In this segment of the lecture, we're going to review the impact of that allocation of funds to primary care on the workforce and Service Delivery building blocks. We'll also review briefly the pharmaceutical building block and the access to pharmaceuticals in Brazil. First, let's focus on the Workforce building block. I want to focus on the number of doctors. This is a measure of capacity, in the period 2000 to 2015, there was an increase in the number of doctors per 1000 of the population from 1.5 per thousand to 1.8 per thousand. This places Brazil well below the OECD average, but it does indicate an increase in capacity to support access to primary care for a larger proportion of the population. It's also important to note that the number of doctors per thousand of population was significantly less than 1.5 per thousand in 1990. While there was this increase in the number of doctors, there was a shortage of doctors to support the policy of increasing access to primary care. There are problems of hiring and maintaining doctors as part of the Family Health Strategy. This led amongst other things in 2013 to the introduction of the More Doctors program. This was an effort to use doctors from outside of Brazil to increase capacity. One of the primary source of those doctors was Cuba. By 2017, there was some 8,500 Cuban doctors working in underserved areas in Brazil. However in 2018, President Bolsonaro encouraged Cuba to pull those doctors out of Brazil and to cease participation in the More Doctors program. As with everything in Brazil, there is a complicated story concerning the workforce. There is an increase in capacity, but nowhere near enough to achieve the broad goal. In our analysis of the service delivery building block, I want to review the implementation of the Family Health Strategy. There is an important story to tell about access to hospitals and medium and high complex care, but for our purposes today, I want to primarily focus on the Family Health Strategy because this was the primary vector for increasing access to primary care services. And as we've noticed, modest increases in health spending made increasing access to primary care possible. The Family Health Strategy was one of the most important programs that relied upon this increase in funding available to support primary care. We can conclude with some qualifications that the implementation of the Family Health Strategy is a story of success and achievement. As background to the implementation of the Family Health Strategy, it's first important to note a reduction in the number of hospital beds in Brazil. The number of hospital beds per thousand of the population fell in the period between 2000 and 2015. This is consistent with movements in many other health systems. There were significant decreases in hospital beds per 1,000 of the population in the United Kingdom and in the United States. These decreases in the number of hospital beds were the results of efforts to increase the efficiency and use of hospital stays. By contrast, in Brazil, the reduction of hospital beds was part of an allocation of funding away from hospitals to our patients, which reflected the increased priority given to primary care. It is not a very big movement in priorities, but it is a significant one. One important measure of increased access to primary care is the number of consultations with doctors per person per year. We know in high-income countries these can be as little as four consultations per year in the United States to as many as ten consultations per year in Germany. There's been a significant increase in Brazil from 2.3 to 2.8 consultations per year in the period 2000 to 2015. More significantly though in 1990, that figure was around 1.5 consultations per person per year. This measure of utilization is one measure of the success of the Family Health Strategy in increasing access to healthcare. So what was the Family Health Strategy? It was a team-based approach to healthcare, each team included a doctor, a nurse, a nurse assistant and up to six community workers. Each team served a thousand families or approximately 3,500 people. The Family Health Strategy was designed to provide the first point of contact for those seeking care. It aimed to provide comprehensive and whole person care coordinated with other services emphasizing care that takes place within the context of family and community. The strategy was heavily focused on prevention and promotion outreach activities with monthly visits to enroll family members. The important element of this is that while the Family Health Strategy was about increasing access, it was also about connecting families with broader programs that will enable improved individual and population health. So what did the Family Health Strategy achieve between 1998 and 2010? The numbers of Family Health Strategy teams increased from 4,000 to 31,600, enrollments increased from 10.6 million in 1998 to 100 million in 2010. The Family Health Strategy was present in some 90% of the 5,565 municipal regions. Having said this, by 2008, only 58% of the population report regularly using the SUS as their primary source of care. And finally the Family Health Strategy was significant in connecting communities with Public Health Resources and initiatives. It was less successful in coordinating interactions between primary care and emergency care and with connecting interactions between primary care and hospital care. As we noted earlier, the introduction of the Family Health Strategy was consistent with an increase in the utilization of healthcare. In this graph, the red line measures the significant increase in