Team 1_Brazil

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BRAZIL Comparative Health Care Project:

BRAZIL Comparative Health Care Project Team 1 : Rachael Greene, Abby Gallagher, Nicole Thede, Jennifer Asmus and Michaela Piccolo

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POPULATION BRAZIL UNITED STATES Size 203,429,773 (5 th largest) 313,232,044 (3 rd largest) Age distribution 0-14: 26.2% 15-64: 67% 65+: 6.7% 0-14 : 20.1% 15-64 : 66.8% 65 : 13.1% Gender .98males/ female 1.047 male/female Age 29.3 years 36.9 years Ethnicity 53.7% white, 38.5% mixed, 6.2% black, .9% other, and .7% unspecified white 79.96%, black 12.85%, Asian 4.43%, Amerindian and Alaska native 0.97%, native Hawaiian and other Pacific islander 0.18%, two or more races 1.61% Language /Literacy Portuguese/ 88.6% over 15 years old can read and write English/ 99 % over 15 years old can read and write Immigration -0.09% migrants/1,000 4.18 migrant(s)/1,000 population (CIA, The World Factbook, 2011)

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GEOGRAPHY/CLIMATE BRAZIL UNITED STATES Location Eastern South American North America Size 8,514,877 sq km 9,826,675 sq km Density/distribution of population 87% Urban 13% Rural 82% Urban 18% Rural Major population centers Sau Paulo, Rio de Janerico, Belo horizonte, Porto Alegre, and Brasilia (capital) New York, Los Angeles, Chicago, Miami, and Washington D.C. (capital) Transportation Airports, roadways, waterways, and railways Airports, roadways, waterways, and railways Unique features of climate Mostly tropical but temperate in the south mostly temperate with some extremes (CIA, The World Factbook, 2011)

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HISTORICAL/CURRENT SOCIO-CULTURAL AND ECONOMIC FEATURES BRAZIL UNITED STATES Employment by occupation agriculture: 20% industry: 14% services: 66% manufacturing 20.3% managerial, professional, and technical: 37.3% sales and office: 24.2% other services: 17.6% Major industry Agricultural, mining, manufacturing, and service sectors high-technology innovator, petroleum, steel, chemicals, electronics, food processing, consumer goods, lumber Exports/Imports Exports: transport equipment, iron ore, soybeans, footwear, coffee, autos. Imports: machinery, electrical and transport equipment, chemical products, oil, automotive parts, electronics Exports: agricultural, industrial supplies, capital goods, and consumer goods. Imports: agricultural, industrial supplies (crude oil) capital goods and consumer goods (CIA, The World Factbook, 2011)

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HISTORICAL/CURRENT SOCIO-CULTURAL AND ECONOMIC FEATURES BRAZIL UNITED STATES Per capita income $2,842.36 per person $33,070.03 per person Poverty 26% below poverty line 12% below the poverty line Major religions 73.6% Roman Catholic, 15.4% Protestant, 1.3% Spiritualist, 0.3% Bantu/Vodoo, 1.8% other, 0.2% unspecified, and 7.4% none Protestant 51.3%, Roman Catholic 23.9%, Mormon 1.7%, other Christian 1.6%, Jewish 1.7%, Buddhist 0.7%, Muslim 0.6%, other or unspecified 2.5%, unaffiliated 12.1%, none 4% Human Development Index High (73) Very High (4) (CIA, World Factbook, 2011; Nation Master, 2011; United Nations Development Program, 2010 )

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HISTORICAL/CURRENT SOCIO-CULTURAL AND ECONOMIC FEATURES BRAZIL UNITED STATES Educational system Required for children ages 7 to 14.  Public and private sectors. Public education is free. Government gives 25% of the revenue to the public education system. Average years in school: 4.9 Required ages 6-16. Pre-primary, primary, middle, secondary, and post-secondary Public and private Average years in school: 12 Lifestyle issues/societal issues Unequal distribution of income, pre-occupied with class, access to health care Immigration, pollution, unemployment , illicit drug use, debt issues , access to health care Role of family members in decision making Extended family very important, male is head , children tend to stay close Differs in household, more joint , children live with parents then move away (Countries and their culture, 2011; Paschalis, M; The European Education Dictionary, 2011)

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HEALTH INFORMATION AND VITAL STATISTICS BRAZIL UNITED STATES Birth rate 17.79 births/1000 13.83 births/1,000 Death rate 6.36 deaths/1000 8.38 deaths/1,000 Major causes of death and illness Diseases of circulatory system, injuries/poisoning and cancer Heart disease, cancer, stroke, and accidents Total expenditure on health 7.9% 14.6% (CDC, 2011; CIA, The World Factbook , 2011; Global Micronutrient Project, 2011; Nation Master, 2011)

