Hospital de Câncer de Barretos- FundaçãoPio XII

This case study is part of the CHMI case study series.

CENTER FOR HEALTH MARKET INNOVATIONS (CHMI)

CHMI identifies, analyzes and connects programs working to improve health and financial protection for the poor. CHMI works through a network of partner organizations in 16 countries where there are large numbers of private health care providers. CHMI is funded by the Bill & Melinda Gates Foundation and the Rockefeller Foundation.

ACCESS Health International

ACCESS Health International, Inc. has the founding conviction that all people, no matter where they live, have a right to access high quality, affordable healthcare. The organization identifies and documents models and policies for high-quality, affordable health care. It transfers knowledge of these solutions through publications, workshops and teaching material. ACCESS Health International also supports design and implementation of models for efficient health care delivery and financing.

For additional information, visit http://www.accessh.org.

Case study - Hospital de Câncer de Barretos- FundaçãoPio XII

Hospital do Amor (Hospital of Love) Av. Antenor Duarte Villela, 1331 Barretos - SP | Phone: +17 3321-6600 http://www.cliquecontraocancer.com.br/contato.cfm

Introduction

This case study describes the services provided and current funding structure of the Hospital de Câncer de Barretos (HCB), an internationally renowned oncology and research institute based in the countryside of the state of São Paulo, Brazil.

The hospital serves 3,000 patients each day, coming from all regions of Brazil and suffering from all types and levels of cancer. City governments from different parts of Brazil organize transportation and sometimes rent houses for patients to undertake their treatment at the hospital. All the treatment, medicine, housing and food are provided to the patients for free.

The following case study intends to look at the Hospital’s structure, services, marketing ability and financial strategy and discuss alternative sources of funding and long-term financial stability.

Prof. Dr. Edmundo Mauad

Prof. Dr. Mauad is a medical graduate of the Faculty of Medicine of Campos County, Rio de Janeiro (1978). He then went on to complete an Internal Medicine and Gastroenterology residency. He subsequently completed Master of Science at the University of Bristol where he worked as a researcher in the Department of Medicine, Bristol Royal Infirmary Hospital. Prof. Dr. Mauad then went on to complete his PhD at Faculty of Medicine of the Federal University of São Paulo. He also has an MBA in International Health Administration from the São Paulo State Getúlio Vargas Foundation.

Prof. Dr. Mauad is a member of the Board of Directors of Barretos Cancer Hospital since 1987, and Chief of the Cancer Prevention Department and Head Administrator of the Teaching and Research Institute.

He has been directing programs of opportunistic and organized cancer screenings of the breast, cervix, prostate and skin since 1994. He has simultaneously studied different aspects of cancer prevention such as cost-effectiveness, community intervention, introduction of new technologies, role of information in assessing patients' adherence, educational programs for patients and professionals and strategies to improve quality of screening programs in underprivileged population in Brazil.

Henrique Prata

Mr. Prata is a landowner and livestock raiser in Barretos. His parents Paulo Prata and Scyla Prata were both doctors and founders of Hospital São Judas Tadeu, the hospital that founded the Hospital de Cancer de Barretos. Mr. Prata took over the management of the hospital in 1988 and continues to manage the hospital.

Hospital Background

In 1967 Dr. Paulo Prata noticed that cancer patients in the countryside of the state of São Paulo did not have access to cancer treatment. At the time, the only public and specialized cancer hospital was A.C. Camargo in the capital. Barretos, 427km away from the capital, did not provide its citizens with cheap and easy transportation options to reach São Paulo. He founded the Hospital São Judas Tadeu in Barretos that offered treatment to patients in the region.

Dr. Prata established a philosophy of equal access to care for all patients at the hospital. He treated privately and publicly insured patients the same way and preached humane medicine practices in his hospital. His humane practices meant treating all patients with kindness, politeness and respect, irrespective of their background or condition. Dr. Prata initially financed deficits of the hospital with his own family wealth. In 1988, the hospital was in a bad financial conditions and Dr. Prata considered shutting it down. His son, Henrique Prata, was able to raise money with fellow farmers of the region to pay the hospital debt and invest in new equipment and an expansion. Hospital de Cancer de Barretos (HCB) was then founded.

Since 1988, Mr. Henrique Prata took over the management and has taken care of its operations and expansion. To help finance the hospital activities, Mr. Prata has developed a series of fundraising activities that complement the money paid by the Brazilian government for SUS1, including concerts with Brazilian celebrities, cattle auctions, tax breaks, and individual private donations (more details are described below).

In 1997 the Associação Voluntária de Combateao Câncer (AVCC- Voluntary Association to Combat Cancer) was founded. In 1998, the hospital arranged a concert with 3 of the most famous country duos in the country called AMIGOS (friends) in Barretos. The US$1 million generated in revenue from the concert was given to the Hospital.

