An Assessment of Equity in the Brazilian Healthcare System: Redistribution of Healthcare Professionals to Address Inequities in Remote and Rural Healthcare

Original Articles 25 An Assessment of Equity in the Brazilian Healthcare System: Redistribution of Healthcare Professionals to Address Inequities in Remote and Rural Healthcare

P. M. N. Akindo (Prudence M. N. Akindo)

Original Articles Health Administration & Human Resources, McGurrin Hall, Scranton, PA 18510-4699

E-mail address: [email protected]

Reprint address: Health Administration & Human Resources 4th Floor McGurrin Hall Scranton, PA 18510-4699

Suource: Clinical Social Work and Health Intervention Volume: 7 Issue: 4 Pages: 25 – 32 Cited references: 0

Reviewers: Dr. Johnson Nzau Mavole, Ph.D. Catholic university of Eastern Africa, Nairobi, Kenya e-mail: [email protected] prof. MUDr. Anton Gúth, CSc. Univerzitná nemocnica Bratislava e-mail: [email protected]

Key words: Brazil’s healthcare system, Healtcare professionals, Urban areas, Lucrative icentives.

Publisher: International Society of Applied Preventive Medicine i-gap

Abstract: This document provides an in-depth assessment of Brazil’s healthcare system with specific emphasis on the characteristics that shape the distribution of providers across the country. The drastic differences in the ratio of providers between the public and private sectors, alongside an even bigger distinction between available providers in rural and urban areas

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presents a hindrance to Brazil’s premise of equal access to care for all. This document also presents three proven solutions that can successfully redistribute healthcare professionals (physicians in particular), in favor of Brazils remote vulnerable communities and rural regions. These proven recommendations include (1) the use of telehealth; (2) Lucrative incentives; (3) Creating and strengthening public and private partnerships.

Introduction

Figure 1 Geographic Regions of Brazil

Since the institution of Sistema Único However, increases in healthcare utilization de Saúde (SUS), Brazil’s Universal Health- has consistently not been matched by suffi- care System, access to healthcare in Brazil cient healthcare spending. Between 2011 and has increased with utilization increases no- 2015, Brazil spent 9.7 percent of it’s gross ticeable in all 26 states and demographics. domestic product (GDP) on healthcare. With Instituted under the belief that healthcare is a 2015 physician density “averaging 1.95 a right and it is the duty of the government to physicians per 1.000 habitants”, “far below provide it, SUS made Brazil one of the larg- neighboring Argentina (3.2) and Uruguay est public healthcare providers in the world. (3.7),” the impact of physician shortages on

