Monitoring and evaluating progress towards Universal Health Coverage in Brazil

Use of phthalocyanine-derived mouthwash as a protective factor for COVID-19: a community trial

Aim

In a population profile corrected for sociodemographic factors, the aim of this study was to examine sociodemographic the protective effect of a phthalocyanine-derived mouthwash (APD) before infection with SARS-CoV-2, in addition to analyzing the survival of the at-risk population and the confirmed diagnosis of COVID-19.

Methods

For individuals from the Uru municipality, a structured questionnaire consisting of two parts was completed before the distribution of APD. Subsequently, subjects received two bottles containing 600 mL of APD and were instructed to rinse/gargle with 3 mL of the solution 3 to 5 times per day for 1 min for 2 months. Data were obtained from the electronic system of the municipal health center, organized in a spreadsheet, and analyzed using multiple linear regression and Cox regression analysis.

Results

The study included 995 participants with the following sociodemographic data: 98/995 individuals (p<0.002) who did not complete high school used the APD 66.30 times more than did individuals with higher education. The results in terms of survival were meaningful in relation to the duration of APD use. The protective factor for COVID-19 was 14.1%.

Conclusion

Daily use of a solution containing phthalocyanine derivatives provided a higher protection factor against COVID-19 infection, predominantly in individuals without a school-completion certificate.

The impact of residency training in family medicine on hospital admissions due to Ambulatory-care Sensitive Conditions in Rio de Janeiro

Lack of skilled human resources in primary care remains a major concern for policymakers in low- and middle-income countries. There is little evidence supporting the impact of residency training in family medicine in the quality of care, and it perpetuates misconceptions among policymakers that the provision of primary care can be easily done by any physician without special training. This article compares the risk of patients being hospitalized due to Ambulatory care sensitive conditions and the odds of having follow-up visits in primary care after hospital discharge, according to the type of their medical provider: (1) Generalists (reference), (2) Family physicians; and, (3) patients with no consultations prior to the event. Multilevel multivariate binomial regression models estimated the relative risks of a patient being hospitalized in a given month and the relative risks for the occurrence of a follow-up visit in primary care in a retrospective cohort of 636.640 patients between January 2013 and July 2018 in Rio de Janeiro. For all 14 conditions, there was a higher risk of hospitalization when patients had no consultation in primary care prior to the event. Except for Ear, Nose and Throat infections, patients seen by family physicians had a lower risk of being hospitalized, compared to patients seen by Generalists. Follow-up visits were more likely to happen among patients treated by family physicians for almost every condition analyzed. With two years of training in family medicine, Family physicians can reduce the risk of their patients being hospitalized and increase the likelihood of those patients having a follow-up consultation in primary care. Investments in residency training in family medicine should be made to fix the shortage of skilled physicians in primary care, reduce hospitalizations and improve quality and continuity of care.

[Recommendations for the development of resilient health systems in the AmericasRecomendações para o desenvolvimento de sistemas de saúde resilientes nas Américas]

This article offers opinion and analysis outlining strategic lines of action to build resilient health systems while promoting recovery in the post-COVID-19 pandemic period, with a view to maintaining and protecting public health gains. It contextualizes the challenges and opportunities in the Region of the Americas and offers recommendations for implementation of the strategic lines.It is urgent to promote the development of resilient health systems through the implementation of four lines of action defined in the strategy adopted by the Member States of the Pan American Health Organization in September 2021. The transformation of health systems must be based on the adoption of an integrated model of primary health care, a priority focus on the essential public health functions, strengthening of integrated health service networks, and increased public funding, especially for the first level of care. Implementation of these lines of action is focused not only on consolidating immediate crisis response; it is also framed within efforts toward the recovery and sustainable development of health systems, reducing their structural vulnerabilities to better prepare the response to future crises.

Challenges to the provision of specialized care in remote rural municipalities in Brazil

This case study analyses the challenges to providing specialized care in Brazilian remote rural municipalities (RRM). Interviews were conducted with managers from two Brazilian states (Piauí and Bahia). We identified that the distance between municipalities is a limiting factor for access and that significant care gaps contribute to different organizational arrangements for providing and accessing specialized care. Physicians in all the RRMs offer specialized care by direct disbursement to users or sale of procedures to managers periodically, compromising municipal and household budgets. Health regions do not meet the demand for specialized care and exacerbate the need for extensive travel. RRM managers face additional challenges for the provision of specialized care regarding the financing, implementation of cooperative arrangements, and the provision of care articulated in networks to achieve comprehensive care, seeking solutions to the locoregional specificities.

Surgical capacity assessment in the state of Amazonas using the surgical assessment tool. Cross-sectional study

OBJECTIVE

Brazil is a country with universal health coverage, yet access to surgery among remote rural populations remains understudied. This study assesses surgical care capacity among hospitals providing care for the rural populations in the Amazonas state of Brazil through in-depth facility assessments.

METHODS

a stratified randomized cross-sectional evaluation of hospitals that self-report providing surgical care in Amazonas was conducted from July 2016 to March 2017. The Surgical Assessment Tool (SAT) developed by the World Health Organization and the Program in Global Surgery and Social Change at Harvard Medical School was administered at remote hospitals, including a retrospective review of medical records and operative logbooks.

RESULTS

18 hospitals were surveyed. Three hospitals (16.6%) had no operating rooms and 12 (66%) had 1-2 operating rooms. 14 hospitals (77.8%) reported monitoring by pulse oximetry was always present and six hospitals (33%) never have a professional anesthesiologist available. Inhaled general anesthesia was available in 12 hospitals (66.7%), but 77.8% did not have any mechanical ventilation device. An average of 257 procedures per 100,000 were performed. 10 hospitals (55.6%) do not have a specific post-anesthesia care unit. For the regions covered by the 18 hospitals, with a population of 497,492 inhabitants, the average surgeon, anesthetist, obstetric workforce density was 6.4.

CONCLUSION

populations living in rural areas in Brazil face significant disparities in access to surgical care, despite the presence of universal health coverage. Development of a state plan for the implementation of surgery is necessary to ensure access to surgical care for rural populations.

Performance evaluation of tuberculosis control in Brazilian municipalities

OBJECTIVE

To evaluate the performance of tuberculosis control in Brazilian municipalities.

METHODS

This is an ecological study on Brazilian municipalities that notified at least four new cases of tuberculosis, with a minimum of one new case of pulmonary tuberculosis between 2015 and 2018. The municipalities were stratified according to the population in < 50 thousand, 50-100 thousand, 100-300 thousand, and > 300 thousand inhabitants, and the k-means method was used to group them within each population range according to the performance of six indicators of the disease.

RESULTS

A total of 2,845 Brazilian municipalities were included, comprising 98.5% (208,007/211,174) of new tuberculosis cases in the period. For each population range, three groups (A, B, and C) of municipalities were identified according to the performance of the indicators: A, the most satisfactory; B, the intermediates; and C, the least satisfactory. Municipalities in group A with < 100 thousand inhabitants presented results above the targets for laboratory confirmation (≥ 72%), abandonment (≤ 5%), and cure (≥ 90%), and comprised 2% of new cases of the disease. Conversely, municipalities of groups B and C presented at least five indicators with results below the targets - HIV testing (< 100%), contact investigation (< 90%), directly observed therapy (< 90%), abandonment (> 5%), and cure (< 90%) -, and corresponded to 66.7% of new cases of tuberculosis. In group C of municipalities with > 300 thousand inhabitants, which included 19 of the 27 capitals and 43.1% of new cases of tuberculosis, the lowest percentages of contact investigation (mean = 56.4%) and directly observed therapy (mean = 15.4%) were verified, in addition to high abandonment (mean = 13.9%) and low coverage of primary health care (mean = 66.0%).

