O Futuro das Condições de Saúde da População Brasileira. Mauricio L Barreto Instituto de Saúde Coletiva Universidade Federal da Bahia

Transcrição

1 O Futuro das Condições de Saúde da População Brasileira Mauricio L Barreto Instituto de Saúde Coletiva Universidade Federal da Bahia

2 Population composition by age and sex

3 Brazil Trends Urban-Rural population, Fonte: IBGE. Anuário estatístico do Brasil, 1986, 1990, 1993 e 1997; Censo demográfico, 2000; Síntese Fonte: IBGE. Anuário estatístico do Brasil, 1986, 1990, 1993 e 1997; Censo demográfico, 2000; Síntese de indicadores sociais, Fonte: IBGE. Anuário estatístico do Brasil, 1986, 1990, 1993 e 1997; Censo demográfico, 2000; Síntese

4 Water Supply

5 Sanitation

6 GINI Index Social Inequalities The Gini index is a measure of statistical dispersion and is used as a measure of inequality of wealth (eg. income) distribution. It varies from 0 to 1, where a value of 0 corresponds to perfect equality and a value of 1 corresponds to perfect inequality

7 Coeficiente de Gini Coeficiente de Gini Coeficiente de Gini Recent Trends in Gini Index in Brazil 0,60 0,58 Brazil 0,599 0,597 0,597 0,599 0,591 0,592 0,586 0, UK 0.5%/year 0.2 ponto/ano 27 anos 0,56 0,7 %/year 0,568 0,565 0,558 0, ys. 30 Ano %/ year USA 0, ys 0,54 0, Ano 0, Ano

8 Brazil: Social inequalities

9 Trends in deaths patterns according to causes, Brazil

10 Infant deaths per 1,000 (Iog scale) Time trend of infant mortality, Mean Anual Reduction Rates IMR (Log scale) % = 3,2% = 5,5% = 5,5% = 4,4% C M I Source: Demographic Censuses, , and MIX model (Ministry of Health)

11 Mortalidade infantil por Infant mortality rate per Region 1990, 2000 e North Northeast Southeast South Centre-West Norte North Northest Southeast South Center-West

12

13 Life Expectancy at Birth Years Infant Mortality Rates

14 Déficit de altura/idade (%) Height deficit in under 5 ys. children per Region, 1974/5-2006/ North Northeast Southeast Sul South Center-West N North Northeast Southeast South Sul Centre-West 1974/ /7

15 `Height Deficit (%) Height deficit in under 5 ys. according to family income, 1974/5-2006/7 100% 80% 1974/ /7 60% 40% 20% 0% Poorest 2 2nd 3 3rd 4 4th Richest

16 Caesareans High level of medicalization of pregnancy and delivers Caesarean sections 35% in SUS 80% private sector

17 LEPROSY DETECTION RATE BY MUNICIPALITY, BRAZIL BRAZIL

18 Leprosy prevalence and detection rate (total and for <15 years). Brazil

19 TB incidence rate. Brazil, Per 100 thousand inhab. Decrease = 26% (average 1,4% per year, %) 51,7 37,7 Source: MS / SVS / SINAN.

20 Tuberculosis Incidence Rates WHO 2011

21 Vulnerable Populations (RR comparing with general population) Afrodescendent population: 2 times* Indigenous population: 4 times* Prisoners: 25 times* PLHA: 30 times* Homeless: 67 times** * Source: Brazilian Surveillance System (SINAN) ** Source: Adorno 2010

22 OR tuberculosis Relationship between family income (in minimum wages per capita) and TB ocurrence. Brazil, ,00 1,00 MW MW <1/4 SM 1/4 a 1/2 SM 1/2 a 1 SM 1 a 2 SM 2 a 3 SM MW MW MW 0,76 0,74 0,76 0,59 0,10 Family income (per capita) Source: PNAD, Minimum Wage = R$415 (US$ 225)