Starting in 2001, the hospital engages artists to record music albums and all sales revenues are channeled to the Hospital. With the help of funding from the Ministry of Health in 2002 three additional departments for Surgical Center, Intensive Care Unit and Interning Department were built.

AVON and Brazilian artist Ivete Sangalo partnered to finance the construction of a 7,200 sq. meter Prevention Institute in 2008.

In 2000, the Ministry of Health of Brazil recognized HCB as the number one in Hospital Quality among the 6,530 public and private hospitals evaluated. In 2007 the Organização Nacional de

1Sistema Único de Saúde (Unified Health System) is the Brazilian integral and universal public health insurance. All Brazilian population has access to treatment in any hospital that accepts this government insurance. It covers from medicines, primary, secondary cares to organ transplants. SUS was created in 1988 with the Brazilian Constitution. www.portal.saude.gov.br Saúde (ONA- the national health organization) accredited the hospital with Level 1 Health Quality.

The hospital has grown to attract the best oncologists in Brazil and has specialists in every practice. It has also started partnerships with laboratories, schools and pharmaceutical companies to develop oncology research, treatment techniques and training of specialists.

Goals of the organization

The 2009 report of activities of the hospital lists as main goals:

a. Provide free medical and hospital assistance to all patients who need oncologic treatment; b. Promote research and studies in oncology, incrementing investigation and promotion; c. Promote early cancer detection and prevention; d. Create and maintain post-graduate studies and specializations within oncology; e. Contribute to solving medical and social issues, including extending benefits to other public and private institutions.

HCB seeks excellence in treatment by promoting humane care, constant professional and technical improvement and development of outreach and education and research in oncology. The hospital also sees it as their mission to strengthen and improve services financed Interview with Dr. Valter Penna by SUS. Prof. Dr. Valter Penna specialized in orthopedics during his residency at Hospital Matarazzo in São Paulo in 1980. He did Governance his Doctorate studies in orthopedic surgery and orthopedics at the FreienUniversitat Berlin from 1981 to 1984. Prof. Dr. Penna worked at hospitals Albert Einstein, SirioLibanes and The board of directors is composed of three AC Camargo in São Paulo and in his private practice for 15 years before moving to Hospital de Câncer de Barretos. Since directors from the Duarte Prata family: 2002, he has been the Chief of the Orthopedic Oncology Scylla Duarte Prata (wife of the founder of Services at HCB.

Hospital São Judas Tadeu) as the President Prof. Dr. Penna explained that after working for many years in of the Administrative Board, Henrique São Paulo in between hospitals and private practices, he saw the opportunity of dedicating himself to the practice of medicine Duarte Prata as Vice-President of the in Barretos. He explained that “although you make more Administrative Board and his son Antenor money working in the capital, you work too much and do not have time to dedicate for research and professional Duarte Prata as the Secretary to the development.” HCB requests exclusivity from its doctors. That Administrative Board. Ms Scylla Duarte is, according to Prof. Dr. Valter Penna, the best opportunity for doctors to learn and become the best professionals in their Prata is a gynecologist and is paid for her specializations. He mentioned that the environment of HCB is services as a doctor. Mr Henrique Duarte very dynamic.

Prata and Antenor Duarte Prata do not Doctors have exposure to all different levels of cancers and work or earn wages from HCB, both are complications due to the very high volume of patients. “Surgeries vary from simple to the most complex possible and independent entrepreneurs. there are all the best possible resources to treat the patients,” he explained. After his routine at the hospital, he has time to dedicate to research in the hospital laboratories and libraries. Following Dr. Prata’s humanitarian Prof. Dr. Penna mentions that there is a very good balance philosophy that patients are the most between clinic and research at HCB and the exposure to young resident students is stimulating. important people in the hospital all doctors, nurses and technicians treat their patients “There is a sheer sense of cooperation and passion for medicine. At HCB I remembered why I decided to study with kindness and full attention. A very medicine: to help people in need. There is nothing more active ombudsman office ensures this rewarding than that,” he finalized. humanitarian treatment. The office has workers in every sector of the hospital to talk to patients and follow up on their suggestions and complaints (more information below)

Vision

Bring to Brazil the best practices in oncology treatment, research and hospital management seen around the world.

Medical staff selects doctors to visit the best medicine schools in the world. Hospitals that have been visited by Dr. Mauad and his team include:

• MD Anderson Cancer Center (Barretos has academic partnership with the center) • Memorial Sloan-Ketterling • Mayo Clinic • Johns Hopkins • The Royal Marsden • Institut de cancérologie Gustave Roussy • Karolinska Institutet/Göteborg University

Other hospitals in Berlin, Spain, Portugal and Japan have also been visited by Dr. Mauad’s team. The goal is to learn not only techniques and scientific practices, but also learn about management and organization of other centers.