Clinical Social Work and Health Intervention Vol. 7 No. 4 2016 Original Articles 27 overall quality of care cannot go unnoticed. the favorable working conditions associated Therefore, an increase in healthcare expen- with it, the significant disparities that exist diture will help Brazil improve its allocation between the public and private health sec- of federal, state and municipal resources to tors of Brazil are not surprising. favor the poorest regions and segments of its population: shifting from just a focus on Urban vs. Rural Provider equal access to healthcare for all towards high quality healthcare for all. Distributions As with most other countries in the world, the shortage of physicians in rural ar- Public vs. Private Provider eas is one of the contributing factors to poor Distributions health outcomes associated with remote re- Brazil’s national health system is char- gions. In spite of SUS, and its push for equal acterized by a public and private sector. The access to healthcare for all Brazilians, “peo- public sector which is funded by the feder- ple living in remote and vulnerable com- al, state and municipal governments through munities still face poor access to operative taxes and social contributions, accounts for health services.” In 2014, 14.6 percent of about 75 percent of the Brazilian population; the Brazilian population was considered to mostly the lower-income and poor. Care in be living in rural areas. The north, northeast the public sector is provided free at point of and center west regions are areas experienc- delivery by public or contracted private pro- ing the greatest shortage of physicians. For viders. The public sector makes up about 32 example, in 2014, the State of Maranhão in percent of all Brazil hospitals and about 44 the northeast, had 0.58 physicians per 1,000 percent of all Brazilian physicians. It is ev- inhabitants while the richer Rio de Janeiro ident that the provider ratio is not sufficient had 3.44. (Figure 1. shows the geographic to handle the patient population in the public breakdown of Brazil by regions). sector which is often characterized by over- Numerous initiatives, including the re- crowding, long patient wait times, access dif- cent Primary Care Professional Apprecia- ficulty etc. More so, “46 percent of Brazil’s tion Program (Programa de Valorização dos health spending was funded by public sourc- Profissionais da Atenção Básica -PROVAB), es in 2012, compared to an average of 72 per- have been implemented in efforts to attract cent in OECD countries.” Therefore, inade- health professionals to remote areas. Howev- quate governmental spending in the public er, these programs have not been as success- sector is also a major contributor to the poor ful given that physician professional partici- quality of care commonly associated with it. pation has remained below local or regional Brazil’s poor public health system is needs. In 2013, the “Mais Médicos” Program “boosting the use of private healthcare and was introduced in Brazil “as part of a series employer-subsidized private health insur- of measures to fight inequalities in access to ance” among 25 percent of the Brazilian operative primary care.” The Program was population who can afford it. Responsible for structured on three levels of action: the “Pro- about 52 percent of total healthcare spend- jeto Mais Médicos para o Brasil” (More ing in 2013, the private sector is the main Physicians for Brazil Project or PMMB; an source of health funding in Brazil’s national emergency physician provision program for health system. This sector makes up about vulnerable areas. As shown in Figure 1., the 65 percent of all Brazils hospitals and about success of PMMB was reliant on the success- 56 percent of the physician population. With ful recruitment of foreign physicians from the healthcare professionals choosing to work 49 participating countries, primarily Cuba for the private system over the public due to (11,429 physicians); crediting PMMB to be

Clinical Social Work and Health Intervention Vol. 7 No. 4 2016 28 Clinical Social Work and Health Intervention the most effective in recruiting and placing that the core of Brazil’s physician shortage the magnitude of physicians demanded for problem actually lies in how physicians are the remote communities. These foreign doc- distributed throughout the country. tors “sign a three year contract”, promising to dedicate their “activities to basic family Recommendations medicine” in the city or town designated by Rather than continue with foreign recruit- the ministry “in exchange for a 10,000 BRL ing, which although effective, is only a short- ($5,000) monthly payment.” term strategy which results in high turnover;

Figure 2 Countries of origin (professional practice) of the participating physicians of the Mais Médicos Para o Brasil Program.

sustainable strategies must be implemented The recruitment of foreign physicians in efforts to address long-term, the physician was met with lots of opposition from most shortage problem in Brazil. Investments in Brazilian doctors who claim “the main cause telehealth, public-private partnerships, and for inadequate physician coverage” is the incentives, will result in the distribution of country’s “inadequate medical infrastruc- physicians in remote vulnerable areas; re- ture.” In addition, the fact that these foreign ducing the existing health inequities and en- doctors are only allowed to sign three-year hancing the quality of health in these areas. contracts, questions the sustainability of the PMMB program. What happens after the three years is up and the doctor decides to Telehealth return back to his/her home country; does “Health professionals in remote areas the system start all over again with recruit- tend to be young and inexperienced and are ing and placing a new foreign physician, or often isolated and in need of further train- does that area return to its physician-short- ing.” “The use of telehealth to provide care, age condition? The problem therefore lies impart education or conduct research,” has beyond the numbers. The federal govern- the potential to reduce existing healthcare in- ment and medical groups must recognize equities prevalent in rural areas. By serving

