: Cross-section study

BACKGROUND

The ongoing COVID-19 pandemic has emphasized the necessity of a well-functioning surveillance system to detect and mitigate disease outbreaks. Traditional surveillance (TS) usually relies on healthcare providers and generally suffers from reporting lags that prevent immediate response plans. Participatory surveillance (PS), an innovative digital approach whereby individuals voluntarily monitor and report on their own health status via Web-based surveys, has emerged in the past decade to complement traditional data collections approaches.

OBJECTIVE

This study compares novel PS data on COVID-19 infection rates across nine Brazilian cities with official TS data to examine the opportunities and challenges of using the former, and the potential advantages of combining the two approaches.

METHODS

The traditional surveillance data for Brazil, prospectively called the TS data, is publicly accessible on GitHub. The participatory surveillance data was collected through the Brazil Sem Corona - a Colab platform. To gather information on an individual's health status, each participant was asked to fill out a daily questionnaire into the Colab app on symptoms as well as exposure.

RESULTS

We find that high participation rates are key for PS data to adequately mirror TS infection rates. Where participation was high, we document a significant trend correlation between lagged PS data and TS infection rates, suggesting that the former could be used for early detection. In our data, forecasting models integrating both approaches increased accuracy up to 3% relative to a 14-day forecast horizon model based exclusively on TS data. Furthermore, we show that the PS data captures a population that significantly differs from the traditional observation.

CONCLUSIONS

In the traditional system, the new recorded COVID-19 cases per day are aggregated based on positive lab-confirmed tests. In contrast, the PS data shows a significant share of reports categorized as potential COVID-19 case that are not lab-confirmed. Quantifying the economic value of a PS system implementation remains hard. But scarce public funds as well as persisting constraints to the TS system motivate for a PS system, making it an important avenue for future research. The decision to set up a PS system requires careful evaluation of its expected benefits, relative to the costs of setting up platforms and incentivizing engagement to increase both coverage and consistent reporting over time. The ability to compute such economic trade-offs might be key to have PS become a more integral part of policy toolkits moving forward. These results corroborate previous studies when it comes to the benefits of an integrated and comprehensive surveillance system, but also shed lights on its limitations, and on the need for additional research to improve future implementations of PS platforms.

CLINICALTRIAL

Health systems resilience: is it time to revisit resilience after COVID-19?

The concept of health system resilience has been challenged by the COVID-19 pandemic. Even well-established health systems, considered resilient, collapsed during the pandemic. To revisit the concept of resilience two years and a half after the initial impact of COVID-19, we conducted a qualitative study with 26 international experts in health systems to explore their views on concepts, stages, analytical frameworks, and implementation from a comparative perspective of high- and low-and-middle-income countries (HICs and LMICs). The interview guide was informed by a comprehensive literature review, and all interviewees had practice and academic expertise in some of the largest health systems in the world. Results show that the pandemic did modify experts' views on various aspects of health system resilience, which we summarize and propose as refinements to the current understanding of health systems resilience.

Evaluation of health system resilience in 60 countries based on their responses to COVID-19

Introduction

In 2020, the COVID-19 epidemic swept the world, and many national health systems faced serious challenges. To improve future public health responses, it's necessary to evaluate the performance of each country's health system.

Methods

We developed a resilience evaluation system for national health systems based on their responses to COVID-19 using four resilience dimensions: government governance and prevention, health financing, health service provision, and health workers. We determined the weight of each index by combining the three-scale and entropy-weight methods. Then, based on data from 2020, we used the Technique for Order of Preference by Similarity to Ideal Solution (TOPSIS) method to rank the health system resilience of 60 countries, and then used hierarchical clustering to classify countries into groups based on their resilience level. Finally, we analyzed the causes of differences among countries in their resilience based on the four resilience dimensions.

Results

Switzerland, Japan, Germany, Australia, South Korea, Canada, New Zealand, Finland, the United States, and the United Kingdom had the highest health system resilience in 2020. Eritrea, Nigeria, Libya, Tanzania, Burundi, Mozambique, Republic of the Niger, Benin, Côte d'Ivoire, and Guinea had the lowest resilience.

Discussion

Government governance and prevention of COVID-19 will greatly affect a country's success in fighting future epidemics, which will depend on a government's emergency preparedness, stringency (a measure of the number and rigor of the measures taken), and testing capability. Given the lack of vaccines or specific drug treatments during the early stages of the 2020 epidemic, social distancing and wearing masks were the main defenses against COVID-19. Cuts in health financing had direct and difficult to reverse effects on health systems. In terms of health service provision, the number of hospitals and intensive care unit beds played a key role in COVID-19 clinical care. Resilient health systems were able to cope more effectively with the impact of COVID-19, provide stronger protection for citizens, and mitigate the impacts of COVID-19. Our evaluation based on data from 60 countries around the world showed that increasing health system resilience will improve responses to future public health emergencies.