HCB reflects the best practices doctors bring from around the world. Laboratories are set in the same way as the ones at MD Anderson, with which HCB has close scientific collaborations. All units are fully equipped, allowing full access and no competition between scientists. All technology and equipment are the best in the market. Dining, resting lounges and architecture of departments are inspired by European hospitals. Doctors, nurses and technicians’ relationships are as horizontal as possible - interaction is motivated in cafeterias, resting lounges and in meetings.

Medical staff

All senior doctors in the hospital are expected to have post-graduate degrees. Doctors that are approved for residency test in HCB, are motivated to Human Resources conduct research and obtain degrees after they Employees 1622 specialize. Paid Interns 15

Doctors at the hospital have a technical vision, Permanent Volunteers 190 understanding and scientific engagement. HCB is the Temporary Volunteers 15 only Hospital in Brazil where doctors must have Unpaid Interns 402 exclusive dedication (they cannot have a second job). Consultants 80 Compensation varies according to experience, but not practice. Doctors are motivated to collaborate and work in teams, in order to provide each other a more efficient working environment.

Reward system for medical staff is translated into scientific and career opportunities. Doctors are motivated to go abroad for training and post-graduate studies, as well as developing their own research at the hospital.

Patients that are directed to HCB are high complexity cancer patients. Doctors are exposed on a daily basis to complex and challenging cancer patients. The hospital has developed working collaborations through its partnerships with international hospitals. Almost on a daily basis, doctors have videoconference calls with international centers to discuss cases, techniques and treatments of complex patients.

Doctors feel that the professional development in Barretos is far more rewarding than the financial remuneration opportunities. They also have a better lifestyle by not working many shifts. Hospitals in Sao Paulo pay better, but doctors work longer hours and have no time dedicated to scientific development. Doctors also mentioned that at HCB they feel the satisfaction of helping very poor patients.

Ombudsman

The ombudsman office is at the core of the hospital and its philanthropic nature. It was created in 2003, to learn and understand the needs of patients, companions, employees, service providers, volunteers and general public. The office managed by Ms Clarisse Duarte Prata, daughter of the founders, facilitates quality improvement and the detection of faults in the hospital and administrative processes. All employees work full time with the ombudsman office.

The department has one assistant in each hospital department, who talks to patients and interacts with nurses and doctors. For example, if a patient is left alone for a period of time, these assistants will call the attention of responsible personnel; or if a patient seems unhappy with a diagnosis, the office directs the patient to another available professional for second opinion. Boxes are available through hospitals, where patients can submit their suggestions, complaints or compliments.

According to HCB, the ombudsman office is not only a management tool for improvement but also a fast communication channel between the hospital and its beneficiaries. It provides guidelines to general management on deficiencies and irregularities. The department promotes hospital ethics and is guided by impartiality, legality and the National Policy on Humanization developed by the Ministry of Health2.

All requests and suggestions by patients are followed up with a letter. These letters are mostly either a follow up of the ombudsman office with the doctor involved in the case, the medical response or a conclusion of the process. Through this channel the hospital has reached over 80 percent approval rate from its beneficiaries.

Structure

2 Policy created in 2003, requiring hospitals to value patients, doctors and other employees; provide autonomy to these individuals; increase co-responsibility of doctors and hospital management; establish solidarity and engagement channels on management; map interaction of participants; commitment with quality of services, among others. http://portal.saude.gov.br/portal/saude/cidadao/visualizar_texto.cfm?idtxt=28288 The hospital offers treatment and surgery for all cancer types. HCB sees and treats 3,000 patients every day. It receives patients from 1,210 cities in Brazil (data from 2009), from all states in the country. Unit 1 Size (sq. mtrs) 35,000 The main hospital provides patients Number of beds 124 chemotherapy, radiology, radiotherapy, Intensive Care Unit Beds 20 surgeries, examinations, biopsies and Surgical Room 4 paediatric oncology. Hospital São Judas Surgeries per month 1350 Tadeu has become a palliative center, Unit 2 receiving terminal patients offering Prolonged Palliative beds 40 housing, treatment, food and care. HCB has General beds 22 1,000 beds for patients that come from out of town and need prolonged stay in Barretos with a family member. The hospital also offers housing for children and their parents for ongoing and palliative treatment.

HCB offers inpatients services, with rooms for two patients and one companion each. The hospital receives over 850 inpatients a month. The intensive care unit has 20 individual beds with computerized parametric monitoring. Multidisciplinary teams of doctor, nurses and therapists attend to these sectors.

Coverage The hospital also has an independent team

of doctors and nurses specialized in infection Visits coveredby SUS 212,633 control under international standards. HCB Visits coveredby private insurance 609 Microbiology Laboratory utilizes diagnostics Private procedures 3 techniques for infection control in all hospital departments. Total 213,245 Full support is given to patients. There are full time physiotherapists, psychologists (for patients and family members) and a musicologist (specialist in using music as therapy). Volunteers also visit the hospital to engage patients in activities. Dr. Edmundo Mauad mentioned that some relatives staying at the hospital engage in volunteer work to raise money for the hospital, such as knitting clothing pieces for sale. However, overall companions dedicate full time to their sick relatives and are not required to engage in activities for the hospital.