CONCLUSIONS

Most new cases of tuberculosis occurred in municipalities with unsatisfactory performance for disease control. Expanding the coverage of primary health care in these places can reduce abandonment and increase the contact investigation and directly observed therapy.

Strengths, Weaknesses, Opportunities and Threats (SWOT) Analysis of the Implementation of Public Health Policies on HTLV-1 in Brazil

Human T lymphotropic virus 1 (HTLV-1) is a public health issue for most countries and imposes important consequences on patients' health and socioeconomic status. Brazil is one of the global leaders of the public health response to these viruses. The country has challenges to overcome to implement meaningful policies aiming to eliminate HTLV-1/2. An analysis of strengths, weaknesses, opportunities, and threats (SWOT) for the implementation of public health policies on HTLV-1/2 was performed. The strengths identified were the Brazilian Unified Health System (SUS); Brazilian expertise in public health programs successfully implemented; currently available policies targeting HTLV; and strong collaboration with researchers and patient's representative. Lack of awareness about HTLV, insufficient epidemiological data, lack of reference centers for patient care, insufficient availability of confirmatory tests, lack of universal antenatal screening, and absence of cost-effectiveness studies were identified as weaknesses. Some interesting opportunities included the increased interest from international organizations on HTLV, possibility of integrating HTLV into other programs, external funding for research, available online platforms, opportunity to acquire data from HTLV-1/2 surveillance to gather epidemiological information, and HTLV policies that were implemented independently by states and municipalities. In addition to the COVID-19 pandemic, existing demands from different diseases, the country's demography and its marked sociocultural diversity and the volatility of the technical team working with HTLV-1/2 at the Brazilian Ministry of Health are threats to the implementation of public policies on HTLV-1/2. This SWOT analysis will facilitate strategic planning to allow continuous progress of the Brazilian response to HTLV-1/2 infection.

Health services utilization in the Brazilian Amazon: panel of two cross-sectional studies

OBJECTIVE

To investigate the use of health services among adults living in Manaus, Amazonas.

METHODS

This was a panel of two cross-sectional studies conducted in Manaus in 2015 and 2019. Individuals aged ≥ 18 years were selected by probabilistic sampling and interviewed at home. The study outcomes were doctor visits and hospitalizations in the previous 12 months, and unmet surgical needs. Variations between 2015 and 2019 were tested using chi-squared goodness-of-fit test. Poisson regression with robust variance was employed to calculate the prevalence ratios (PR) of the outcomes with 95% confidence intervals (95%CI).

RESULTS

The surveys included 5,800 participants in total. Visits to the doctor decreased from 2015 (78.7%) to 2019 (76.3%; p < 0.001), hospital admissions increased from 2015 (7.9%) to 2019 (11.5%; p < 0.001), and unmet surgical needs decreased in the period (15.9% to 12.1%; p < 0.001). These variations were particularly observed in vulnerable individuals – sicker; poorer; non-whites; and those belonging to lower social classes, with less access to education, formal jobs, and health insurance (p < 0.05). Doctor visits were higher in people with fair health status (PR = 1.09; 95%CI 1.06–1.12), health insurance (PR = 1.13; 95%CI 1.09–1.17), and chronic diseases (p < 0.001) but lower in men (PR = 0.87; 95%CI 0.84–0.90) and informal workers (PR = 0.89; 95%CI 0.84–0.94). Hospitalizations were higher in people with worse health statuses (p < 0.001), without partners (PR = 1.27; 95%CI 1.05–1.53), and with multimorbidity (PR = 1.68; 95%CI 1.33–2.12) but lower in men (PR = 0.55; 95%CI 0.44–0.68), older adults (p < 0.001), informal workers (PR = 0.67; 95%CI 0.51–0.89), and unemployed (PR = 0.72; 95%CI 0.53–0.97). Unmet surgical needs were higher in older adults (p < 0.001), middle-class people (PR = 1.24; 95%CI 1.01–1.55), worse health statuses (p < 0.001), and chronic diseases (p < 0.001) but lower in men (PR = 0.76; 95%CI 0.65–0.86).

CONCLUSIONS

From 2015 to 2019, less people visited the doctor, more were admitted to hospitals, and less were in need of surgery or aware of that need, potentially indicating poorer access to health services.

Has Latin America achieved universal health coverage yet? Lessons from four countries

Background

Seven years after the commitment to United Nations’ call for Universal Health Coverage, healthcare services in Argentina, Brazil, Colombia, Mexico are generally accessible and affordable; but they still struggle to meet population health demands and address the rising health care costs. We aim to describe measures taken by these four countries to commit by Universal Health Coverage, addressing their barriers and challenges.

Methods

Scoping literature review, supplemented with targeted stakeholders survey.

Results

The four countries analysed achieved an overall index of essential coverage of 76–77%, and households out of pocket health expenditures fall below 25%. Services coverage was improved by expanding access to primary healthcare systems and coverage for non-communicable diseases, while provided community outreach by the increase in the number of skilled healthcare workers. New pharmaceutical support programs provided access to treatments for chronic conditions at zero cost, while high-costs drugs and cancer treatments were partially guaranteed. However, the countries lack with effective financial protection mechanisms, that continue to increase out of pocket expenditure as noted by lowest financial protection scores, and lack of effective financial mechanisms besides cash transfers.

Conclusions

Argentina, Brazil, Colombia, and Mexico have made progress towards UHC. Although, better financial protection is urgently required.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-022-00793-7.

This review presents the current situation of UHC implementation in Argentina, Brazil, Colombia, and Mexico, using different elements from the WHO in their 13th Program of Work to compare service coverage and financial protection.

During the 1990s, health systems within several Latin American countries, anticipating to Universal Health Coverage increasing the service coverage, but struggling to fulfill financial protection standards. Still the four countries struggle to find mechanisms that could increase pooling mechanisms capable of increasing service coverage, while reducing financial inequities among people.

The decentralization of the primary healthcare system, the development of public-private partnerships, and the implementation of progressive financing mechanisms like conditional cash transfers are potential manners to improve service delivery and financial protection contributing to effective UHC.

Avaliação da capacidade cirúrgica do estado do Amazonas utilizando uma ferramenta de avaliação cirúrgica. Estudo transversal

RESUMO Objetivo: o Brasil é um país com cobertura universal de saúde, mas o acesso à cirurgia entre populações remotas permanece pouco estudado. Este estudo avalia a capacidade cirúrgica em hospitais que servem populações rurais no estado do Amazonas, Brasil, por meio de avaliações aprofundadas das instalações. Métodos: foi realizada avaliação estratificada randomizada transversal de hospitais que relataram prestar assistência cirúrgica de julho de 2016 a março de 2017. A Ferramenta de Avaliação Cirúrgica desenvolvida pela Organização Mundial da Saúde e o Programa de Cirurgia Global e Mudança Social da Harvard Medical School foi administrada em hospitais remotos, incluindo uma revisão retrospectiva de registros médicos e livros cirúrgicos. Resultados: 18 hospitais foram pesquisados. Três hospitais (16,6%) não tinham salas cirúrgicas e 12 (66%) tinham 1-2. 14 hospitais (77,8%) relataram que a oximetria de pulso estava “sempre presente” e seis hospitais (33%) nunca têm um anestesiologista disponível. A anestesia inalatória estava disponível em 12 hospitais (66,7%), 77,8% não possuíam dispositivo de ventilação mecânica. Em média, 257 procedimentos por 100.000 foram realizados. 10 hospitais (55,6%) não possuem unidade de recuperação anestésica. Para as regiões de abrangência dos 18 hospitais, com população de 497.492 habitantes, a densidade média de força de trabalho cirúrgica, anestesista e obstétrica foi de 6,4. Conclusão: as populações que vivem em áreas rurais no Brasil enfrentam disparidades significativas no acesso à assistência cirúrgica, apesar da presença de cobertura universal de saúde. O desenvolvimento de um plano estadual de cirurgia é necessário para garantir acesso à assistência cirúrgica às populações rurais.