Clinical Social Work and Health Intervention Vol. 7 No. 4 2016 Original Articles 29 as a platform for effective “communication electrocardiographs, digital cameras (e.g. between primary care practitioners and spe- for photographing skin lesions), webcams cialists in reference centers,” telehealth facil- and low-band-width internet.” The “pri- itates access to diagnostic tests thus enhanc- mary care professionals used the networks ing healthcare quality in underserved com- website to address questions to University munities. The results of pilot studies con- staff in areas such as Medicine, Nursing, ducted on the use of telehealth in vulnerable Dentistry, Physiotherapy, Nutrition, Phar- communities of Brazil have been successful macy, Psychology and Audiology; allowing in addressing the needs of healthcare pro- them to perform their clinical activities with fessionals in those regions. However, these the support of a network of Specialists on studies have not been replicated or enforced duty in the Universities.” Monitoring for as the standard of care in most of Brazil’s re- quality, and user satisfaction, in addition mote vulnerable regions. to using economic indicators such as im- In 2005, the government of Minas Gerais plementation cost per site, unitary activity State funded the establishment of The Tele- per site and patient referral cost to perform health Network, connecting the teaching cost-effectiveness analyses; the results of hospitals of five public Universities with the project proved effective, technically and Municipal Health Departments. financially feasible, and physician satisfaction in remote locations increased markedly.

Figure 3 Electrocardiograms (EKGs) and teleconsultations conducted through the Telehealth Network of Minas Gerais, Brazil, June 2006–October 2011

In 2007, the Telehealth Network began Another pilot project, Connected Healthy providing teleconsultations with a focus on Children (CHC)-Brazil, was performed in tele-cardiology (Minas Telecardio Project). February 2014 by Cisco in partnership with the The “network relied on low-cost technical state of Sergipe Brazil. This project also result- equipment easily accessible to poor vil- ed in significant improvements to healthcare lages such as computers, printers, digital access as well as the quality of care received

Clinical Social Work and Health Intervention Vol. 7 No. 4 2016 30 Clinical Social Work and Health Intervention by patients. Sergipe is located in the northeast of Sergipe” in the Sergipe municipalities of region of Brazil, an area prone to the shortage Tobais Barreto and Lagarto. The goals of the of Medical Specialists. Limited access to col- program were to; improve clinician–to-patient laboration technologies in Sergipe (and other care; facilitate clinician-to-clinician collabo- rural states) is also another challenge; leav- ration; enhance continuing medical education; ing clinicians in these rural regions “virtual- extend healthcare information and telehealth ly unable to connect with medical peers who communications to the community at large. have the specialized expertise they need.” Figure 4 and 5 below show the steps taken The CHC pilot program was first launched to ensure that consultations and collaboration “in collaboration with the Federal University goals were accomplished.