The hospital offers day-care facilities for employees’ children. It also offers resting places for bus drivers who bring patients from all around Brazil.

Every day, buses and vans arrive in Barretos bringing patients from different cities around Brazil. These buses and vans are mostly financed by municipalities, to take citizens for visits, surgeries and other treatments. The drivers stay at the Drivers Lodge provided by the hospital. The hospital provides food to all guests at the facility. This service has as a goal to offer drivers rest and ensure that patients return home safely after treatment.

Patients, family members and drivers receive free meals. Every month the hospital receives 40 tons of food donations, out of which 10 tons are meat and poultry produce. The Hospital has no expenses for food.

Next to the main hospital, HCB has opened a Prevention Center that hosts laboratories for biomolecular and genetic oncology and other specialties. The Prevention center also hosts libraries, convention centers, video and photography labs, education strategy groups and early detection practices.

Most Frequent Cases Females Males Breast 5,629 Prostate 8,015 Cervical 3,060 Lung 2,102 Lung 939 Stomach 1,813 Stomach 786 Esophagus 1,266 Colon 745 Larynx 924 Excluded skin cancer

Patients who are treated and cured receive life-long support from the Hospital. They are followed up through the hospital system and invited for check-ups. (For more detailed patients data see APPENDIX I)

Department of Diagnostic Imaging

The department of Diagnostic Imaging of HCB performs 90,000 imaging exams and 4,000 imaging-guided procedures annually. It has the following equipments:

- One 1.5 Tesla Magnetic Resonance Unit; - Two Helical Computed Tomography Scanners, one of which a multi-detector unit; - Four Ultrasound units with Doppler; - Four Mammography units, - One dedicated breast biopsy table - Four standard and two mobile radiography units - Two Computed Radiography units and a comprehensive PACS system, which integrates all the imaging modalities, with real-time image distribution to both hospitals.

A team of ten radiologists and two sonographers diagnose and stage a wide variety of neoplasms.

Nuclear Medicine

Through secure, painless techniques and using radioactive elements this medical specialty performs exams (scintilography) and treatments. The exams performed at the hospital are: cerebral, myocardial perfusion, bone, renal (static and dynamic), thyroid and pulmonary scintigraphies.

The Nuclear Medicine department has four beds regularized by the Comissão Nacional de Energia Nuclear (CNEN- National Commission for Nuclear Energy) for interning cases with iodine-therapy for treatment of thyroid tumors and other treatments. It also treats ambulatory patients with Samarium-153-EDTMP for palliative treatment of metastatic bone pain and iodine- therapy for benign thyroid illnesses.

The Department of Nuclear Medicine has four doctors, out of which two are specialized in the area. It offers residency programs for medicine students and has achieved a Level III (maximum level) from the National Accreditation Organization (ONA).

Clinical Pathology

The Clinical Pathology Laboratory offers services in hematology, biochemistry, microbiology, serology, organic fluids, hormonal dosages, immunology and tumor markers. The staff performs exams, processing samples for clinical analysis and releasing reports.

The laboratory provides 24-hour services to interned patients and emergencies from the Center for Ambulatory Occurrences (CIA).

Pathological Anatomy

The Pathology laboratory performs exams on the material collected during surgery (breast, uterus, ovary, prostate, stomach, colon, rectum, lung etc.) It performs biopsy of various tissues as well as liquids from hemorrhages, secretions and imprints. It also analyses material obtained from fine-point needle punctures.

This laboratory has a bank of more than 120 antibodies, adding in situ studies of neoplasias of indeterminate origin. In conjunction with the School of Medicine of the University of the State of São Paulo (UNESP- Universidade do Esdado de São Paulo), HCB has a tumor bank storing for future genetic studies. The tumor bank was financed by FAPESP (Fundação de Amparo à Pesquisa do Estado de São Paulo).

Hematology

The Hematology services provides assistance to patients with oncohematological illnesses and to those with bone marrow transplants. It is under the quality control standards of the Brazilian Society of Hematology and Hemotherapy.

Every year the hematology center handles 18,000 blood collections, including aphaeresis to obtain hemo-components and 30,000 blood collections for bone marrow registry at the REDOME (the national registry of bone marrow donors).

Endoscopy

The endoscopy service has three rooms for endoscopic examinations, preparation rooms for patients awaiting colonoscopies and eight hospital beds for recuperation post-sedation.

The three rooms are equipped with video endoscopy units, Olympus Exera CV 160, a system for capturing and storing images, three video colonoscopy units, one video laryngoscopy unit, one video therapeutic duodenoscopy unit and two urethra-cistoscopy units.