23 Relation between GNI per capita, PPP (current international $) and estimated TB incidence rate per 100,000 population (left), and expected reduction in TB incidence by increase in GNI per capita (right), 2009 *USA - United States of America; CAN - Canada; TTO - Trinidad and Tobago; ATG - Antigua and Barbuda; MEX Mexico; ARG - Argentina; KNA - Saint Kitts and Nevis; CHL - Chile; URY - Uruguay; VEN - Venezuela; PAN - Panama; CRI - Costa Rica; BRA - Brazil; LCA - Saint Lucia; VCT - Saint Vincent and the Grenadines; COL - Colombia; DMA - Dominica; PER - Peru; DOM - Dominican Republic; ECU - Ecuador; GRD - Grenada; JAM - Jamaica; SLV - El Salvador; GTM - Guatemala; PRY - Paraguay; BOL - Bolivia; HND - Honduras; NIC - Nicaragua Source: OPAS / Tuberculosis in the Region of the Americas, 2009.

24 Area of Malaria transmission, Amazon Region, Brazil, 2008

25 Trends in AIDS incidence rates (per inhabitants) by region and by year, Brazil,

26 Municipalities with at least one autochthonous case of AIDS. Brazil,

27 Number of municipalities Annual distribution of Dengue incidence rates per 100,000 inhabitants and number of Aedes aegypti infested municipalities Brazil, Incid /100, Nu Municipalities inc Rate/100,000 0,0 34,50 64,60 1,10 3,80 27,30 71,10 2,50 4,90 36,80 87,70 117,00 60,90 345,70 127,70 144,40 221,90 399,70 158,90 40,50 81,90 143,20 251,00 308,90 171,80 Source: Ministry of Health, Brazil 0

28 Casos notificados Number of reported dengue fever cases and number of hospitalized dengue cases, Brazil Hospitalizações Casos notificados Hospitalizações ,3 million cases 95,000 Hospit. 308 Deaths Epidemic DENV1 Epidemic DENV3 Epidemic DENV

29 Municipalities by the level of Visceral Leishmaniasis transmission

30 2-Cenário no Brasil Schmidt MI, et al Lancet, 2011

31 Mortality Chronic non-comunicable diseases Legenda (Óbitos/100000) Schmidt MI, et al, Lancet, 2011

32 Non-Comunicable Diseases death rates 2008 Males WHO, 2010 Females WHO 2011

33 Prevalence of overweight, ages Males WHO, 2010 Females WHO 2011

34 Diabetes Mortality Rates Legenda (Óbitos/100000) Schmidt MI, et al Lancet, 2011

35

36 Obesity and overweight How long will take to be at the same level as USA today? % MEN % ,2 52, % ,4 14, VIGITEL ( BRFSS para EUA NUPENS/USP

37 Obesity in the World

38 Proportional Mortality by External Causes, Brazil 2007, 2007

39 Homicides - Mortality Rates per hab. by sex. Brazil China - 1,2 Argentina - 5,2 África do Sul - 36,5 Colômbia - 38,8

40 Homicide mortality Rate

41 Mortality Rates by Injuries Related to Trafic Mortalidade relacionada ao trânsito (por habitantes) por tipo de vítima,

42 Example 4 Family Health Program (FHP) FHP teams physician (1) nurse (1) nursing staff (2) community health workers (CHW) (6), oral health professionals (1) NASF multi-professional support teams NASF 1: at least five specialists linked to the minimum of 8 to 20 Family Health Teams. NASF 2: at least three specialists linked to the minimum of 3 Family Health Teams.

43 Family Health Program

44 Impact of FHP on childhood mortality Ecological (panel data) design Municipality unity of analysis Mortality rates/year by direct calculation from health databases PSF coverage/year Analysis multivariate negative binomial regression models for panel data with fixed effect modification

45 Am J Public Health. 2009;99(1):87-93 Fixed-Effects Models for the Bivariate Association Between Infant Mortality Rate and Family Health Program Coverage: Brazil,

46 Random-Effects Models for the Association Between Infant Mortality Rate and Family Health Program Coverage, by Baseline Infant Mortality Rate and Human Development Index, Brazil,

47 Models for the Bivariate Association Between Family Health Program (FHP) Level of Implementation and Primary Care Indicators: Brazil,