Analysis of demand and access to services in the last two weeks previous to the National Health Survey 2013 and 2019

OBJECTIVE

Compare the demand and use of health services between 2013 and 2019, and analyze the associated sociodemographic and health variables in 2019.

METHODS

Cross-sectional study with data from the National Health Survey (PNS) 2013 and 2019. The prevalence and 95% confidence intervals (95% CI) for the demand and use of health services were estimated. In 2019, the differences in the indicators were analyzed according to sociodemographic variables and the crude and adjusted by sex and age prevalence ratios (RP) were estimated.

RESULTS

There was an increase of 22% in the demand for health care in the last two weeks, going from 15.3% (95%CI 15.0-15.7) in 2013 to 18.6% (95%CI 18.3-19.0) in 2019. There was a reduction in use in the last two weeks, from 97% (95%CI 96.6-97.4) in 2013 to 86.1% (95%CI 85.4-86.8) in 2019, which was observed for most Federation Units. In 2019, the demand for care was greater among women, the elderly, those with high schooling, individuals with health insurance and poor self-rated health. They obtained greater access to health services in the fifteen days prior to the survey: men, children or adolescents up to 17 years of age, people with health insurance and poor health self-assessment.

CONCLUSION

The demand for health services has grown and reduced access in the last 15 days between 2013 and 2019. These differences may have been exacerbated by the austerity measures implemented in the country.

Multimorbidity and use of health services in the oldest old in Brazil

OBJECTIVE

To estimate the prevalence of multimorbidity in long-lived Brazilian individuals (age ≥80 years) and to associated it with the use of health services.

METHODS

Cross-sectional population-based study with data from the 2019 National Survey of Health (n=6,098). Frequencies of use of services were estimated for older people with multimorbidity and according to sex, health insurance ownership, and self-rated health. The prevalence rates, crude and adjusted prevalence ratios, and the respective 95% confidence intervals were calculated.

RESULTS

The average age of the older adults was 85 years and about 62% were women; the prevalence of multimorbidity was 57.1%, higher in women, in those who have health insurance, and who reside in the southern region of the country (p<0.05). In the oldest old with multimorbidity, the use of services in the last 15 days reached 64.6%, and more than 70% were hospitalized in the last year or did not carry out activities in the previous two weeks for health reasons. Differences were observed for the indicators of service use in relation to sex, health insurance ownership, and self-rated health, according to multimorbidity.

CONCLUSION

Indicators for the use of health services were higher in older individuals who have two or more chronic diseases, regardless of sociodemographic conditions and self-rated health, showing the impact of multimorbidity per se in determining the use of services among the oldest old.

Punt Politics as Failure of Health System Stewardship: Evidence from the COVID-19 Pandemic Response in Brazil and Mexico

We present a new concept, Punt Politics, and apply it to the COVID-19 non-pharmaceutical interventions (NPI) in two epicenters of the pandemic: Mexico and Brazil. Punt Politics refers to national leaders in federal systems deferring or deflecting responsibility for health systems decision-making to sub-national entities without evidence or coordination. The fragmentation of authority and overlapping functions in federal, decentralized political systems make them more susceptible to coordination problems than centralized, unitary systems. We apply the concept to pandemics, which require national health system stewardship, using sub-national NPI data that we developed and curated through the Observatory for the Containment of COVID-19 in the Americas to illustrate Punt Politics in Mexico and Brazil. Both countries suffer from protracted, high levels of COVID-19 mortality and inadequate pandemic responses, including little testing and disregard for scientific evidence. We illustrate how populist leadership drove Punt Politics and how partisan politics contributed to disabling an evidence-based response in Mexico and Brazil. These cases illustrate the combination of decentralization and populist leadership that is most conducive to punting responsibility. We discuss how Punt Politics reduces health system functionality, providing lessons for other countries and future pandemic responses, including vaccine rollout.

The COVID-19 Vaccination Strategy in Brazil-A Case Study

Brazil is among the countries which have faced two devastating infection waves of COVID-19 in the past year. Despite the fact the country has one of the world's leading immunization programs, Brazil only slowly established a national COVID-19 vaccination strategy and campaign. This case study is based on an integrative review of primary and secondary literature sources. Different search strategies on Medline and Google Scholar were performed for the case presentation, for the management and outcome of the COVID-19 outbreak and for the state of the COVID-19 vaccination program. Official documents from the Brazilian Ministry of Health, the website of the World Health Organization and pharmaceutical companies were also reviewed. Searches were limited to English, French, German, Portuguese and Spanish. This article describes the Brazilian COVID-19 vaccination campaign and the drivers and barriers to its implementation; and evaluates further investigations needed to have a conclusive overview over the constantly evolving situation. Healthcare inequalities, which were widened during the pandemic, a lack of coordination at the federal level, the absence of federal government support for scientific research and the lack of endorsement and commitment to the mitigation of the COVID-19 pandemic set the country's COVID-19 vaccination campaign off to a challenging start. However, Brazil had a well-developed primary care system and national vaccination program prior to the pandemic, which are both important facilitators. At the time of writing, six vaccines are currently available in the country, and the program is advancing. The scientific community needs to continue to investigate the country's vaccination strategy and its implementation to make sure that maximum effort is undertaken for the health of the Brazilian population.

Impact of the Brazilian Family Health Strategy on child oral health-related quality of life: a cohort study

Most of the Brazilian population is covered by the Family Health Strategy (FHS), however no longitudinal study has assessed the impact of the FHS on child oral health-related quality of life (OHRQoL). The objective of the study was to evaluate the longitudinal impact of the FHS on the OHRQoL. This study followed up 459 children aged 2 to 5 years for 2 years. OHRQoL was assessed by the Brazilian version of the Early Childhood Oral Health Impact Scale (ECOHIS) at baseline (April to November 2016) and follow-up (April to December 2018). Children's parents answered a questionnaire regarding sociodemographic information, FHS service, and dental service. Participants were clinically examined for dental caries. Multilevel Poisson regression was used to assess the associations between FHS variables at baseline and overall/domain-specific of the ECOHIS scores over time. A total of 365 children were reassessed for OHRQoL (follow-up rate: 79.5%). The absence of FHS coverage from the child's first year of age was associated with higher scores in the family function domain [rate ratio (RR) = 2.42; 95% confidence interval (CI) 1.28-4.58)]. Home visits by the FHS team members were associated with higher psychological domain scores (RR = 1.60; 95%CI 1.01-2.57). Children not covered by the FHS since the first year of age reported worse OHRQoL over time. This fact highlights the importance of an integrated health approach to promote children's health.

Performance assessment of the county healthcare systems in Kenya: a mixed-methods analysis

INTRODUCTION

A well performing public healthcare system is necessary for Kenya to continue progress towards universal health coverage (UHC). Identifying actionable measures to improve the performance of the public healthcare system is critical to progress towards UHC. We aimed to measure and compare the performance of Kenya's public healthcare system at the county level and explore remediable drivers of poor healthcare system performance.