Dr. Wagner Colaiacovo, chief of the Endoscopy department designed the department so that patients who arrive and have to go through preparation do not interact with patients who have gone through the procedures. A disinfection room was also designed for the maximum hygiene. The practice has the most recent equipments for diagnostics and procedures. His team is also developing surgical equipments for the treatment of patients. Dr. Colaiocovo, a highly respected specialist in his field, mentioned that “from the surgical beds to the scalpels used at HCB, all can be found in the most expensive hospitals in Brazil.”

Dr. Colaiacovo directs a team of seven doctors, nurses and nurses’ aides, all trained in endoscopic diagnostics and therapeutic processes.

Hematopoietic Stem Cell Transplant

The Hematopoietic Stem Cell Transplant department was accredited by the National Health Ministry in 2003. It performs familial allogenic and autocologic transplants.

The department has four beds to perform transplants and day care in the ambulatory area for post-operative patient care.

Surgical Center

The Surgical Center has eight surgical rooms and four ambulatory surgery rooms. HCB provides oncological surgeries in the areas of: head and throat, urology, gynecology, thorax, neurosurgery, digestive tract, soft tissues, skin, mastology, reconstruction, orthopedics and pediatrics.

A total of 1,350 surgeries are performed every month. They comprise an average of 550 large, medium and small surgeries and 800 ambulatory surgeries.

Mobile Units

Cancer prevention program with mobile unit started in 1994. Dr. Edmundo Mauad trained a nurse to go visit primary care units in Barretos and surroundings with a gynecology table on a bicycle, for cervical cancer prevention. This active search prevention program has improved and expanded. HCB estimates the program enables the hospital to find 80 percent of cancers at early stages.

HCB has six mobile units for prevention of breast, cervical, prostate and skin cancer. Two mobile units go around Barretos and region. One in Jales, a city next to the border of the states of São Paulo, MatoGrosso do Sul and Minas Gerais and another mobile unit works in the southern part of the state of Bahia.

The largest mobile unit goes on monthly incursions in the states of MatoGrosso do Sul, MatoGrosso and Rondonia. These units travel from Barretos to different cities and are stationed at main squares for a few days to see patients. In these incursions, a team of one doctor, two nurses and technicians perform simple procedures for cancer prevention, in addition to screening. For example, moles are removed on patients to avoid development of skin cancer and some gynecological treatments are prescribed.

Therapies

Chemotherapy

The chemotherapy session specializes in five specialties: clinical oncology, hematology, bone marrow transplant, thorax and oncopediatrics. The department covers 1,520 sq. mtrs and is divided into a wing for adults and one for children. There are four rooms with 56 reclining chairs and other five rooms with 36 beds, where 4,680 patients are treated per month.

Radiotherapy

Radiotherapy serves on average 500 patients everyday. The department has a multidisciplinary staff providing treatment in diverse segments. The department occupies an area of 1,430 sq. mtrs.

Odonthology and Prosthesis

The Odonthology department is part of the rehabilitation department, aiming to improve quality of life of patients. The treatment covers head and throat and emphasizes on reducing pain and improving functionality.

The department advises patients on hygiene and prophylaxes and treats collateral effects of some treatments such as xerostomy. Buccomaxilofacial rehabilitation is performed through prosthetics reconstruction as well as intrabuccal prostheses. The prosthetic department also provides preventative and therapeutic laser therapy, osseointegrated implants and prosthetic support for patients who undergo breast removal, through prosthetic rehabilitation of the lost breast.

Speech and Hearing

This department rehabilitates patients with altered speech, breathing, chewing, swallowing, voice and language. These are common consequences of head and throat cancer, brain tumors and pediatric oncology.

Treatments in the department involve: - Pre and post operation orientation for patients and family on possible challenges; - Bed care- evaluation of alterations on patient (palliative or clinical); - Pediatric bed care; - Ambulatory care: orientation and rehabilitation; - Total laryngectomy group: monthly meetings for information exchange with patients to improve self-esteem and social interaction; - Care in conjunction with odontology- confection of obdurate prosthetics.

Physiotherapy

This department interacts will all others in the hospital, providing integral service to all patients according to their needs. Patients have a physiotherapist throughout their treatment.

Ambulatory patients are treated in a 250 sq. mtrs area, served with the most modern rehabilitation equipment (thermotherapy, electrotherapy, hydrotherapy, kinesiotherapy, lymphoterapy and urogynecology.) Employees are also engaged in work exercises to improve physiological and psychological welfare.

The institution provides resources for the acquisition of prostheses, arm braces and elastic compression socks.

Palliative Care

In the case of advanced cancer stages and metastasis, patients and families are advised to go home and continue treatment with the family. Many patients however chose not to go home, since their family members would not be able to take care of them. In August 2010, the hospital had 1,200 patients under palliative care, including interned, in ambulatory and at home.

The Palliative Care and Pain Control services work in the old Hospital São Judas. The facility offers special care for patients, providing them with comfort and quality of life.