48 Rasella D, Aquino R, Barreto ML Pediatrics. 2010;126:e Fixed-Effect Negative Binomial Models for Association Between Causes of Mortality of Children Younger Than 5 Years and FHP Coverage: Brazil,

49 Synergistic effect of family health program (FHP) and the conditional cash transfer program (BFP) on childhood mortality in Brazil Rasella D, Aquino R, Barreto ML

50 Introdução Interação entre PBF e PSF O PSF e o PBF são programas federais com ampla cobertura nacional Evolução temporal da cobertura populacional do PBF e PSF no Brasil Fonte: MS, 2011 MDS, Um dos objetivos do PBF é promover intersetorialidade, e sinergia das ações sociais entre educação, saúde, assistência social e segurança alimentar e nutricional (Brasil, 2004). - A Estratégia de Saúde da Família é o modelo principal de organização da atenção básica pelos beneficiários do Programa Bolsa Família, sendo fundamental no acompanhamento das condicionalidades em saúde (MS, 2008). 50

51 Métodos Variáveis dependentes: Taxa de mortalidade em menores de cinco anos obtidas pelo cálculo direto. Categorias da Classificação Internacional de Doenças, 10 ª Revisão (WHO, 2010): doenças diarréicas (A00, A01, A03, A04, A06-A09), desnutrição (E40-E46), infecções respiratórias das vias aéreas inferiores (LRI: J10-J18, J20-J22) causas externas (V01-Y98). Variáveis independentes. Determinantes da mortalidade na infância disponíveis: renda per capita percentagem da PTP sobre a população total do município percentual de indivíduos sem alfabetização entre a população acima de 15 anos percentual de indivíduos que vivem em domicílios com saneamento inadequado taxa de fecundidade total taxa de internação cobertura anual do Programa Saúde da Família Variável independente principal. Indicadores de cobertura anual de PBF: 1) Cobertura da população alvo (PTP): baixa (<% 70,0), intermediário(de 70,0% a 99,9%), elevada ( % 100,0). 2) Cobertura da população total do município,tercis da distribuição: baixa (de 0,0% para 17,1%), intermediária(de 17,2% para 32,0%) e alta (>32,0%). 3) Composição das duas coberturas anteriores : baixa (de 0,0% para 17,1% da população total do município) intermediária (de 17,2% para 32,0%) alta (superior a 32,0%) consolidada (cobertura da população total do município superior a 32,0% e cobertura PTP 100% para os 4 anos precedentes ou mais). 51

52 Métodos Análises estatística: - Regressão binomial negativa para dados em painel com efeitos fixos (Hilbe JM. 2007). - Modelos longitudinais incluem termo para controlar características não observadas invariantes no tempo (geográficas, históricas, ou sociocultural) - Escolha de modelos à efeitos fixos baseada no teste de especificação de Hausman (Woodridge, 2005). U5MR it = β 0 + β 1 PBF it + β n X it + V i + ξ it U5MR it : Taxa de mortalidade em menores de 5 anos no município i no ano t PBF it : nível de cobertura do Programa Bolsa Família no município i no ano t β n X it : conjunto das covariáveis no município i no ano t V i : componente do erro invariante no tempo ξ it : componente do erro no município i no ano t 52

53 Resultados TABLE 1. Means of Mortality Rates and Variables of Selected Municipalities (N= 2853): Brazil, Variable Mortality rates (per 1000 live births) U5MR U5MR for Diarrheal Diseases U5MR for Malnutrition U5MR for Lower Respiratory Infections U5MR for External Causes BFP target population coverage BFP county population coverage FHP county population coverage Per capita income (monthly, in BR) Percentage of BFP target population Percentage of individuals living in households with inadequate sanitation Percentage of illiterates among individuals >15 y Total fertility rate (No. of children per childbearing-aged woman) Hospitalization rate (per 100 inhabitants)

54 Fixed-Effect Negative Binomial Models for Association Between Under-five Mortality Rates (U5MR) for different causes and FHP and CCT Coverage: Brazil, Adjusted by: Per capita income, Percentage of BFP target population, Percentage of individuals living in households with inadequate sanitation, Percentage of illiterates among individuals over 15 years old, Fertility rate, Hospitalization rate (per 100 inhabitants Adjusted by: Per capita income, Percentage of BFP target population, Percentage of individuals living in households with inadequate sanitation, Percentage of illiterates among individuals over 15 years old, Fertility rate, Hospitalization rate