METHODS

Using administrative data from fiscal year 2014/2015 through fiscal year 2017/2018, we measured the technical efficiency of 47 county-level public healthcare systems in Kenya using stochastic frontier analysis. We then regressed the technical efficiency measure against a set of explanatory variables to examine drivers of efficiency. Additionally, in selected counties, we analysed surveys and focus group discussions to qualitatively understand factors affecting performance.

RESULTS

The median technical efficiency of county public healthcare systems was 84% in fiscal year 2017/2018 (with an IQR of 79% to 90%). Across the four fiscal years of data, 27 out of the 47 Kenyan counties had a declining technical efficiency score. Our regression analysis indicated that impediments to the flow of funding-measured by the budget absorption rate which is the ratio between funds spent and funds released-were significantly related to poor healthcare system performance. Our analysis of interviews and surveys yielded a similar conclusion as nearly 50% of respondents indicated issues stemming from poor budget absorption were significant drivers of poor healthcare system performance.

CONCLUSION

Public healthcare systems at the county-level in Kenya general performed well; however, addressing delays in the flow of funding is a concrete step to improve healthcare system performance. As Kenya-and other countries-provides additional funding to meet their UHC goals, establishing a strong and robust public financial management system is critical to ensure that the benefits of UHC are realised.

A partisan pandemic: state government public health policies to combat COVID-19 in Brazil

INTRODUCTION

To present an analysis of the Brazilian health system and subnational (state) variation in response to the COVID-19 pandemic, based on 10 non-pharmaceutical interventions (NPIs).

MATERIALS AND METHODS

We collected daily information on implementation of 10 NPI designed to inform the public of health risks and promote distancing and mask use at the national level for eight countries across the Americas. We then analyse the adoption of the 10 policies across Brazil's 27 states over time, individually and using a composite index. We draw on this index to assess the timeliness and rigour of NPI implementation across the country, from the date of the first case, 26 February 2020. We also compile Google data on population mobility by state to describe changes in mobility throughout the COVID-19 pandemic.

RESULTS

Brazil's national NPI response was the least stringent among countries analysed. In the absence of a unified federal response to the pandemic, Brazilian state policy implementation was neither homogenous nor synchronised. The median NPI was no stay-at-home order, a recommendation to wear masks in public space but not a requirement, a full school closure and partial restrictions on businesses, public transportation, intrastate travel, interstate travel and international travel. These restrictions were implemented 45 days after the first case in each state, on average. Rondônia implemented the earliest and most rigorous policies, with school closures, business closures, information campaigns and restrictions on movement 24 days after the first case; Mato Grosso do Sul had the fewest, least stringent restrictions on movement, business operations and no mask recommendation.

CONCLUSIONS

The study identifies wide variation in national-level NPI responses to the COVID-19 pandemic. Our focus on Brazil identifies subsequent variability in how and when states implemented NPI to contain COVID-19. States' NPIs and their scores on the composite policy index both align with the governors' political affiliations: opposition governors implemented earlier, more stringent sanitary measures than those supporting the Bolsonaro administration. A strong, unified national response to a pandemic is essential for keeping the population safe and disease-free, both at the outset of an outbreak and as communities begin to reopen. This national response should be aligned with state and municipal implementation of NPI, which we show is not the case in Brazil.

Multimorbidity and population at risk for severe COVID-19 in the Brazilian Longitudinal Study of Aging

This study aimed to measure the occurrence of multimorbidity and to estimate the number of individuals in the Brazilian population 50 years or older at risk for severe COVID-19. This was a cross-sectional nationwide study based on data from the Brazilian Longitudinal Study of Aging (ELSI-Brazil), conducted in 2015-2016, with 9,412 individuals 50 years or older. Multimorbidity was defined as ≥ 2 chronic conditions based on a list of 15 diseases considered risk conditions for severe COVID-19. The analyses included calculation of prevalence and estimation of the absolute number of persons in the population at risk. Self-rated health status, frailty, and basic activities of daily living were used as markers of health status. Sex, age, region of the country, and schooling were used as covariables. Some 80% of the sample had at least one of the target conditions, which represents some 34 million individuals. Multimorbidity was reported by 52% of the study population, with higher proportions in the Central, Southeast, and South of Brazil. Cardiovascular diseases and obesity were the most frequent chronic conditions. An estimated 2.4 million Brazilians are at serious health risk. The results revealed inequalities according to schooling. The number of persons 50 years or older who presented risk conditions for severe COVID-19 is high both in absolute and relative terms. The estimate is important for planning strategies to monitor persons with chronic conditions and for preventive strategies to deal with the novel coronavirus.

Reasons for encounter in primary health care in Brazil

BACKGROUND

Primary health care (PHC) delivery in Brazil has improved in the last decades. However, it remains unknown whether the Family Health Strategy teams are meeting the health needs of the population.

OBJECTIVES

To describe the reasons for encounter (RFEs) in PHC in Brazil and to examine variations in RFEs according to sex, age and geographic region.

METHODS

This descriptive study is part of a national cross-sectional study conducted in 2016. The sample was stratified by the number of PHC physicians per geographic region. Physicians who had been working for at least 1 year in the same PHC unit were included. For every participating physician, 12 patients aged ≥18 years who had attended at least two encounters were included. Patients were asked about their RFEs, which were classified according to the International Classification of Primary Care.

RESULTS

In 6160 encounters, a total of 8046 RFEs were coded. Seven reasons accounted for 50% of all RFEs. There was a high frequency of codes related to test results, medication renewal and preventive medicine. RFEs did not vary significantly by sex or geographic region, but they did by age group (P < 0.001). The rates of prescriptions, requests for investigations and referrals to specialized care were 71.1%, 42.8%, and 21.3%, respectively.

CONCLUSION

This novel study opened the 'black box' of RFEs in PHC in Brazil. These findings can contribute to redefining the scope of PHC services and reorienting work practices in order to improve the quality of PHC in Brazil.

Socioeconomic inequalities in women's access to health care: has Ecuadorian health reform been successful?

BACKGROUND

Over the last 12 years, Ecuador has implemented comprehensive health sector reform to ensure equitable access to health care services according to need. While there have been important achievements in terms of health care coverage, the effects of these reforms on socioeconomic inequalities in health care have not been analysed. The present study assesses whether the health care reforms implemented in the decade between 2007 and 2017 have contributed to reducing the socioeconomic inequalities in women's health care access.

METHODS

The present study was based on two waves (2006 and 2014) of the Living Standards Measurement Survey conducted in Ecuador. Data from women of reproductive age (15 to 49 years) were analysed to evaluate health care coverage across three indicators: skilled birth attendance, cervical cancer screening, and the use of modern contraceptives. Absolute risk differences were calculated between the heath care indicators and the socioeconomic variables using binomial regression analysis for each time period. The Slope Index of Inequality (SII) was also calculated for each socioeconomic variable and period. A multiplicative interaction term between the socioeconomic variables and period was included to assess the changes in socioeconomic inequalities in health care over time.

RESULTS

Access to health care increased in the three studied outcomes during the health sector reform. Significant reductions in inequality in skilled birth attendance were observed in all socioeconomic variables except in the occupational class. Cervical cancer screening inequalities increased according to education and occupation, but decreased by wealth. Only a poorer education was observed for modern contraceptive use.

CONCLUSIONS

While most socioeconomic inequalities in skilled birth attendance decreased during the reform period, this was not the case for inequalities in cervical cancer screening or the use of modern contraceptives. Further studies are needed to address the social determinants of these health inequalities.

The burden of disease among Brazilian older adults and the challenge for health policies: results of the Global Burden of Disease Study 2017

BACKGROUND

Brazil is the world's fifth most populous nation, and is currently experimenting a fast demographic aging process in a context of scarce resources and social inequalities. To understand the health profile of older adults in Brazil is fundamental for planning public policies.