The unit works with a team of doctors, nurses, physiotherapists, psychologists, occupational therapists, speech and hearing therapists, nutritionists, dental surgeons, pharmacists, music therapists and social workers. Hospital, ambulatory and home care are provided. This unit relies on the collaboration of over 60 volunteers organized by the hospital.

Pediatric Unit

The unit treats around 150 new cases every year. The pediatrics ambulatory has 12 beds and one isolation room and serves more than 50 children a day with chemotherapy and specific exams. It has its own toy room.

Pediatrics also has an intern ward, with 10 beds and a classroom, where children are given education according to their school year. The department provides psychological support for parents and patients as well as rehabilitation.

Through social services, children and a family member are placed in accommodations, which offer free boarding and food. All paediatric oncology practices are offered for the patients.

Expansions

In 2011, Hospital de Cancer de Barretos is expected to open the first high-definition center for laparoscopy in Latin America. There will be 22 special rooms for surgeries with pigs and humans, auditorium with live stream of surgeries and laboratories. There are two equivalent centers to this in the world: Strasbourg (covering the European Union) and Taiwan (covering Asia). In 2015 Dubai will launch its center. The investment for this project is US $18 million, financed by Storz3 (US $14 million) and Covidien4 (US $4 million). Both companies have also agreed on a US $250,000 per year financing of the center for 15 and 5 years respectively.

HCB has raised funds and is building its specialized Children Hospital, to be inaugurated in 2011. Ronald McDonald Foundation is building a house for children and their families next to the new hospital.

Scientific studies

Clinical Research Doctors, therapists and in-house scientists are encouraged to develop studies to discover new forms of treatment and innovative products. Through partnerships with international institutions and pharmaceutical companies, hospital patients can receive new drugs, being tested internationally.

The hospital has become a benchmark in clinical research in Latin America.

Teaching and Research

The department offers specialized courses in: 1. Head and throat; 2. Upper digestive tract; 3. Gynecology; 4. Mastology; 5. Neurosurgery; 6. Prevention; 7. Mammary; 8. Radiology; 9. Pathology; 10. Urology; 11. Colorectal video-surgery; and 12. Orthopedics

The hospital offers residence programs in Oncological Surgery, Radiotherapy, Clinical Oncology, Radiology and Nuclear Medicine.

In support of research projects, there is an institutional and technological exchange program and clinical body improvement program. Approximately 29 percent of participants of these programs possess either Doctorates or Masters degrees, while 12 percent have post-graduate education.

3http://www.karlstorz.com/cps/rde/xchg/karlstorz-en/hs.xsl/146.htm

4http://www.covidien.com/covidien/pages.aspx?page=Home

The hospital has the largest tumor bank in Brazil, aiding the development of molecular biology projects. The Cancer Hospital Registry has cataloged patients since 1985 and in 2007 it had totaled 78,641 patients. The Research Ethics Commission evaluates the ethical principles of institutional or multi-center clinical protocols.

Information Technology

HCB has a department offering Oracle databank and tools for all departments of the hospital - Medical and Statistical Archives Services (SAME- Serviço de Arquivo Médico e Estatística). SAME stores and provides records on daily activities for all medical specialties. It is divided into three areas: Active, Semi-Active and Ambulatory registries. It has over 200,000 records.

The digitalization of old patients records has started through scanning and is still ongoing.

Legal Department

HCB Legal Department serves the hospital as well as patients and companions. It handles 60 cases per week and approximately 3,000 cases a year.

The department helps patients apply for social security, sick-leaves, retirement due to disability, assisted support for disabled people, tax calculations, income tax exemptions, among other services.

The department also handles donations of properties for institutional benefits, collection of auction checks and negotiations on behalf of the institution.

Fundraising

Every month HCB spends on average R$ 12 million (US $ 7 million). The Federal Brazilian government repays the hospital R$ 8 million (US $ 4.7 million) and to pay the remaining R$ 4 million (US $ 2.4 million) deficit, the hospital raises funds from the state and municipal governments as well as private donations.

In private donations, HCB receives on average R$ 2 million (US $ 1.2 million) per month. The sources for private funding are: 1. Cattle auctions organized by 300 volunteer coordinators spread in cities around Brazil. Farmers who want to help the hospital give cattle at no costs. 2. Concerts by celebrities- they donate their revenues. 3. Coin/cash donation receptacles in 132 cities in Brazil, taken care by 135 volunteers. 4. Bom Samaritano (Good Samaritan) campaign- mailing of quarterly magazines printed by the hospital together with a donation request (raised R$ 90,000 in 2009.) 5. Nota fiscal paulista- donation of tax credit to the hospital by tax payers in the city of São Paulo. HCB has partnerships with drugstores, shops and the largest supermarket chain in the State: GrupoPão de Açucar. The campaign started in 2009 and is estimated to have raised so far R$ 80,000. 6. Tax incentive law created by the federal government to stimulate the investment in children health programs: allows companies to donate 1 percent and individuals to donate 6 percent of their tax breaks. 7. Non perishable goods (clothing, kitchenware, shoes etc) confiscated by the federal police from smuggling or lack of tax payment are donated to the hospital and sold at very low prices to the community. 8. Private donation through its webpage.

