Navigating Healthcare in Brazil

As described in “Diabetes: A Platform for Chronic Disease,” using the patient care path is one of the most effective ways to understand how a patient moves from one state of health, and facility, to another. As Gabi and I discovered this week as well, it’s equally important to get a varied range of perspectives from healthcare theoricists (i.e. political / healthcare leadership), providers (primary, secondary , tertiary), and multiple patient groups to understand what really works and is needed in the system.

For a person with diabetes in Brazil it looks like your options, in general, would be pretty good.

One of the greatest challenges is that most patients are being detected for diabetes (both Type 1 and Type 2) when complications start to show or impact day-to-day life. The onset of complications implies that the diabetes has already progressed quite a bit, which results in an immediate treatment with pharmaceuticals, nutrition / exercise changes, and depending on the circumstance, hospitalization and daily doses of insulin. In addition, the current pre-diabetic population in Brazil is almost completely left out of the system lacking the educational or diagnostic infrastructure to help prevent the progression of the disease. This suggests that an increase in the capability and capacity for primary care to educate and diagnose patients with diabetic and pre-diabetic conditions is a HUGE opportunity.

Brazil’s progressive Programa Saúde Familia (PSF, or Family Health Program) is a unique “push” model that literally takes primary care to the homes of millions of Brazilians on a monthly basis. Teams of trained healthcare workers supported by a group of physicians and specialists, visit patients homes recording symptoms and conditions that may warrant a referral to a clinic or secondary healthcare facility. Chronic care (both hypertension and diabetes) has become a focus for this program.

Specialized Chronic Care Facilities or Centro de Olhos Hipertensão e Diabetes, have been set up around the country to help Brazil cope with the increasing prevalence of chronic disease in the communities. These include specialists like endocrinologists, cardiologists, nutritionists, psychologists, and ophthalmologists for treatment of the physical, emotional, and peripheral effects of the disease. A wider range of therapies is offered in these facilities, all of which are covered by the public healthcare system.

Which leads us to the second challenge with the system: capacity constraints in the specialized centers are increasing. We were told at the specialized centers that the wait to enter the facility was about 3-4 months; the PSF team on the other hand, indicated that they’ve had patients waiting up to year to have a visit scheduled. The goal is that these facilities would be 100% scalable because each patient once stabilized would be counter-referred to their primary physician. However, four barriers prevent this from occurring in reality:

1. Patients trust the specialists in the facility and don’t want to give them up, especially psychiatric services
2. Not all drugs (see right) provided in the facility are covered through primary care centers or pharmacies
3. Patient information is tracked paper via one health record per patient; when patients are counter-referred the primary care physicians do not have any history on the patient’s treatment
4. Finally, primary care physicians (as witnessed from our PSF interviews) do not necessarily have the skills or confidence to treat counter-referred patients from these facilities – which then reinforces point #1 with the patient…

This suggests that an increase in the capability and capacity for primary care to treat (in addition to educate and diagnose) patients with diabetic and pre-diabetic conditions is an URGENT need. The good news is that local and national health leadership in Brazil is already starting to do a lot to address these challenges (and in fact, this infrastructure is already proactively treating chronic diseases in a way that most countries are not). Teams of the chronic care experts are now starting to support the PSF groups and providing “real time” practical learning opportunities for them through weekly reviews of complex patient cases.

Claudio Duarte, Recife’s Secretary of Education and ex-National Ministry of Health lead on chronic disease, described other progressive programs such as “the city’s gym” which is hoping to focus on prevention through increase physical activity within the community.

In addition, training healthcare workers and patients are Project HOPE’s core capabilities! Discussions with the various stakeholders, physicians, patients, and leadership show that both a trainer-of-trainer (TOT) model for healthcare workers and peer-to-peer patient support groups for awareness, diagnosis, and compliance would greatly benefit Brazil’s patient population.

My last day in Brazil, a 12 year old girl asking for money on the street saw Gabi’s Guaraná Zero (Brazilian soda) and asked us “I have diabetes, can I have your Guaraná?” That blew me away. It’s clear that this is a real issue, and although we spent days seeking out diabetes in Brazil, in the end it, found us.

For a complete list of interviewees, notes, pictures, and videos please visit the Brazil Country Profile!