METHODS

The estimates were derived from data obtained through the collaboration between the Brazilian Ministry of Health and the Institute of Health Metrics and Evaluation of the University of Washington. The Brazilian Institute of Geography and Statistics provided the population estimates. Data on causes of death came from the Mortality Information System. To calculate morbidity, population-based studies on the prevalence of diseases in Brazil were comprehensively searched, in addition to information obtained from national databases such as the Hospital Information System, the Outpatient Information System, and the Injury Information System. We presented the Global Burden of Disease (GBD) 2017 estimates among Brazilian older adults (60+ years old) for life expectancy at birth (LE), healthy life expectancy (HALE), cause-specific mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life years (DALYs), from 2000 to 2017.

RESULTS

LE at birth significantly increased from 71.3 years (95% UI to 70.9-71.8) to 75.2 years (95% UI 74.7-75.7). There was a trend of increasing HALE, from 62.2 years (95% UI 59.54-64.5) to 65.5 years (95% UI 62.6-68.0). The proportion of DALYs among older adults increased from 7.3 to 10.3%. Chronic noncommunicable diseases are the leading cause of death among middle aged and older adults, while Alzheimer's disease is a leading cause only among older adults. Mood disorders, musculoskeletal pain, and hearing or vision losses are among the leading causes of disability.

CONCLUSIONS

The increase in LE and the decrease of the DALYs rates are probably results of the improvement of social conditions and health policies. However, the smaller increase of HALE than LE means that despite living more, people spend a substantial time of their old age with disability and illness. Preventable or potentially controllable diseases are responsible for most of the burden of disease among Brazilian older adults. Health investments are necessary to obtain longevity with quality of life in Brazil.

Field-testing of primary health-care indicators, India

Objective

To develop a primary health-care monitoring framework and health outcome indicator list, and field-test and triangulate indicators designed to assess health reforms in Kerala, India, 2018–2019.

Methods

We used a modified Delphi technique to develop a 23-item indicator list to monitor primary health care. We used a multistage cluster random sampling technique to select one district from each of four district clusters, and then select both a family and a primary health centre from each of the four districts. We field-tested and triangulated the indicators using facility data and a population-based household survey.

Findings

Our data revealed similarities between facility and survey data for some indicators (e.g. low birth weight and pre-check services), but differences for others (e.g. acute diarrhoeal diseases in children younger than 5 years and blood pressure screening). We made four critical observations: (i) data are available at the facility level but in varying formats; (ii) established global indicators may not always be useful in local monitoring; (iii) operational definitions must be refined; and (iv) triangulation and feedback from the field is vital.

Conclusion

We observe that, while data can be used to develop indices of progress, interpretation of these indicators requires great care. In the attainment of universal health coverage, we consider that our observations of the utility of certain health indicators will provide valuable insights for practitioners and supervisors in the development of a primary health-care monitoring mechanism.

Política Nacional de Atenção Básica de 2017: análise da composição das equipes e cobertura nacional da Saúde da Família

Resumo A Estratégia Saúde da Família é a principal forma de organização do sistema de saúde brasileiro. Contudo, a terceira edição da Política Nacional de Atenção Básica (PNAB) passou a reconhecer financeiramente outros tipos de equipes. Para analisar os efeitos da PNAB de 2017 na composição das equipes, foi realizado um estudo de série temporal de 2007 a 2019 utilizando dados do Cadastro Nacional de Estabelecimentos de Saúde (CNES) de postos de trabalho e de equipes e a cobertura nacional da Saúde da Família. Observou-se a concentração de médicos nas regiões Sudeste e Nordeste e oscilação dessa categoria profissional ante os acontecimentos do Programa Mais Médicos. Houve acréscimo de 5% de enfermeiros e redução de 0,3% dos ACS no país. A despeito da autorização e financiamento para implantação de equipes de “Atenção Básica” (eAB), elas correspondem a menos de 1% do total de equipes. Vale ressaltar que a modalidade preferencial dos gestores municipais se mantem pela Equipes de Saúde da Família, correspondendo a 75% do total de equipes e em crescimento. Apesar dos questionamentos e expectativas gerados pela PNAB de 2017 no contexto da Atenção Primária à Saúde, conclui-se que, em relação às equipes e suas composições, não houve mudança significativa após dois anos de sua vigência.

[Recommendations to strengthen primary health care in BrazilRecomendaciones para el fortalecimiento de la atención primaria de salud en Brasil]

Objective

To formulate strategic recommendations to strengthen primary health care (PHC) in Brazil's Unified Health System (SUS) based on expert consultation.

Method

The present qualitative study, developed from March to August, 2018, included administration of an open questionnaire followed by consensus building among 20 participants representing the five Brazilian regions, selected using the criterion of recognized professional expertise in the field of PHC. Participants answered an online questionnaire created by the authors. The findings were systematized as recommendations, which were submitted for priority ranking by the expert group using a one-round Delphi technique. The final recommendations were discussed in a face-to-face workshop.

Results

Of 20 experts, 18 answered the open questionnaire, generating 84 themes for analysis, which were systematized into 44 proposals. Evaluation of these proposals resulted in 20 recommendations, emphasizing expansion of the Family Health Strategy (FHS); enhanced access to PHC; training of professionals for multidisciplinary work in the PHC setting; allocation of technologies to ensure PHC resolvability; improvement of regulation/coordination of services to strengthen a foundational role of PHC in the SUS; human resources, provision of professionals, and support/stimulus for teams; production and dissemination of knowledge; transparency in PHC initiatives; and mediating role of PHC in the healthcare system.

Conclusions

The findings support the FHS as the best model to ensure a strong PHC in the SUS, combined with policies that prioritize essential PHC attributes, especially through innovation in care, management, and communication technologies.

Chronic pain is associated with increased health care use among community-dwelling older adults in Brazil: the Pain in the Elderly (PAINEL) Study

BACKGROUND

Chronic pain is known to increase health care use in high-income countries, but in Brazil, little is known.

OBJECTIVE

To investigate the association between chronic pain and health care use among Brazilian older adults and explore the relationship between pain severity and health care use.

METHODS

This cross-sectional study was derived from the population-based study Frailty in Brazilian Older People-FIBRA. Chronic pain, pain intensity and pain-related disability were assessed through additional telephone interviews. Health care use was measured by the number of doctor visits, hospitalization events and high health care use (highest quartile of the distribution for number of doctor visits) in the last 12 months. Associations were tested in regression analyses adjusted for predisposing, enabling and illness-level components from the Andersen Model.

RESULTS

The 383 participants were predominantly female (71.0%), mean age was 75.6 (6.1 SD). The prevalence of chronic pain was 30.0%. Chronic pain was associated with number of doctor visits [unstandardized B coefficient 1.48; 95% confidence interval (CI) = 0.35-2.62] and high health care use [odds ratios (OR) = 2.27; 95% CI = 1.39-3.72]. Pain intensity was associated with high health care use in univariate (OR = 1.13; 95% CI = 1.06-1.20) but not multivariate analysis (OR = 1.12; 95% CI = 0.94-1.33). Pain-related disability was not associated with any outcome.

CONCLUSION

Chronic pain increased health care use among Brazilian older adults. Improving the quality of primary care management of individuals at greater risk of chronic pain should be a cornerstone of health policies directed towards reducing the personal and societal burden of ageing.

Inequity in utilizing health services in the Brazilian Amazon: A population-based survey, 2015

BACKGROUND

Although Brazil has a public and universal healthcare system, utilization of health services is marked by social and regional discrepancies.