55 Fixed-Effect Negative Binomial Models for Association Between Under-five Mortality Rates (U5MR) for different causes and FHP and BFP Coverage: Brazil, Adjusted by: Per capita income, Percentage of BFP target population, Percentage of individuals living in households with inadequate sanitation, Percentage of illiterates among individuals over 15 years old, Fertility rate, Hospitalization rate (per 100 inhabitants Adjusted by: Per capita income, Percentage of BFP target population, Percentage of individuals living in households with inadequate sanitation, Percentage of illiterates among individuals over 15 years old, Fertility rate, Hospitalization rate

56 Fixed-Effect Negative Binomial Models for Association Between Under-five Mortality Rates (U5MR) for different causes and FHP and CCT Coverage: Brazil, Adjusted by: Per capita income, Percentage of BFP target population, Percentage of individuals living in households with inadequate sanitation, Percentage of illiterates among individuals over 15 years old, Fertility rate, Hospitalization rate (per 100 inhabitants Adjusted by: Per capita income, Percentage of BFP target population, Percentage of individuals living in households with inadequate sanitation, Percentage of illiterates among individuals over 15 years old, Fertility rate, Hospitalization rate

57 Fixed-Effect Negative Binomial Models for Association Between Under-five Mortality Rates (U5MR) for different causes and FHP and CCT Coverage: Brazil, Adjusted by: Per capita income, Percentage of BFP target population, Percentage of individuals living in households with inadequate sanitation, Percentage of illiterates among individuals over 15 years old, Fertility rate, Hospitalization rate (per 100 inhabitants Adjusted by: Per capita income, Percentage of BFP target population, Percentage of individuals living in households with inadequate sanitation, Percentage of illiterates among individuals over 15 years old, Fertility rate, Hospitalization rate

58 Fixed-Effect Negative Binomial Models for Association Between Under-five Mortality Rates (U5MR) for different causes and FHP and CCT Coverage: Brazil, Adjusted by: Per capita income, Percentage of BFP target population, Percentage of individuals living in households with inadequate sanitation, Percentage of illiterates among individuals over 15 years old, Fertility rate, Hospitalization rate (per 100 inhabitants Adjusted by: Per capita income, Percentage of BFP target population, Percentage of individuals living in households with inadequate sanitation, Percentage of illiterates among individuals over 15 years old, Fertility rate, Hospitalization rate

59 Resultados Proporção de óbitos nos municípios provenientes de populações vulneráveis. D p : óbitos provenientes da população pobre D tot : óbitos totais do município RR : Razão entre a mortalidade na população pobre (MR p ) e a mortalidade na população não pobre (MR r ) K p : Proporção de óbitos totais provenientes da população pobre D p = K p D tot K p = RR PP p / ( PP p (RR-1) + 1 ) 59

60 Comentários Finais As condiçoes de saúde da população brasileira apresenta avanços importantes, mas ainda também mantém alguns velhos problemas não resolvidos e está criando alguns novos; As mudanças positivas estao relacionadas a políticas e acoes publicas, muitas fora da area da saúde

61 Comentários Finais O desenvolvimento e uso de tecnologias de saúde (p.ex vacinas, alguns medicamentos) e politicas de saúde (p.ex programa nacional de imunizaçoes, Progragrama de Saúde da Familia, Farmacia popular etc) reorganizando o sistema e ampliando o seu acesso pode dar importantes contribuicoes no avanço das condiçoes de saúde O futuro da condicoes de saúde da população brasileira envolve o continuado esforço para desenvolver e tornar acessivel novas tecnologias de saúde, principalmente focada em problemas relevantes, mas tambem de acoes que reduzam as desigualdades sociais, que modifiquem as questoes ambientais, em especial urbanas, e por acoes regulatorias sobre certos setores industrias cuja produtos sfetam diretamente as condicoes de saude (destaco

62