Health inequalities in Brazil: proposed prioritization to achieve the Sustainable Development Goals

This study aimed to develop a prioritization index to speed up the achievement of national health targets proposed in the 2030 Agenda. This is an ecological study that addressed the Health Regions in Brazil. The index incorporated 25 indicators with analytical proximity to the official indicators of the 2030 Agenda whose data are available from public municipal sources for the period of 2015-2019. According to our study, the index was a powerful method to support health management decisions. The results showed the most vulnerable territories are located in the North Region of the country, and therefore, these are priority areas for resource allocation. The analysis of subindices highlighted local health bottlenecks, reinforcing the need for municipalities in each region to set their own priorities while making decisions for health resource allocation. By indicating Health Regions and priority themes for more investments, this investigation shows paths to support the implementation of the 2030 Agenda, from the local to the national level, in addition to providing elements that can be used by policy makers to minimize the effects of social inequalities on health, prioritizing territories with worse indices.

Perceptions of institutional performance and compliance to non-pharmaceutical interventions: How performance perceptions and policy compliance affect public health in a decentralized health system

Trust in institutions is a key driver to shape population attitudes and behavior, such as compliance of non-pharmaceutical interventions (NPI). During the COVID-19 pandemic, this was fundamental and its compliance was supported by governmental and non-governmental institutions. Nevertheless, the situation of political polarization in some countries with decentralized health systems increased the difficulty of such interventions. This study analyzes the association between non-pharmaceutical interventions' compliance and individual perception regarding institutions' performance during the COVID-19 pandemic in Brazil. A web survey was conducted in Brazil between November 2020 and February 2021. Bivariate analysis and ordered logit regressions were performed to assess the association between NPIs compliance and perceived institutions' performance. Results suggest a negative association between NPIs' compliance and Federal Government and Ministry of health perceived performance, which may reflect the political positioning of the respondents. Moreover, we find a positive association between NPI compliance and the perceived performance of the remaining institutions (state government, federal supreme court, national congress, WHO, media and SUS). Our contribution goes beyond the study of a relationship between non-pharmaceutical interventions' compliance and institutions' performance, by pointing out the importance of subnational and local governmental spheres in a decentralized health system, as well as highlighting the importance of social communication based on health organizations' information and scientific institutions.

Distributive conflict: analysis of the Program for Improving Access and Quality of Primary Care (PMAQ-AB) in two Brazilian northeastern capitals

Este artigo analisa a execução do PMAQ-AB a partir de sua contextualização em um cenário político nacional de profundas transformações, desde o reformismo fraco que promoveu lenta extensão de direitos até o contrarreformismo forte da restauração neoliberal. Para debater os elementos relacionados ao trabalho e às disputas pela distribuição dos recursos públicos, foi realizado estudo de caso com trabalhadores, gestores e conselheiros de saúde em duas capitais do nordeste brasileiro. Os resultados evidenciam o acirramento do conflito distributivo e o resultado desfavorável aos trabalhadores no contexto pós-golpe parlamentar de 2016. As dinâmicas locais expõem processos de contração salarial e individualização das relações de trabalho e a reafirmação da meritocracia como justificativa ideológica da precarização. A isso, trabalhadores se contrapõem pela reafirmação de sua condição coletiva de classe, em favor de benefícios derivados do PMAQ, como recomposição salarial para todos.

Distributive conflict: analysis of the Program for Improving Access and Quality of Primary Care (PMAQ-AB) in two Brazilian northeastern capitals

This article analyzes the implementation of the Program for Improving Access and Quality of Primary Care (PMAQ-AB) in the context of a national political scenario of deep transformations, from the weak reformism that promoted slow extension of rights to the strong counter-reformism of neoliberal restoration. It is a case study with health workers, managers, and counselors in two capital cities in northeastern Brazil, discussing matters of work and distributive disputes of public resources. Results show the intensification of these conflicts in health and the unfavorable outcome for workers after the parliamentary coup in 2016 political context. Local dynamics expose the wage contraction and individualization of labor relations and the reassertion of meritocracy as an ideological ground for precariousness. Workers oppose this, reaffirming their collective class condition, favoring the benefit derived from PMAQ for fully regaining their group wages.

What has affected the governance effect of the whole population coverage of medical insurance in China in the past decade? Lessons for other countries

Objective

This study aimed to explore the current state of governance of full population coverage of health insurance in China and its influencing factors to provide empirical references for countries with similar social backgrounds as China.

Methods

A cross-sectional quantitative study was conducted nationwide between 22 January 2020 and 26 January 2020, with descriptive statistics, analysis of variance, and logistic regression models via SPSS 25.0 to analyze the effectiveness and influencing factors of the governance of full population coverage of health insurance in China.