OBJECTIVE

To assess the prevalence and factors associated with underutilization of healthcare services in the Brazilian Amazon.

METHOD

Cross-sectional, population-based study. Adults aged over 18 years old were selected through probabilistic sampling. Underutilization of healthcare services was defined as never seeing a physician or a dentist. Poisson regression with robust variance was performed to calculate prevalence ratios (PRs) and 95% confidence intervals (CIs). A complex sample design was considered.

RESULTS

A total of 4001 individuals were included, of which 419 (10.4%; 95% CI, 9.5-11.4%) never visited a physician or a dentist. In the adjusted analysis, underutilization was higher among poorer people (PR = 3.32; 95% CI, 2.16-5.11), men (PR = 1.34; 95% CI, 1.10-1.65), people with brown skin color (Brazilian mixed race; PR = 1.34; 95% CI, 1.02-1.76), and people who are separated (PR = 1.40; 95% CI, 1.01-1.94) and widowed (PR = 1.55; 95% CI, 1.02-2.37), when compared with the reference categories. Individuals with informal jobs, those who are retired, students/housewives, and unemployed people were more vulnerable to underutilization than formal workers (P < .04).

CONCLUSION

Underutilization of healthcare services occurs in one-tenth of adults in Manaus Metropolitan Region and is associated with social and economic inequities.

Brazil's unified health system: the first 30 years and prospects for the future

In 1988, the Brazilian Constitution defined health as a universal right and a state responsibility. Progress towards universal health coverage in Brazil has been achieved through a unified health system (Sistema Único de Saúde [SUS]), created in 1990. With successes and setbacks in the implementation of health programmes and the organisation of its health system, Brazil has achieved nearly universal access to health-care services for the population. The trajectory of the development and expansion of the SUS offers valuable lessons on how to scale universal health coverage in a highly unequal country with relatively low resources allocated to health-care services by the government compared with that in middle-income and high-income countries. Analysis of the past 30 years since the inception of the SUS shows that innovations extend beyond the development of new models of care and highlights the importance of establishing political, legal, organisational, and management-related structures, with clearly defined roles for both the federal and local governments in the governance, planning, financing, and provision of health-care services. The expansion of the SUS has allowed Brazil to rapidly address the changing health needs of the population, with dramatic upscaling of health service coverage in just three decades. However, despite its successes, analysis of future scenarios suggests the urgent need to address lingering geographical inequalities, insufficient funding, and suboptimal private sector-public sector collaboration. Fiscal policies implemented in 2016 ushered in austerity measures that, alongside the new environmental, educational, and health policies of the Brazilian government, could reverse the hard-earned achievements of the SUS and threaten its sustainability and ability to fulfil its constitutional mandate of providing health care for all.

Realizing the right to health in Brazil's Unified Health System through the lens of breast and cervical cancer

Background

Health is recognized as a fundamental right in Brazil’s constitution. In the absence of a clearly defined benefit packages of healthcare services that are financed under the Unified Health System (Sistema Único de Saúde, SUS), courts have become important in adjudicating coverage decisions. Empirical assessments of equity and the right to health tend to focus on simple measures of access. However, these empirical perspectives belie the significant inequalities and rights violations that arise in the case of more complex health needs such as cancer. To shed light on these issues, this paper focuses on the care pathways for breast and cervical cancer and explores access and quality issues that arise at different points along the care pathway with implications for the realization of the right to health in Brazil.

Method

A mixed method approach is used. The analysis is primarily based on a quantitative analysis of national representative administrative data principally from the cervical and breast cancer information systems and the hospital cancer registry. To gain more insights into the organization of cancer care, qualitative data was collected from the state of Bahia, through document analysis, direct observation, roundtable discussions with health workers (HWs), and structured interviews with health care administrators.

Results

The paper reveals that the volume of completed screening exams is well below the estimated need, and a tendency toward lower breast cancer screening rates in poorer states and for women in the lowest income brackets. Only 26% of breast cancer cases and 29% of cervical cancer cases are diagnosed at an early stage (stage 0 or I), thereby reducing the survival prospects of patients. Waiting times between confirmed diagnosis and treatment are long, despite new legislation that guarantees a maximum of 60 days. The waiting times are significantly longer for patients that follow the recommended patient pathways, and who are diagnosed outside the hospital.

Conclusion

The study reveals that there are large variations between states and patients, where the poorest states and patients fare worse on key indicators. More broadly, the paper shows the importance of collecting data both on patient characteristics and health system performance and carry out detailed health system analysis for exposing, empirically, rights violations and for identifying how they can be addressed.

Electronic supplementary material

The online version of this article (10.1186/s12939-019-0938-x) contains supplementary material, which is available to authorized users.

Resource allocation for equity in Brazilian health care: a methodological model

ABSTRACT It is a fundamental requirement of governments that they allocate resources to public services among institutions or populations that are potential competitors for funding. In Brazil, a country with clear social inequalities, equitable allocation of resources in the Unified Health System (SUS) poses a particular challenge. The present study proposes an individual-level matrix model for allocating health resources in the SUS based on data from the National Health Survey (PNS) 2013. This model is founded on a matrix of the following variables: age, sex, education, employment and income and the relationships between them. A morbidity score is used to estimate weights for each category. This model provides an opportunity for managers to use objective methods to provide a clear guide for decision-making in accordance with principles laid down in Brazilian law and in a manner based on health needs and epidemiological and demographic factors, in addition to the capacity to offer services.

Exploring challenges, threats and innovations in global health promotion

Global health faces a broad spectrum of old and new challenges. Besides epidemiological problems, political conflicts, economic crisis and austerity policies are jeopardizing progress towards Universal Health Coverage (UHC), affecting the most vulnerable populations. During the 22nd International Union for Health Promotion and Education (IUHPE) World Conference on Health Promotion held in Curitiba, Brazil, in 2016, challenges and threats for global health, in addition to a wide range of innovative experiences in health promotion, were discussed with participants from 65 countries. At the end of the conference, a public statement was approved claiming for Democracy and Human Rights in all countries around the world as essential conditions for the promotion of health and equity. In this paper, we explore challenges, threats and innovations in global health promotion. We use scientific literature, analysis of the current situation of the Brazilian health system, and material presented during the 22nd IUHPE World Conference. Also, we discuss strategies to strengthen health systems, policies and practices through the approach of STI and illustrative local experiences presented at the congress mentioned above, including examples developed in the city of Curitiba. We conclude that STI is crucial to support strengthening local health systems, design effective intersectoral public policies, scaling up innovative initiates, and skilling staff in addressing the contemporary challenges. Finally, the Declaration of the 22nd World Conference on Health Promotion of the IUHPE is a fundamental policy statement based on the prioritization of democracy and human rights as essential conditions for the promotion of health and equity.

Remembering Alma-Ata: challenges and innovations in primary health care in a middle-income city in Latin America

The year 2018 is an opportune time to explore health system reforms and primary health care (PHC) in Brazil, given the anniversaries of the Alma-Ata Declaration (40 years) and of the Constitution of Brazil (30 years), the basis of the Unified Health System (SUS). In this context, health system analysis in the municipal setting is an important instrument for acknowledging achievements and innovations, as well as weaknesses and threats. Due to the principle of decentralization of SUS, municipalities have assumed a leadership role in health policy development and implementation. The cities also come first in expressing the failures of the health system and the consequences of austerity measures. Thus, analysis of health system transformations at the municipal level are fundamental to studying PHC achievements and gaps.