Figure 4 Steps in a Typical Consultation

Figure 5 Physician-to-Physician Collaboration

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“Telemedicine benefits the University in Incentives the areas of research and information gath- In Brazil, “most medical students and ering. But its role in the community is direct doctors tend to come from wealthier areas and important. It can serve a large number which is usually where they stay.” Poor ur- of children and other people where face to- ban and rural areas are usually not attractive face visits aren’t possible” says Professor to this elite group of professionals. Barriers Angelo Antoniolli, Dean at the Federal Uni- hindering physician desire to practice in ru- versity of Sergipe. 40 patients were able to ral areas include but are not limited to the benefit from telehealth consultations in the fact that these physicians fear professional initial pilot of CHC. This number included isolation—having no one to consult on a dif- the case of... “a two-year-old boy from ru- ficult case. Therefore, to better manage the ral Tobias Barreto who showed symptoms distribution of the healthcare workforce the of urticarial (hives), an allergic reaction that government must provide lucrative incen- can have many causes. The boy needed to tives that attract physicians to rural vulner- see a Specialist to confirm the diagnosis and able areas. Educational, technological and receive a treatment plan. Instead of making financial resources should be leveraged on a two-hour, 80-mile (130 km) trip to Ara- by the federal government to get physicians caju for an office visit, the patient’s- fami to move shop. ly walked with him to a local family health clinic. There, using high-definition video- Given that majority of Brazilian phy- conferencing, a Pediatric Allergy Specialist sicians come from wealthy communities from UFS’s Teaching Hospital conducted which is where they choose to practice, pro- a real-time consultation. The doctor never viding educational incentives such as schol- had to leave the hospital, and the family arships, grants, and tuition reimbursements avoided a stressful journey—saving travel to rural students who choose to study med- time, travel costs, and missed work.” icine, or to students who chose to practice in rural regions, is influential in attracting The effectiveness of telehealth in address- the workforce demanded in these vulnerable ing inequities in the rural regions is evident regions. It must also be noted that as more in the number of respondents who support students from rural areas attain physician it (93%). The telehealth pilot programs de- status, the probability of them returning to veloped to support healthcare professionals practice close to family is much higher than in Minas Gerais and Sergipe, Brazil, have that of students from wealthy urban areas. produced good results overall at relatively China and Thailand (countries experienc- little cost. These programs are proving to ing similar healthcare workforce distribu- be sustainable long-term strategies, helping tion problems as those in Brazil) have had to bridge access to care gaps between urban success in this strategy through the recruit- and rural regions in Brazil. Government in- ment of rural students for free education vestment and enforcing of telehealth as the in medical schools in exchange for home- standard of care across Brazil will promote town placement. Thailand has also insti- needed replication of such models in all ru- tuted a mandatory requirement for clinical ral regions helping the government fulfill rotations for medical students in rural areas it’s constitutional premise of equal access to during medical studies; all possible strate- high-quality care for all. gies Brazil can emulate to attract and retain physicians in rural areas.

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Governmental investments in telehealth health services while also establishing a new programs that foster collaboration between benchmark within the public health sys- Clinicians in remote and urban areas will tem that could be replicated throughout the challenge the fear of professional isolation country.” Because payments to the private typically associated with rural areas. Know- partner were linked to key performance in- ing that they can virtually connect with dicators based on qualitative and quanti- medical peers who have the specialized tative targets, this PPP “created incentives expertise they need access to, serves as an for high levels of performance.” Also, mit- incentive for more physicians to move. Of igating government risk was done through course, lucrative salaries and benefits also the establishment of a payment mechanism have the potential of incentivizing physi- which resulted in “increasing interest by the cians to move and practice in rural areas. private sector and the possibility of obtain- As stated by Francisco Eduardo de Campos ing financing for the project.” The success of (Executive Secretary of UNASUS), one of the Hospital do Subúrbio’s PPP has resulted the barriers to attracting health profession- in six other Brazilian states currently devel- als for work in rural areas is few job op- oping PPPs. An even more successful trend portunities for their spouses. Often times, will be to see more states, especially those such a move leaves the physician as the sole in rural areas replicate such PPPs so as to provider for his/her household. Therefore, fulfill the premise of universal access to high offering lucrative salaries/benefits for such quality healthcare. remote locations eliminates this barrier and increases the likelihood for physicians to Conclusion move and stay. To successfully move in the direction mandated by SUS, Brazil must redistribute Public and Private Partnerships its workforce to support its most vulnera- Public-private partnerships (PPP) in Bra- ble populations. Lack of skilled healthcare zil are essential to the quality of care. Such professionals in rural regions is a primary partnerships allow for the expansion of care, contributing factor to the negative health improvement of facilities and increases in outcomes that characterize the overall health service efficiency. Opened in 2010, Hospital status of the country. By investing in the do Subúrbio, located in the underserved area use of telehealth; provision of lucrative in- of Salvador, Bahia in the northeast region, centives; encouraging partnerships between was the first PPP in Brazil. This facility was public and private sectors; all proven strate- built by the public sector, but equipped, op- gies that have positively impacted the qual- erated and managed by the private sector. ity of care in certain rural regions, Brazil “The objectives of the government of Bahia stands a better chance of successfully bridg- for this PPP were to ensure that all its popu- ing that gap between access and high quality lation had access to high quality emergency care.

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