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GOVERNMENT BRAZIL UNITED STATES Type Federal Republic Constitution based federal-republic Organization 3 branches: Executive, Legislative, and Judicial President Dilma ROUSSEFF 3 branches: Executive, Legislative, and Judicial President Barack H. OBAMA Role of the people Voluntary between ages 16-18 and 70+ and required over 18 and under 70 years old- military conscripts do not vote. Elected by the people 18+ are allowed to vote Elected by the people (CIA, The World Factbook, 2011)


O rganization

Brazilian Healthcare Network:

Brazilian Healthcare Network Federal Ministry of Health State Secretaries of Health Municipal Secretaries of Health Votes every 4 years on healthcare budget 27 States 5,561 Municipals Develop healthcare policy Regulation of services Planning International agreements Training Organization Brazilian National Health Surveillance Agency (ANVISA) Pharmaceuticals, private health insurance Hiring Delivery & Control Administration of the Unified Health System (SUS) Evaluation (Trade Partners, 2003)

Brazilian Healthcare Network:

Brazilian Healthcare Network Private Purchase insurance independently Receive insurance through employer Insurance is costly Public (Unified Health System) Sistema Unico de Saude Created under the Brazilian Constitution of 1988 Principles : Universal healthcare, Equitable distribution, Social control Serves 192 million Citizen: No qualification or registration Foreigners/Immigrants: Emergent care provided (WHO, 2010; Woge , 2008)

Family Health Strategy (FHS) :

Family Health Strategy (FHS) Launched in 1994 to meet the SUS principle of equitable access Provides primary health care Serves 50.7% of the population 23,000 Teams 1 physician, 1 nurse, 1 medical assistant, and 6 community health workers Each team is assigned to a geographical location and is responsible for 800-1000 families (Barros, Matijasevich, Requejo, et al. 2010)

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Healthcare Professional Brazil United States Physicians 292,000 -Medical residency -Regulatory agency: Brazilian Federal Council of Medicine 661,400 4 years of undergraduate study + 4 years of medical school + 3-8 years of residency Regulatory agency: State Medical Board Nurses 118,707 -18 month training with 1200 hours of on the job training -Bachelor degree, 4 year program -Regulatory agency: Federal Nursing Board (COFEn) and Regional Nursing Board (COREn) 2,600,000 -Associate degree, 2 year program -Bachelor degree, 4 year program -Pass National Council Licensure Examination -Regulatory agency: State Board of Nursing (Bureau of Labor Statistics, 2010; Marziale, Hong, Morris, et al., 2010)

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Healthcare Professional Brazil United States Dentists 178,000 -4 years undergraduate+ 4 years graduate + 1year internship -Brazilian dental license -National Council of Dentistry -60% of children have 3 decayed teeth -80% >65 years old have no teeth 141,000 -Bachelors degree + 4 years of dental school -Pass the National Board for Dental Examination -Regulatory agency: Board of Dental Examiners Pharmacists 6,231 -4 years undergraduate + 1 year internship, can go on to graduate school 269,900 -PharmD, 2 years of pre-pharmacy education + 4 years of professional pharmacy + 1-3 years internship -Pass North American Pharmacist Licensure Exam (Bureau of Labor Statistics, 2010; Marziale, Hong, Morris, et al., 2010; (Pan American Health Organization, 2007) )



Gatekeepers, Referrals & Provider Role :

Gatekeepers, Referrals & Provider Role Private SUS Private insurance/Health Maintenance Organizations HMO’s finance and provide healthcare ~similar to HMO’s in United States Gatekeepers are PCP’s Referrals required Complex procedures not covered 25% of the population has some form of supplemental insurance, in addition to SUS Gatekeepers are FHS teams Health promotion and disease prevention Coordinate care Prioritize interventions Referrals needed if care is not possible through the FHS Provider management of illness varies depending on level of care needed (Hudson, 1997; World Health Organization, 2006)

Slide 17:

Access and Utilization Rates Brazil United States Hospitals 4,809 private (70% provided services to the SUS) 2588 public -13 million hospitalizations contracted by the SUS (Pan American Health Organization, 2007) 11,014 -123 million (American Hospital Association, 2006) Ambulatory Care 11,040 34,960 -15% of ambulatory care was contracted by the SUS (Pan American Health Organization, 2007) 5,174 (American Hospital Association, 2006) Pharmaceutical sales 1.8% of global market (World Health Organization, 2011) 52.9 of global market (World Health Organization, 2011) Pharmacies 45,000 Private 529 Popular Pharmacy SUS (World Health Organization, 2011) 56,000 (World Health Organization, 2011) Cesarean Sections 36% of births (Zoltan, 2009) 31% of births (Grady, 2010)

Slide 18:

Access and Utilization Rates Brazil Hearing Aids 36,000 paid for with private funding 84,000 paid for with public funding (Iorio & Costa, 2008; Kochkin, 2005) Immunizations 196 million doses (Pan American Health Organization, 2007) Durable Medical Equipment 1.7% of the world market (Pan American Health Organization, 2007) Diagnostic Centers 123,000 private 4,100 public (Pan American Health Organization, 2007) Psychiatric Care Facilities 343 private 86 public (Pan American Health Organization, 2007)



Slide 20:

National Health Expenditures Brazil United States Percent of GDP 9.05% 16.2% Percent of federal government budget 17% 26.2% Percent of state and local government budget State 12% Municipal 15% State and local 14.4% ( Jurberg & Humphreys, 2010; National Center for Health Statistics, 2011)

Public Sector:

Public Sector Funding of the SUS 59.7% Federal government 26.6% State government 22.7% Municipal government Sources of funding in the SUS Social Security (first 5 years) Tax on financial transactions General tax revenues Major Health Expenditures Family Health Services Pharmaceuticals Immunizations Sanitary system Water system ( Elias and Cohn, 2003; Pan American Health Organization, 2007)

Private Sector Expenditures:

Private Sector Expenditures 1/3 of private sector expenditures Companies providing health services and insurance to employees Philanthropic donations from within and abroad 2/3 of private sector expenditures Direct disbursements from individuals and families 37% medication, 29% private insurance, 17% dental, 17% other (Pan American Health Organization, 2007)

Slide 23:

(Joint Learning Network for Universal Health Coverage, 2011)

Quality Indicators:

Quality Indicators

Quality of Brazil’s Healthcare:

Quality of Brazil’s Healthcare SUS is underfunded limiting access to healthcare, especially for the poor Private plans are also underfunded and have raised their premiums decreasing access Hospitals are paid based on number of procedures, not patient outcomes Few hospitals actually measure outcomes SUS patient information is not organized or digitized for easy information flow ( Economist Intelligence Unit, 2010 )

Quality of Brazil’s Healthcare:

Quality of Brazil’s Healthcare There are two accreditation organizations: Brazilian Consortium for Accreditation of Health Care Systems and Services (CBA) for private hospitals Currently has accredited 4 hospitals Pass or fail approach, no levels of accreditation National Accreditation Organization (ONA) for public hospitals Currently has accredited 20 hospitals Three levels of accreditation available U.S. has The Joint Commission and Magnet Recognition ( Zeribi & Marquez, 2005) (The Joint Commission, 2011) (American Nurses Credentialing Center, 2011)

Quality Indicators:

Quality Indicators Infant mortality varies by region Life expectancy is improved but still low compared to the U.S. and the rest of Latin America Half of the doctors in Brazil work in the private sector so aren’t available to everyone Number of people living with AIDS is 1% which is low Vaccination rates are high Brazil U.S. Infant Mortality per 1,000 births 23 6 Number of Doctors per 1,000 1.3 3.3 Number of Hospital Beds per 1,000 2.2 3.0 Life Expectancy at Birth 73 79 (Economist Intelligence Unit, 2010) (UNICEF, 2011)

WHO-UNICEF Estimates of Immunization Coverage 2010:

WHO-UNICEF Estimates of Immunization Coverage 2010 Immunization Brazil U.S. 1 st dose DTP 99% 99% 3 rd dose DTP 98% 95% 3 rd dose HepB 96% 92% 3 rd dose Hib 99% 93% Measles 99% 92% 3 rd dose Polio 99% 93% (World Health Organization, 2011)

Patient Satisfaction:

Patient Satisfaction Few hospitals measure patient satisfaction When it is measured it is not often used to make changes Satisfaction surveys vary widely so comparison between facilities is impossible A national survey done in 2002 showed patients were generally adequately satisfied The main issue indicated in the survey was wait times for ambulatory services (La Forgia & Couttolenc , 2008)

Cost Control:

Cost Control

Issues Surrounding Cost:

Issues Surrounding Cost Lack of public funding Lack of private funding Lack of professional management ( Economist Intelligence Unit, 2010)

Cost Control Solutions:

Cost Control Solutions Public Private Partnerships (PPP’s) Sophisticated management tools Pay for Performance (P4P) ( Economist Intelligence Unit, 2010) (Pay for Performance in Brazil, 2010)

Summary :

Summary Strengths Public healthcare regardless of citizenship or ability to pay Private insurance and/or supplemental insurance options Family Health System High Vaccination Rates


Summary Limitations Limited access based on geographic location Complex management of varying degress of illness Lack of funding for both private and public insurance High cost of private and supplemental insurance Lack of medical professionals to service the public system Lack of accreditation sources for health care facilities and providers

Ethical Issues:

Ethical Issues Ditributive Justice “Benefits, risks, and costs of actions…be apportioned fairly and without discrimination on both societal and institutional levels” (Post et al, 2007, p.17) The system is meant to provide equal access to health care yet many still go underserved FHS are payed based on families numbers and not on performance, further debilitating equal access to care (Post et al., 2007)

Application in the U.S.:

Application in the U.S. Aspects of Brazils system with benefit in the US Public system for universal health care FHS teams Rationale and Evidence for application 45.3 million uninsured individuals in the U.S. 26.9% individuals with yearly income <$25,000 21.8% with yearly income $25,000-$49,999 15.4% with household income $50,000-$74,999 (U.S. Census Bureau, 2010)

Policy Recommendation:

Policy Recommendation Implementation of federally funded Family Health Strategy (FHS) teams in the United States Incidence of uninsured varies in geographic locations Most of the uninsured live in metropolitan areas Potential benefits: targeting areas with high rates of uninsured could improve access to health care Potential barriers: Health care workers might not be willing to participate. More money spent out of the federal budget (U.S. Census Bureau, 2010)


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References Iorio , M. C. & Costa, L. P. (2008). Universal hearing health care: Brazil. The Asha Leader. Retrieved from Joint Learning Network for Universal Health Coverage (2011). Brazil: Unified health system. Retrieved from Jurberg , C. & Humphreys, G. (2010). Brazils’ march towards universal coverage. Bulletin of the world Health Organization, 88 (9), 646-647. doi : 10.2471?BLT.10.020910 Kochkin , S. (2005). MarkeTrak VII: Hearing loss population top 31 million people. The Hearing Review, 12 (7): 16-29. La Forgia , G.M., & Couttolence , B. (2008). Hospital performance in Brazil: The search for excellence (volume 828). Washington, D.C.: world Bank Publications. Marziale , M. H., Hong, O. S., Morris, J. A., & Rocha. F. L. (2010). The roles and functions of occupational health nurses in Brazil and in the United States. Latino-Americana de Enfermagem , 18 (2), 36-38. doi : 10.1590/S0104-1169201 National Center for Health Statistics (2010). Health, United States, 2010: With Special Feature on Death and Dying. Hyattsville, MD. Nation Master (2011). Health expenditure and per capita income. Retrieved from Pan American Health Organization (2007). Technical cooperation strategy for PAHO/WHO and the federative republic of brazil, 2008-2012. WHO Statistics. Paschalis, Maria. . Education in Brazil. Retrieved from Post, L.F., Blustein , J., & Dubler , N.N. (2007). Handbook for health care ethics committess . Baltimore, MD: The Johns Hopkins University Press. The European education dictionary. (2011). Education in the United States. Retrieved from


References The Joint Commission. (20110). Retrieved from Trade Partners (2003). Overview of Brazil healthcare system. Retrieved from UNICEF. (2011). Retrieved from United nations development program. (2010). Human development index. Retrieved from U.S. Census Bureau (2010). Income, poverty, and health insurance coverage in the united states: 2010. Retrieved from http://www.census.gove/prod/2011pubs/p60-239.pdf . Wong, L. (2008). A comparative analysis of the public and private healthcare provisions in Brazil. Frost & Sullivan Research Firm. Retrieved from Src = RSS&docid =146757019 World Health Organization (2006). WHO Global InfoBase Online. Retrieved from World Health Organization . (2011). Retrieved from World Health Organization (2011). World drug situation. Retrieved from Zeribi , K.A. & Marquez, L. (2005). Approaches to healthcare quality regulation in Latin America and the Caribbean: regional experiences and challenges . LASCHSR report number 63. U.S. Agency for International Development by the Quality Assurance Project. Zoltan , M. (2009). C-Section rate in Brazil - 36 percent of births . Retrieved from http://