This report identifies the challenges and innovations of PHC implementation in Curitiba, beginning with a brief history of the city's health system development. The city was a pioneer in linking urban planning with health system design, improving access to health care, and obtaining better health outcomes over the past 30 years. This report covers those years, as well as the challenges and strategies implemented during the most recent political cycle (2013 – 2016). There are substantial lessons that can be garnered from the experience of this middle-income city in Latin America, lessons that may be useful as the region moves toward the Sustainable Development Goal of Universal Health Coverage by 2030.

Política econômica e saúde pública: equilíbrio fiscal e bem-estar da população

RESUMO Muitos estudos examinaram os efeitos das crises econômicas e políticas de austeridade em países de renda alta. Contudo, são muito recentes e esparsos os estudos sobre os efeitos sobre países de renda média e baixa. Neste ensaio, revisitam-se os estudos recentes, procurando destacar o que pode ter incidência mais imediata sobre a saúde pública, com especial interesse sobre os grupos de maior vulnerabilidade. Optou-se por tratar de forma conjunta os efeitos da crise econômica e da política de austeridade percorrida até o presente momento no Brasil por entender que os déficit de investimento em políticas sociais e suas implicações sobre a cobertura e sobre qualidade dos serviços ofertados estão associados aos dois fenômenos. As publicações recentes indicam a piora de indicadores básicos de saúde nacionais, sugerindo que a redução de investimentos em saúde já se faz sentir nas políticas de promoção, prevenção e atenção. O debate econômico atual apresenta erroneamente as medidas de austeridade como único caminho para um regime de responsabilidade fiscal. O País precisa rever sua rota de desenvolvimento não apenas para enfrentar os efeitos da crise econômica em curso, mas também para recuperar sua trajetória de inclusão social e econômica e de melhora da saúde de sua população.

Primary care and healthcare utilization among older Brazilians (ELSI-Brazil)

OBJECTIVE

To characterize healthcare access and utilization among older Brazilians.

METHODS

Data are from the baseline wave of the Brazilian Longitudinal Study of Aging (ELSI-Brazil), which is a nationally representative, population-based cohort study of persons aged 50 years and older conducted in 2015/2016 (n = 9,412). The prevalence of barriers to primary care and number and type of doctor visits in the past 12 months are compared by three main sources of healthcare (private, Family Health Strategy, traditional public clinics). Two-part multivariable hurdle analyses assess the relation between healthcare utilization, primary care problems, and source of healthcare, while controlling for healthcare determinants.

RESULTS

Females comprised 54% of the sample, with a mean age of 63 years. There were no demographic differences by source of healthcare. Nearly 83% had at least one doctor visit in the past 12 months, with higher use among private health plan holders. Private health plan holders most frequently visited specialists, while those using the public system were more likely to visit a general practitioner. Primary care barriers averaged 3.5 out of 12 and were the highest among those using traditional health posts. A greater number of primary care problems was negatively associated with all types of healthcare utilization.

CONCLUSIONS

By international standards, access to basic healthcare among older Brazilians is relatively high. Nevertheless, different levels of primary care problems between the public and private sectors and resulting utilization patterns suggest the need to continue working to close remaining gaps.

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

The Unified Health System (Sistema Único de Saúde (SUS)) has enabled substantial progress towards Universal Health Coverage (UHC) in Brazil. However, structural weakness, economic and political crises and austerity policies that have capped public expenditure growth are threatening its sustainability and outcomes. This paper analyses the Brazilian health system progress since 2000 and the current and potential effects of the coalescing economic and political crises and the subsequent austerity policies. We use literature review, policy analysis and secondary data from governmental sources in 2000-2017 to examine changes in political and economic context, health financing, health resources and healthcare service coverage in SUS. We find that, despite a favourable context, which enabled expansion of UHC from 2003 to 2014, structural problems persist in SUS, including gaps in organisation and governance, low public funding and suboptimal resource allocation. Consequently, large regional disparities exist in access to healthcare services and health outcomes, with poorer regions and lower socioeconomic population groups disadvantaged the most. These structural problems and disparities will likely worsen with the austerity measures introduced by the current government, and risk reversing the achievements of SUS in improving population health outcomes. The speed at which adverse effects of the current and political crises are manifested in the Brazilian health system underscores the importance of enhancing health system resilience to counteract external shocks (such as economic and political crises) and internal shocks (such as sector-specific austerity policies and rapid ageing leading to rise in disease burden) to protect hard-achieved progress towards UHC.

Child morbidity and mortality associated with alternative policy responses to the economic crisis in Brazil: A nationwide microsimulation study

BACKGROUND

Since 2015, a major economic crisis in Brazil has led to increasing poverty and the implementation of long-term fiscal austerity measures that will substantially reduce expenditure on social welfare programmes as a percentage of the country's GDP over the next 20 years. The Bolsa Família Programme (BFP)-one of the largest conditional cash transfer programmes in the world-and the nationwide primary healthcare strategy (Estratégia Saúde da Família [ESF]) are affected by fiscal austerity, despite being among the policy interventions with the strongest estimated impact on child mortality in the country. We investigated how reduced coverage of the BFP and ESF-compared to an alternative scenario where the level of social protection under these programmes is maintained-may affect the under-five mortality rate (U5MR) and socioeconomic inequalities in child health in the country until 2030, the end date of the Sustainable Development Goals.

METHODS AND FINDINGS

We developed and validated a microsimulation model, creating a synthetic cohort of all 5,507 Brazilian municipalities for the period 2017-2030. This model was based on the longitudinal dataset and effect estimates from a previously published study that evaluated the effects of poverty, the BFP, and the ESF on child health. We forecast the economic crisis and the effect of reductions in BFP and ESF coverage due to current fiscal austerity on the U5MR, and compared this scenario with a scenario where these programmes maintain the levels of social protection by increasing or decreasing with the size of Brazil's vulnerable populations (policy response scenarios). We used fixed effects multivariate regression models including BFP and ESF coverage and accounting for secular trends, demographic and socioeconomic changes, and programme duration effects. With the maintenance of the levels of social protection provided by the BFP and ESF, in the most likely economic crisis scenario the U5MR is expected to be 8.57% (95% CI: 6.88%-10.24%) lower in 2030 than under fiscal austerity-a cumulative 19,732 (95% CI: 10,207-29,285) averted under-five deaths between 2017 and 2030. U5MRs from diarrhoea, malnutrition, and lower respiratory tract infections are projected to be 39.3% (95% CI: 36.9%-41.8%), 35.8% (95% CI: 31.5%-39.9%), and 8.5% (95% CI: 4.1%-12.0%) lower, respectively, in 2030 under the maintenance of BFP and ESF coverage, with 123,549 fewer under-five hospitalisations from all causes over the study period. Reduced coverage of the BFP and ESF will also disproportionately affect U5MR in the most vulnerable areas, with the U5MR in the poorest quintile of municipalities expected to be 11.0% (95% CI: 8.0%-13.8%) lower in 2030 under the maintenance of BFP and ESF levels of social protection than under fiscal austerity, compared to no difference in the richest quintile. Declines in health inequalities over the last decade will also stop under a fiscal austerity scenario: the U5MR concentration index is expected to remain stable over the period 2017-2030, compared to a 13.3% (95% CI: 5.6%-21.8%) reduction under the maintenance of BFP and ESF levels of protection. Limitations of our analysis are the ecological nature of the study, uncertainty around future macroeconomic scenarios, and potential changes in other factors affecting child health. A wide range of sensitivity analyses were conducted to minimise these limitations.

CONCLUSIONS

The implementation of fiscal austerity measures in Brazil can be responsible for substantively higher childhood morbidity and mortality than expected under maintenance of social protection-threatening attainment of Sustainable Development Goals for child health and reducing inequality.

