community care workers symposium “exploring alternatives” johannesburg, 20th,30th april and 1st...
TRANSCRIPT
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Community Care Workers Symposium“Exploring Alternatives”
Johannesburg, 20th,30th April and 1st May 2010
Community Health Workers: the PHC backbone in Brazil
Raphael Aguiar
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Basic Facts about Brazil
• 53% of South America
• Population:190,000,000
• States: 26 + 1 Federal District
• Municipalities: 5,563
• 40% of the population in metropolitan areas
• Multiple Contexts
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Brazilian National Health System
Health as a political issue and a universal right (since 1988)
The National Health System benchmarks are: Universality Equity Comprehensiveness Decentralization Empowerment and social accountability
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• Chronic diseases: Hypertension, diabetes...
• Cancer
• External Injuries (Violence, car accidents etc)
• Social inequalities
OUR MAIN HEALTH ISSUES:
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• HIV prevalence in the 15 to 49 age group in 2008: 0.61% (females: 0.41%, and males: 0.82%)
• Mother‐to‐child transmission rate: 8.5% (2004)
• AIDS incidence rate: 18.2 per 100,000 inhabitants (2008)
• AIDS mortality coefficient: 6.1 per 100,000 inhabitants (2008)
Source: http://data.unaids.org/pub/Report/2010/brazil_2010_country_progress_report_en.pdf
Some information about HIV/AIDS in Brazil
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• 466.5 million condoms were distributed in 2009;
• 2.06 million female condoms were distributed in 2009;
• 2.17 million units of lubricant gel were distributed in 2009;
• Massive campaigns on radio, newspapers and TV;
• Some general counselling activities usually take place in PHC facilities.
Source: http://data.unaids.org/pub/Report/2010/brazil_2010_country_progress_report_en.pdf
Some governamental actions regarding HIV/AIDS:
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The modern community health agent came up in 1991, in a poor Brazilian state (Ceará)
Objectives: to reduce infant mortality and to provide some income to local families
Their work (based on simple actions) decreased infant mortality up to 30% in some areas
This outcome contributed to their definitive insertion in the National Health System as a national cadre
Basic facts about Brazilian Community Health Agents
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Their success stimulated the expansion of the CHA's program in other states;
In 1994 the “Familiy Health” program (a kind of upgrade) was launched based on those outcomes;
Since then, CHA's have been steadily incorporated to Family Health teams. In 2002, the profession was recognized by a federal law
This law establishes minimum requirements for becoming a CHA as well as their scope of practice
Basic facts about Brazilian Community Health Agents
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a) They are usually composed by:
A physician ; A registered nurse 1-2 nursing assistants 4-6 CHA’s
Many teams have also a dentist and 1-2 dentistry technicians (Oral health team)
b) Each team is responsible for delivering health care to about 4,000 citizens
Basic facts about Brazilian Family Health Teams
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c) Each PHC facility may have1-4 Family Health Teams depending on its size and population.
d) Since 2006 many Family Health Teams are being assisted by a multidisciplinary health team (physioterapists, psychologists, nutritionists etc)
Basic facts about Brazilian Family Health Teams
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Number of CHA's in Brazil – 1994 / 2009
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Number of FH teams in Brazil – 1994 / 2009
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2000
1998% of the population covered by health family teams – Brazil, 1998 –2009
0% 0 a 25% 25 a 50% 50 a 75% 75 a 100%FONTE: SIAB - Sistema de Informação da Atenção Básica
PHC rate coverage
2000 2002
2004 2006 2009
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PHC scenario in Brazil (2009)
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As of March 2010...
There were 236,399 CHA’s
and
30,782 Family Health Teams in Brazil
There are only 86 municipalities with CHA’s and no Family Health Teams
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PHC plays a major role in social equity (BLUMENTHAL, 1995; SHI et al., 2003; STARFIELD et al., 2005)
In Brazil, Family Health Teamsuse to be first implemented in most vulnerable areas.
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What are the requirements to become a CHA?
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As of 2009, a Brazilian CHA must:
a) Have at least 18 years old;
b) Have concluded primary school;
c) Have leadership skills and awareness of their reality;
d) Live in the area they will serve by the time of selection;
e) Be trained after being hired.
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CHA Training
• Before professionalization: in-service supervision and short term courses offered by regional joint initiatives composed by universities and regional health schools; • After professionalization (2002):
-They are trained mainly by the Technical Schools of the National Health System;
-Once they are hired they receive:
- Introductory Training (80 hours);- CHW Training Course (400 hours) - financed
by the MoH
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CHA Training
• The CHW Training Course is part of a complete professionalizing course (1200 working hours) offered by technical schools of National Health System;
• Although it is not mandatory, concluding this course is highly desirable;
• However, there are no incentives to conclude it.
• Since 2005, 127,701 CHW have conclude the mandatory part
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CHA Recruitment and supervision
• Municipalities are in charge of selecting and hiring CHA as well as the entire Family Health Team
• Their activities are supervised by the professionals with higher education (physicians and nurses).
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Scope of practices
a) General actions aiming disease prevention and healthpromotion, including counseling activities (major role intreatment adherence as well as in “translating”medical Recommendations);
b) Monthly visits to user's houses to follow up and assess risk situations;
c) Fulfillment of questionnaires for social and demographic Analysis;
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Scope of practices
d) Fulfillment of records regarding births, deaths, illnesses and other relevant situations (only for planning purposes)
e) Promotion of social accountability and citizens' participation on health policies;
f) Engagement in local, intersectoral actions
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Important: a Brazilian CHA is not allowed to perform any direct Procedures in patients
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Evidences of effectiveness
Observation: all the studies take into consideration the entire PHC teamrather than only CHA’s.
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Evidences of effectiveness
Chronic diseases
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Evidences of effectiveness
General decrease in Hospital admissions in Brazil (2000/2005)
a)By conditions which may be influenced by PHC: 15,8%
b)By conditions which are not influenced by PHC: 10,1%
(Alfradique et al., 2009)
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Evidences of effectiveness
Hypertension Control:
A comparison before and after the establishment of a FH team in a health facility has shown that 56% of its patients with hypertension had their BP controlled in six months (Lemos et al., 2006)
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Evidences of effectiveness
Hospital admissions by stroke (per 100,000, more than 40 yrs) according to PHC coverage rate - 1998-2004.
(Ministry of Health, 2006)
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Evidences of effectiveness
Decrease in hospital admissions by stroke (per 100,000, more than 40 yrs) according to PHC coverage rate - 1998-
2003.
(Ministry of Health, 2006)
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Evidences of effectiveness
a) Home care for elders in need:
• In conventional units: 2,9%• In FHT units: 13,3% (p<0,05) (Facchini et al, 2006)
b) Consultancies for adults with hypertension in the last 6 months:
• In conventional units: 31,4% • In FHT units: 46,5% (p<0,05) (Facchini et al, 2006)
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Evidences of effectiveness
c) Consultancies for elders with hypertension in the last 6 months:
• In conventional units: 34,9%• In FHT units: 52,6% (p<0,05) (Facchini et al, 2006)
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Evidences of effectiveness
d) Consultancies for adults with Diabetes Mellitus in the last 6 months:
• In conventional units: 39,3% • In FHT units: 57,6% (p<0,05) (Facchini et al, 2006)
e) Consultancies for elders with Diabetes Mellitus in the last 6 months:
• In conventional units: 38,8% • In FHT units: 52,7% (p<0,05) (Facchini et al, 2006)
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Thank you