Transcript Scope and Characteristics of the Health Worker

Addressing the Challenge of NCDs in LAC:
Brazil Country Case Study
Isabella Danel
Christoph Kurowski
Brazil Country Case Study
Objectives:
 To inform policy dialogue
 Lessons learned from developed countries and the
potential applicability of the most CE strategies in Brazil
 Potential impact of expanding health promotion and
improved NCD management on health outcomes
 Costs and returns from expanding health promotion and
improved NCD management activities
 To inform current and future health project (VIGISUS 2
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and 3, FHP)
To develop and pilot a model for assessing NCD
prevention and control issues in other countries
Brazil Overview
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Largest country in LAC
Population 186 million; 80% urban
Large health disparities
Universal health system since 1990
Decentralized
Family Health Program
% of GDP spent on health: 7.6
Basic health indicators:
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LE: 69 / aging population
TFR: 2.2
IMR: 30 (48 in 1990)
HALE at birth: 57/62 (male/female)
Burden of Disease by Major Disease
Groups, Brazil 1998
Thousands of Disability-Adjusted Life Years
25,000
Communicable,
Maternal, Perinatal,
and Nutritional
Conditions
Non-Communicable
Diseases
20,000
55%
15,000
10,000
Injuries
5,000
24%
21%
0
Source: BOD study 2002
Burden of Disease, Brazil 1998
Thousands of Disability-Adjusted Life Years, Divided into YLLs and YLDs
25,000
Disability,
YLDs
20,000
Deaths,
YLLs
15,000
10,000
5,000
0
Communicable, maternal,
perinatal, nutritional
Non-communicable
Injuries
Source: BOD study 2002
Comparison of Years of Life Lost
Among Several Diseases
Thousands Years of Life Lost due to Premature Mortality
1,800
1,600
1,400
1,200
1,000
800
600
400
Ischemic heart
disease
Cerebro-vascular
disease
Chronic Obstructive
Pulmonary Disease
Lung cancer
HIV
200
0
Source: BOD study 2002
Avoidable DALYs: Brazil compared to Amer-A*
Brazil
Ameri-A
Rate / 1000
Rate / 1000
ALL
270
142
Communicable Maternal
Perinatal, Nutritional
Infectious, parasitic
Respiratory infection
Maternal
Perinatal
Nutritional
65
32
8
5
15
5
10
4
1
<1
2
1
Non-communicable
Cancer
Diabetes
Neuro-psychiatric
Cardiovascular
Chronic respiratory
Other
148
15
13
38
31
18
34
118
17
4
42
21
9
25
Injuries
Unintentional
Intentional
56
45
11
14
9
5
Causes
* Very low child and
adult mortality: Canada
Cuba, USA
Prevalence of risk factors in Brazil
 Study on nutrition / obesity data is national; all others are
smaller studies
 Behavioral Risk Factor Survey in most capital cities has been
completed – data not yet available
 Multiple studies showing wide ranges:
 Tobacco – 35-50% for men; 20-33% for women
 Inactivity – 45-60% in men; 60-80% in women
 Obesity – 10% in adults in ’89 (national survey)
 Hypertension – 20-30% in adults; higher among lower SES
 Tendencies
 Obesity increasing: 6% among adults in ’75; 10% in ’89;
also increasing among the poor: 3.6% for lowest female
tercile in ’75, 9.7% in ’89
 Diabetes increasing: 7.6 / 100,000 for < 15 years old in ’93
(SP); 12.7 in ’98
The challenge of NCD’s in Brazil
Preliminary results of an economic
evaluation
Objectives
For a subset of largely preventable NCDs, to
 estimate the financial costs of treatment and care;
 estimate the future burden of disease;
 estimate the future financial and economic costs; and
 estimate the financial costs of health promotion in
comparison with the financial and economic benefits.