The hospital does not offer private services, or the opportunity for patients to rent room for privacy. Dr. Edmundo Mauad explained that due to the large amount of patients and limited beds the hospital optimizes bed rotations.

The hospital does not raise money through its scientific department yet. The research center started in 2008 and hiring of the team was concluded in 2010. The hospital decided to invest its own capital in initial research and plans on applying for grants with national research agencies such as Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP- São Paulo Research Foundation) and Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq- National Counsel for Scientific and Technological Development.)

Webpage

HCB has a website that describes services offered, informs about fundraising events, features testimonials of patients and collects electronic donations.

The website does not provide visitors with much institutional details, or any information on qualification of medical body, research developed at its laboratories, international partnerships, or articles published by its employees.

APPENDIX I

New Cases (gender and year) Diagnose Year Male Female Total 2000 1,656 1,374 3,030 2001 1,892 1,720 3,612 2002 2,194 1,957 4,151 2003 2,819 2,317 5,136 2004 3,663 2,765 6,428 2005 4,402 3,536 7,938 2006 4,866 3,943 8,809 2007 5,345 3,977 9,322 2008 5,137 3,878 9,015 2009 5,234 4,218 9,452 Total 37,208 29,685 66,893

Obits (gender and year) Diagnose Year Male Female Total 2000 1,008 614 1,622 2001 1,054 663 1,717 2002 1,206 719 1,925 2003 1,451 845 2,296 2004 1,688 1,004 2,692 2005 1,881 1,116 2,997 2006 1,748 1,141 2,889 2007 1,720 931 2,651 2008 1,411 783 2,194 2009 845 479 1,324 Total 14,012 8,295 22,307

APPENDIX II

Balance Sheet 2009 ASSETS R$ US$ CurrentAssets Available 1,977,455.00 1,184,104.79 Attached accounts 19,094,798.00 11,434,010.78 Partnerships, Agreements 0 - Amount to be received by third parties 19,794,298.00 11,852,873.05 Advance payments for employees 1,799,242 1,077,390.42 Other accounts and titles to receive 0 - (-) Provision for debtors 0 - Stock 3,555,464 2,129,020.36 Advance liabilities 5,967,838 3,573,555.69 Other asset accounts 1,990,820 1,192,107.78 Total current asset 54,179,915 32,443,062.87 Long term assets Long term receivables 67,899 40,658.08 Total Long term assets 67,899 40,658.08 Permanent assets Investments 0 Plant 211,787,697 126,818,980.24 (-) AccumulatedDepreciation/ amortization 32,193,737 19,277,686.83 Defered 0 - Other permanent assets 711,480 426,035.93 Total Permanent assets 180,305,440 107,967,329.34 Total ASSETS 234,553,254 140,451,050.30 LIABILITIES (R$) CurrentLiabilities Suppliers 9,990,140 5,982,119.76 Wages 0 - Social Obligations 2,080,646 1,245,895.81 Service Providers 0 - Rent 0 - Client advance 0 - Loans and refinancing 9,272,699 5,552,514.37 Fiscal obligations minus taxes 466,539 279,364.67 Public Insurance 0 - Projects Advance 0 - Public Subventions 0 - Tax incentive law 0 - (-) Receivable of Tax Incentive Law 0 - Provision for taxes 0 - Employment fines to be paid 7,351,467 4,402,076.05 Fines to be paid (excludingwork) 0 - Other current liabilities 16,698,718 9,999,232.34 Total currentliabilities 45,860,209 27,461,202.99 Long term liabilities Long term loans and refinancing 143,993 86,223.35 Bills to pay 0 - Advance rent 0 - Other long term obligations 0 - Total long term liabilities 143,993 86,223.35 Result of future liabilities Results of future liabilities 0 - Total result of future liabilities 0 - Liquid Social Capital Social Capital- Fund 68,587,851 41,070,569.46 Capital donation 31,399,767 18,802,255.69 Reserves 53,855,678 32,248,908.98 Activity Surplus 34,705,756 20,781,889.82 Activity Deficit 0 - Other Capital Accounts 0 - Total Capital 188,549,052 112,903,623.95 Total Liabilities 234,553,254 140,451,050.30 Exercise Results REVENUES R$ Operational Revenues Services provided (ExceptHealth/Education) 0 - Revenues- publicsubventions 0 - Revenues- publiccontributions 0 - Revenues- publicinsurances 0 - Revenues- publicassistance 0 - Revenues- partnershipagreement 0 - Donationsandcostassistance 0 - Revenue from private health insurance 2,119,859 1,269,376.65 Services to non-insured parties 134,770 80,700.60 SUS – SistemaÚnico de Saúde 131,761,555 (governmentinsurance) 78,899,134.73 Exam tuitions 0 - Educational programs 0 - Fees and contributions 0 - Contribution from partner companies 0 - Donations, campaigns and sponsorships 0 - International Revenues 0 - Tax deductions (-) Scholarships 0 - (-) Free serviceprovision 0 - (-) Discounts given 0 - (-)PIS Tax over revenues 0 - (-) COFINS tax over revenues 0 - (-) ICMS tax over sales 0 - (-) ISS tax over services 0 - (-) Canceled sales 0 - (-) other deductions 192,994 115,565.27 Other Operating Revenues Other Operating Revenues 1,935,614 1,159,050.30 Financial Capital Revenues Obtained Discounts 0 - Income from rent 0 - Income from Equity and other investments 3,070,159 1,838,418.56 (-) Taxes over Financial Income 0 - Other Financial Capital Revenues 0 - Non-Operational Revenues Saleof Permanent Asset 0 - Donationsreceivedasmerchandise 0 - Other Non-operational Revenues 65,441,374 39,186,451.50 Other Revenues Other non-classified Revenues 0 - Total Revenues 204,270,337 122,317,567.07 (-) Costs (R$) Personnel Costs Wages 31,617,773 18,932,798.20 Social Expenditures with Personel 2,875,017 1,721,567.07 Diverse Expenditures with Personel 1,340,154 802,487.43 Directors wages 0 - Social Expenditure with Directors 0 - Other compulsory Social Expenditures 0 - Other Personnel Expenditures 0 - Consulting Services External HR – Private 11,739,591 7,029,695.21 External HR – Institutional 37,828,118 22,651,567.66 INSS tax over third party services 0 - Other costswith consulting 1,253,876 750,823.95 Project Costs Costs of Projects 0 - General and Administrative Costs Water, gas, electricity 2,865,992 1,716,162.87 Paid rents 247,627 148,279.64 Automobile costs 297,447 178,111.98 Travel costs 510,316 305,578.44 Accomodation 364,511 218,270.06 Plane/Train Tickets 583,218 349,232.34 Telephone/Fax/Communication Costs 654,782 392,085.03 Technical Publications 23,443 14,037.72 Technical and Specialized Services 3,139,134 1,879,720.96 IT expenditures 6,556 3,925.75 Hired insurance premium 335,377 200,824.55 Social and Cultural Expenditures 0 - Other Administrative Expenditures 117,568 70,400.00 Scholarship Costs to Third Party High School 0 - University 0 - Interns 0 - Masters, PhD and Post-Grad studies 0 - Other Scholarship Costs 0 - Taxes, Fees and Contributions