the number of basic care interactions in the period between 1990 and 2009. The green line shows an increase in the number of consultations per doctor from roughly one point five to three point five per year while the blue line shows an overall decrease in the number of hospital admissions. And this measure of the number of consultations per doctor is different to the one provided by the OECD. It is likely that this figure of three point five consultations is based upon a different definition of what constitutes a consultation. It does confirm greater levels of utilization of primary care services. As a snapshot of this increased access to primary care, in the period 1996 to 2006, the proportion of pregnant women with no prenatal consultation fell from 26% to 1.3% with the mean number of consultations per person and rising from 1.2 to 6.2. In other words, the introduction of the Family Health Strategy was consistent with an increase in the number of consultations with healthcare providers and with a decrease in the use of hospitals, but the SUS and the Family Health Strategy achieved more than just increased utilization. This graph shows the percentage of people who sought and used care by income decile in Brazil in 1986 and 2008. The most significant point about this graph for our purposes is that it shows very high rates of usage of the SUS by those in lower income deciles. Similarly, it shows much lower rates of usage of the SUS by those on higher incomes. Underlying both of these movements was an increase in the percentage of people who sought care in 1986 and 2008, the increase in those seeking care apply to all income deciles, although larger percentage of those with higher incomes sought out healthcare in both 1986 and 2008. Overall the graph shows that the SUS and the Family Health Strategy were significant in providing access to care for those in the lower incomes. In addition, the graph suggests that the Family Health Strategy was successful in changing the first point of contact with the health care system. One of the policies worldwide is to increase access to primary care and to reduce the number of people accessing hospitals as a first point of contact with the health system. The increased usage of the SUS by those with lower incomes is evidence that the Family Health Strategy increased the number of people who used primary care as the first point of contact with the health system. This is a cheaper and more effective way to access healthcare, as important a strategy in achieving universal health coverage as we will see in our review of the Chinese health system. This graph measures hospital discharges and it tells a complicated story. On the one hand, it shows that Brazil, Colombia or Mexico have significantly lower numbers of discharges than other OECD countries. In Brazil in 2015, there were 55.2 hospital discharges per thousand of the population per year. This figure tells us two conflicting forces affecting hospital discharges in Brazil. On the one hand, it is a story of achievement because it indicates that there are a larger number of people using primary care as a first point of contact with the health system and with the consequent reduction in the numbers using hospitals as a first point of access to health care. But it is also indicative of large pools of unmet demand for medium and complex care. This graph is indicative all of the complexity of a single measure such as hospital discharges. This can be both an achievement and a sign of unmet need for healthcare amongst the population. So what we can conclude about the Family Health Strategy, it was an incredibly important program, it increased utilization of services, increased utilization of services by those on low incomes and by those in underserved areas and states. And finally, it increased primary care as a first point of access to healthcare. Let's just note the Pharmaceuticals and Medical Devices building block. This is important for a number of reasons. First, the pharmaceutical drug market in Brazil is the eighth largest market in the world. Secondly, in 1998, the government implanted a national medicines policy. As a result of the implementation of this policy, there was a significant increase in the number of essential medicines available as part of the SUS. The number of essential medicines increased from 327 in 2002 to 869 in 2017. In 2004, the popular pharmacies program was implemented, this program did not provide universal coverage for pharmaceuticals, but it did provide access to a range of essential medicines at reduced cost with lower co-payments. This is significant because in Brazil, expenditure on medicines makes up approximately 60% of the out-of-pocket spending by those on low incomes. The presence of a large market for pharmaceutical drugs also enabled the Ministry of Health to facilitate the formation of a large pharmaceutical industry producing specified generic drugs. There continue to be problems associated with access to essential medicines and with the use of non-SUS medicines, this reflects a lack of regulation of the use of pharmaceuticals and other forms of health technology in Brazil. So in review, we can say that the governance and finance building blocks in Brazil opened up a space for increasing primary access to healthcare. We can see that both in the number of doctors and in the increased utilization of services in Brazil. The Family Health Strategy did achieve the goal of improving access and did move Brazil towards a system of universal health coverage. In the final segment of the lecture, we'll review the impact of the Brazilian health system on population health outcomes.