Human rights and political crisis in Brazil: Public health impacts and challenges

In 31 August 2016, Brazilian president Dilma Rousseff was impeached and replaced by her vice president Michel Temer. Herein, we examine how the conservative agenda of Mr Temer and his supporters is influencing key decisions in the human rights and public health arena in Brazil. The government's austerity agenda includes severe cuts in critical areas such as health, education and science, jeopardising well-known strategies such as the Brazilian Public Health System (SUS) and nationwide cash transfer program, 'Bolsa Familia' - both benefited millions and were the largest of their kind in the world. Mr Temer's decisions show not only severe cuts in critical areas but also a political agenda that clearly demonstrates a broad shift away from the progressivism and social agenda presented and supported by its predecessors. Most vulnerable groups such as the LGBTQ community, women, people who use drugs and disenfranchised communities have been severely affected. Mr Temer's administration is putting Brazil far from its once nationwide goal to foster free and universal health care access and social equity for all its citizens. The near future for Brazil is unknown, but both national and international communities anticipate severe problems within the national human rights arena, if nothing changes.

ABBREVIATIONS

CCT: Conditional Cash Transfer; LGBTQ: Lesbian, Gay, Bisexual, Transgender and Queer (and/or Questioning); SUS: Brazilian Public Health System.

Assessing the relevance of indicators in tracking social determinants and progress toward equitable population health in Brazil

BACKGROUND

The importance of the social determinants of health (SDH) and barriers to the access and utilization of healthcare have been widely recognized but not previously studied in the context of universal healthcare coverage (UHC) in Brazil and other developing countries.

OBJECTIVE

To evaluate a set of proposed indicators of SDH and barriers to the access and utilization of healthcare - proposed by the SDH unit of the World Health Organization - with respect to their relevance in tracking progress in moving toward equitable population health and UHC in Brazil.

DESIGN

This study had a mixed methodology, combining a quantitative analysis of secondary data from governmental sources with a qualitative study comprising two focus group discussions and six key informant interviews. The set of indicators tested covered a broad range of dimensions classified by three different domains: environment quality; accountability and inclusion; and livelihood and skills. Indicators were stratified according to income quintiles, urbanization, race, and geographical region.

RESULTS

Overall, the indicators were adequate for tracking progress in terms of the SDH, equity, gender, and human rights in Brazil. Stratifications showed inequalities. The qualitative analysis revealed that many of the indicators were well known and already used by policymakers and health sector managers, whereas others were considered less useful in the Brazilian context.

CONCLUSIONS

Monitoring and evaluation practices have been developed in Brazil, and the set of indicators assessed in this study could further improve these practices, especially from a health equity perspective. Socioeconomic inequalities have been reduced in Brazil in the last decade, but there is still much work to be done in relation to addressing the SDH.

Changes in access to and costs of overseas treatment after the introduction of universal health coverage in the Maldives: Findings from surveys and the analysis of claims data

Background

Shortages in resources for health and health service delivery in small island states make it inevitable for islanders to seek medical treatment out of the country. This study aimed to assess the changes in access to treatment overseas and its disparities before and after universal health care was introduced in 2012 in the island state of Maldives.

Methods

Using primary and secondary data, two analyses were performed: 1. Analysis of beneficiary data on public subsidy for medical treatment overseas 2010–2013; 2. A comparative analysis of two independent cross-sectional surveys conducted in 2010 and 2013. Public subsidy, financial protection, usage, and costs of medical treatment overseas were analyzed using descriptive statistics and the concentration curve and index.

Results

Number of beneficiaries subsidized for treatment overseas has increased by 199% and the average expenditure per beneficiary has increased by 49.7% during 2010–2013. Average number of visits abroad in a year has slightly decreased from 1.6 in 2009 to 1.4 visits in 2013, but among travelers who made more than one trip abroad, average visits remained at 2.7 per year. Median medical costs have increased by 26.9% and the proportion of household spending on overseas treatment in annual household spending has remained around 20% over the years. The proportion of travelers belonging to average households (household spending below $650) has increased by 107%, and the concentration index decreased from 0.08 in 2009 to 0.04 in 2013 indicating a change towards a more uniform distribution of MTO use.

Conclusions

Despite the fact that the objectives of the two surveys differed which may have led to differences in measurements, it can be concluded that UHC has narrowed the gap between the rich and poor in utilizing medical treatment overseas. However, median out of pocket spending on MTO has increased over the years indicating the need to broaden the benefit package of the UHC program. Further research is needed on the most deprived populations who have not accessed care abroad despite the change in the health financing system in the country.

Implementation of Brazil's "family health strategy": factors associated with community health workers', nurses', and physicians' delivery of drug use services

BACKGROUND

Brazil's "family health strategy" (ESF), provides primary care, mostly to individuals in impoverished communities through teams of physicians, nurses, and community health workers (CHWs). ESF workers are called upon to offer drug use services (e.g., referrals, counseling) as drug use represents an urgent public health crisis. New federal initiatives are being implemented to build capacity in this workforce to deliver drug use services, yet little is known about whether ESF workers are providing drug use services already. Guided by social cognitive theory, this study examines factors associated with ESF workers' provision of drug use services.

METHODS

Cross-sectional surveys were collected from 262 ESF workers (168 CHWs, 62 nurses, and 32 physicians) in Mesquita, Rio de Janeiro State and Santa Luzia, Minas Gerais State.

OUTCOME VARIABLE

provision of drug-use services.

PREDICTORS

capacity to engage in evidence-based practice (EBP), resource constraints, peer support, knowledge of EBP, and job title. Logistic regression was used to determine relative influence of each predictor upon the outcome.

RESULTS

Thirty-nine percent reported providing drug use services. Younger workers, CHWs, workers with knowledge about EBP and workers that report peer support were more likely to offer drug use services. Workers that reported resource constraints and more capacity to implement EBP were less likely to offer drug use services.

CONCLUSION

ESF workers require education in locating, assessing and evaluating the latest research. Mentorship from physicians and peer support through team meetings may enhance workers' delivery of drug use services, across professional disciplines. Educational initiatives aimed at ESF teams should consider these factors as potentially enhancing implementation of drug use services. Building ESF workers' capacity to collaborate across disciplines and to gain access to tools for providing assessment and treatment of drug use issues may improve uptake of new initiatives.

Monitoring progress towards universal health coverage at country and global levels

Universal health coverage (UHC) has been defined as the desired outcome of health system performance whereby all people who need health services (promotion, prevention, treatment, rehabilitation, and palliation) receive them, without undue financial hardship. UHC has two interrelated components: the full spectrum of good-quality, essential health services according to need, and protection from financial hardship, including possible impoverishment, due to out-of-pocket payments for health services. Both components should benefit the entire population. This paper summarizes the findings from 13 country case studies and five technical reviews, which were conducted as part of the development of a global framework for monitoring progress towards UHC. The case studies show the relevance and feasibility of focusing UHC monitoring on two discrete components of health system performance: levels of coverage with health services and financial protection, with a focus on equity. These components link directly to the definition of UHC and measure the direct results of strategies and policies for UHC. The studies also show how UHC monitoring can be fully embedded in often existing, regular overall monitoring of health sector progress and performance. Several methodological and practical issues related to the monitoring of coverage of essential health services, financial protection, and equity, are highlighted. Addressing the gaps in the availability and quality of data required for monitoring progress towards UHC is critical in most countries.

The PLOS "monitoring universal health coverage" collection: managing expectations

The PLOS Medicine editors introduce the PLOS Collection on Monitoring Universal Health Coverage and discuss the challenges ahead in implementing, monitoring, and evaluating UHC. Please see later in the article for the Editors' Summary