Federal Taxes 9,623 5,762.28 State Taxes 110,127 65,944.31 MunicipalTaxes 30,175 18,068.86 CMPF 0 - COFINS 10,250 6,137.72 IOF 76,232 45,647.90 Other tax, fees and contributions 314,654 188,415.57 Donation Expenditures Food Donation 0 - Clothing Donation 0 - Medicine Donation 0 - Other Donation Expenditure 0 - Financial Expenditures Discounts provided 39,354 23,565.27 Banking expenses 177,767 106,447.31 Other financial expenses 833,841 499,305.99 Depreciation, Amortization and Leasing Depreciation Costs 8,029,111 4,807,850.90 Amortization Costs 0 - Leasing Costs 0 - Other Operating Costs (-)Costrecovery 0 - Other Operating Costs 0 - Other Non-operational Costs Cost of sold permanent asset 0 - Cost of checked permanent asset 0 - Other Non-operational Costs 0 - Participation and Contributions Participation and Contributions 0 - Other expenditures and costs Outrasdespesasnão classificada santeriormente 70,958,901 42,490,359.88 Constituted Provisions Taxprovisions 0 - Other Constituted Provisions 0 - Total Costs 176,390,535 105,623,074.85 SURPLUS/DEFICIT (R$) Revenues 138,828,963 83,131,115.57 (-) Tax over revenues 0 - (-) Deduction and amortization 0 - LIQUID REVENUE R$: 138,828,963 83,131,115.57 (-) Cost of Services andproducts 0 - PRE TAX SURPLUS/DEFICIT R$: 138,828,963 83,131,115.57 (-) General and administrative expenses 23,266,544 13,932,062.28 (-) Financial Expenses 1,050,962 629,318.56 (-) Taxexpenses 551,058 329,974.85 (-) Other operational expenses 149,306,620 89,405,161.68 Financial Revenues 0 - OPERATIONAL RESULTS R$: -35,346,221 (21,165,401.80) (-) Non-Operational expenses 0 - Non-Operational Revenues 65,441,374 39,186,451.50 Results before taxes 30,095,153 18,021,049.70 (-) Taxprovision 0 - Results after taxes 30,095,153 18,021,049.70 (-) ParticipationandContributions 0 EARNING SURPLUS or DEFICIT R$: 30,095,153 18,021,049.70