Results

The effectiveness of the governance relating to the total population coverage of health insurance was rated as good by 59% of the survey respondents. According to the statistical results, the governance of the public's ability to participate in insurance (OR = 1.516), the degree of information construction in the medical insurance sector (OR = 2.345), the government's governance capacity (OR = 4.284), and completeness of the government's governance tools (OR = 1.370) were all positively correlated (p < 0.05) on the governance effect of the whole population coverage of health insurance.

Conclusions

The governance of Chinese health insurance relating to the total population coverage is effective. To effectively improve the effectiveness of the governance relating to the total population coverage of health insurance, health insurance information construction, governance capacity, and governance tools should be the focus of governance to further improve the accurate expansion of and increase the coverage of health insurance.

Similarity Analysis in Understanding Online News in Response to Public Health Crisis

BACKGROUND

The "Syphilis No!" campaign the Brazilian Ministry of Health (MoH) launched between November 2018 and March 2019, brought forward the concept "Test, Treat and Cure" to remind the population of the importance of syphilis prevention. In this context, this study aims to analyze the similarity of syphilis online news to comprehend how public health communication interventions influence media coverage of the syphilis issue.

METHODS

This paper presented a computational approach to assess the effectiveness of communication actions on a public health problem. Data were collected between January 2015 and December 2019 and processed using the Hermes ecosystem, which utilizes text mining and machine learning algorithms to cluster similar content.

RESULTS

Hermes identified 1049 google-indexed web pages containing the term 'syphilis' in Brazil. Of these, 619 were categorized as news stories. In total, 157 were grouped into clusters of at least two similar news items and a single cluster with 462 news classified as "single" for not featuring similar news items. From these, 19 clusters were identified in the pre-campaign period, 23 during the campaign, and 115 in the post-campaign.

CONCLUSIONS

The findings presented in this study show that the volume of syphilis-related news reports has increased in recent years and gained popularity after the SNP started, having been boosted during the campaign and escalating even after its completion.

The impact of the COVID-19 pandemic in the frontline health workforce: Perceptions of vulnerability of Brazil's community health workers

The COVID-19 pandemic has resulted in calls for an increased integration of community health workers (CHWs) into the health system response. Historically, CHWs can play an important role in ensuring the sustainability of health policy implementation - by addressing social determinants of health and maintaining care for ongoing health problems. Their frontline work, with close contact to populations, places CHWs in a position of increased vulnerability to becoming infected and to being the target of abuse and violence. These vulnerabilities compound underlying problems faced by CHWs, who often come from poor backgrounds, are insufficiently paid and receive inadequate training. Speaking to a scarcity of studies on how CHWs are impacted by the pandemic, this paper conducts a systematic study of CHWs in Brazil. Based on quantitative and qualitative data collected during June and July 2020, it considers perceptions and experiences of CHWs, comparing them with other health professionals. We study the extent to which the pandemic added to existing vulnerabilities and created new problems and imbalances in the work of CHWs. We conclude that COVID-19 led to a deterioration of the working conditions of CHWs, of their relations with other health professionals, and of their ability to carry out their essential work in the public health system.

Trends in Temperature-associated Mortality in São Paulo (Brazil) between 2000 and 2018: an Example of Disparities in Adaptation to Cold and Heat

Exposure to non-optimal temperatures remains the single most deathful direct climate change impact to health. The risk varies based on the adaptation capacity of the exposed population which can be driven by climatic and/or non-climatic factors subject to fluctuations over time. We investigated temporal changes in the exposure-response relationship between daily mean temperature and mortality by cause of death, sex, age, and ethnicity in the megacity of São Paulo, Brazil (2000-2018). We fitted a quasi-Poisson regression model with time-varying distributed-lag non-linear model (tv-DLNM) to obtain annual estimates. We used two indicators of adaptation: trends in the annual minimum mortality temperature (MMT), i.e., temperature at which the mortality rate is the lowest, and in the cumulative relative risk (cRR) associated with extreme cold and heat. Finally, we evaluated their association with annual mean temperature and annual extreme cold and heat, respectively to assess the role of climatic and non-climatic drivers. In total, we investigated 4,471,000 deaths from non-external causes. We found significant temporal trends for both the MMT and cRR indicators. The former was decoupled from changes in AMT, whereas the latter showed some degree of alignment with extreme heat and cold, suggesting the role of both climatic and non-climatic adaptation drivers. Finally, changes in MMT and cRR varied substantially by sex, age, and ethnicity, exposing disparities in the adaptation capacity of these population groups. Our findings support the need for group-specific interventions and regular monitoring of the health risk to non-optimal temperatures to inform urban public health policies.