Model (I)
Diabetes mellitus
Physical
inactivity
Arterial
hypertension
Smoking
Ischaemic stroke
Ischaemic heart disease
Chronic obstructive
pulmonary disease
Cancer (trachea,
bronchi, lungs)
Current costs of treating a subset of NCD’s
[2002/03]
Risk factor
Sec. Disease
Physical inactivity
IHD, CVD*, DM
3.4
Arterial
hypertension
IHD, CVD
3.2
Smoking
IHD, COPD,
“lung” cancer
3.5
Total
USD 2000 [billion]
10.2
Future burden of disease 2005/2010
LE
2005
2010
2015
2020
Future burden of disease – selected conditions
by risk factor: 2005 to 2010
Risk factor
Sec. Disease
Physical inactivity
IHD, CVD*, DM
4.9
Arterial
hypertension
IHD, CVD
12.6
Smoking
IHD, COPD,
“lung” cancer
3.7
Total
BoD 05-10 [DALY,
million]
21.2
Future costs due to NCD’s 2005/2010
Future costs (status quo persists):
 Financial costs:
Costs of treating secondary diseases
 Economic costs:
Financial costs plus
productivity losses due to disability and premature
mortality
Future economic costs due to NCD’s:
2005/2010
Risk factor
Sec. Disease
Physical inactivity
IHD, CVD*, DM
$130.0
Arterial
hypertension
IHD, CVD
$215.2
Smoking
IHD, COPD,
“lung” cancer
$122.0
Total
Economic costs 0510 [ USD, 2002,
billion]
$467.2
Model II
Scaling up of AGITA SAO
PAULO
Physical
inactivity
Treatment of 25% of
population c hypertension
Arterial
hypertension
10% increase in prices of
cigarettes
Smoking
Medical counseling for
25% of smokers
Scaling up of AGITA SAO PAULO
Intervention: Expansion of program to 25% of population
Financial costs of providing
intervention
DALY’s averted
131 million
127,000
Financial costs in care of secondary
diseases averted
572 million
Losses in productivity averted
452 million
Benefit cost ratio
Costs in USD 2000
7.8
Benefit cost ratios
Scaling up of AGITA SAO
PAULO
7.8
Treatment of 25% of
population c hypertension
1.2
10% increase in prices of
cigarettes
2.9
Medical counseling for
25% of smokers
0.1
Conclusions
 NCDs consume a large share of Total Expenditure on
Health
 Future economic costs accruing over the period of
2005/2010 equal approximately 70% of GDP in 2002
 Effective interventions to prevent NCD’s exist. Some
are financially and economically highly attractive.
Ministry of Health Response to Health
Transition
 Fragmented national policies:
 National policy to reduce injuries and violence
 National anti-tobacco and anti-drug policy
 National Food Security policy
 National and State Cancer Control policies
 National and State Occupational Health policies
 Policies not yet operationalized in national / state /
municipal health plans
 Health Muncipalities project, 2002, UNSP
Ministry of Health Structure
 Executive Secretariat responsible for establishing
health promotion policies and coordinating crosscutting program
 Fragmented national structure:
 No one unit responsible for health promotion
activities
 Four secretariats involved
 Greater activity in some states e.g. Sao Paulo
Ministry of Health:primary health care
 Eight Family Health Program priorities include:
 Control of hypertension and diabetes
 Health promotion
 National plan and guidelines available for
hypertension and diabetes detection and control,
but not health promotion
 Plan has been implemented through training, IEC
campaigns, community work
 Performance measures on hospitalization and
mortality; none for risk factors or HP activities
 In process of defining policies to promote healthy
lifestyles, health promotion and risk prevention.
Interventions in tobacco
 National Tobacco Control Program established,
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1987
Advisory Board on Tobacco Use Control
established, 1987
Warning on cigarettes, 1988; bolder in 2001
Restricted tobacco advertising, 1994
Smoking banned in MOH, 1998
Tobacco considered drug and regulated by
ANVISA, 1999
Various media campaigns
Tobacco advertising only at point of sale, 2000
Tobacco use education and control programs in
the workplace, schools, and health units
Next steps
 National health promotion plan -- involvement of
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multiple sectors; address issues at various levels
Clearly defined priorities and targets
Commitment to financing
Structure that facilitates action
Scale up cost-effective interventions shown to
work in Brazil
Piloting interventions found to be cost-effective in
other countries based on priorities
HP performance measures include in pactos
Information systems to monitor impact and trends