7th Global Conference on Health Promotion7th Global Conference on Health Promotion

Diabetes in DevelopmentDiabetes in Development

STRENGTHENING HEALTH SYSTEMSSTRENGTHENING HEALTH SYSTEMSBrazil focusing on health systems strengthening and integrated approaches to addressing NCDs using diabetes/hypertension as

an entry point

Rosa SampaioNational Coordinator of Hypertension and DiabetesNational Coordinator of Hypertension and Diabetes

Ministry of Health BrazilBrazil

Area: 8.514.876,599 km² States:26 and a FDStates:26 and a FD

Municipalities: 5.564População: 191.480.630 inhabitants (IBGE 2009)p ç ( )

83% of the population lives in urban areasHuman development Index 2007(HDI): 0,800

BrasiliaRio de Janeiro

BRAZIL“HEALTH – Right for all and Duty of State

Federal Constitution- 1988Federal Constitution- 1988Article 196

Universality -Equity -Integrality –Participation and Social Control

Population using public health system : 143.610.04775% (99,1% a 66%)

Population using health insurance plans(complementary health system): 47.870.583 (21,1%)

Chalenges:Continental scale with social and regional inequalitiesTotal of 5 564 municipalities: 71% up to 20.000 inhabitantsinhabitants

Epedemiological transition

Population ageing Risk Factors %

1º Overweight(Obesity)

43,3 (H:47,3M:39,5)13,0 (H:12 0 M:13 6)(Obesity) (H:12,0 M:13,6)

Meat fat33,8

2º Meat-fat consumption (H:44,0 M:25,1)

26 3

2000 3º Sedentarism26,3 (H:29,5 M:23,5)

4º Abusive alcohol consumption

19,0 (H:29,0 M:10,5)

5º Smokers15,2 (H:19,1 M:11,9)

2050

Some importants politics to promote

1 Community health agents (1991):

health1-Community health agents (1991):

person from the comunities where they workpart of the family health team; in some places alone with a nursep y peducation health promotion diseases prevention

2 Familiy Health Strategy for primary care (1995):2-Familiy Health Strategy for primary care (1995):Reorganization of primary care with multidisciplinary teams Health promotion, disease prevention and basic cliniacal carep p

3-Cash Transfer Programs (2004):The “Bolsa Familia” program is a social program of direct incomeThe “Bolsa Familia” program is a social program of direct income

transference under certain conditions, which benefits families in poverty. 5.564 municipalities; US$ 8,4 bi; 11,1 million families; 45 million p y ppeople

Health PromotionFocus:

Heath diet and Physical activityHeath diet and Physical activityTobacco prevention and controlDecrease the morbidity and mortality associated with alcohol

ab se and illicit dr g seabuse and illicit drug useDecrease the morbidity and mortality associated with motor

vehicle accidentsPrevent violence and promote non violent behaviorPromote sustainable development

(Actions are implemented especially in primary care level)

Priorities: programs/actions :Priorities: programs/actions :Social Determinants of Health School’s Health ProgramE ti l t Ph i l A ti iti ( t kEstimulate Physical Activities (network

iniciatives)

Brazil Social Determinants document:http://www.determinantes.fiocruz.br/

Primary Health Care

Family Care: principal t testrategy

2009 Family Care Teams :

30.037 teams with 01 physician, 01 nurse, 01 or 02 nurse tecnicians and 06 or 08 comunity health agents

227.700 comunity health agents 96.3 milions inhabitants – 50,3% of

population5.220 municipalities-92,4%

Surveillance system for NCCDSurveillance system for NCCDVIGITEL 2006-2007-2008

Monitoring System of Risk Factors and Protection for Chronic Non-Monitoring System of Risk Factors and Protection for Chronic NonCommunicable through telephone interviews in adult population (=>

18 years)

Brazil 2008: Diabetes Mellitus prevalence(auto refer disease) : 5 2%(auto-refer disease) : 5,2%7.767.078 people with DM

115 patients with Diabetes 509 with Hypertension for each family care team509 with Hypertension for each family care team

3.000.000

VIGITEL:Diabetes Melitus

2.000.000

2.500.000

Diabetes Melitus(auto-refer)

for age and gender: 1.000.000

1.500.000

for age and gender:Brazil, Vigitel 2008

0

500.000

18 24 25 34 35 44 45 54 55 64 65 e +

25

geral 122.905 260.404 879.372 1.764.198 2.062.646 2.677.553 masculino 86.612 96.641 450.652 763.835 970.886 1.060.808 feminino 36.624 164.437 427.065 1.007.686 1.091.760 1.589.753

18-24 25-34 35-44 45-54 55-64 65 e +

15

20

Total:2% d l

10

15 5,2% adult pop7.767.079 patients

0

5

18 24 25 34 35 44 45 54 55 64 65

geral 0,5 0,8 3,4 8,5 15,4 20,7masculino 0,7 0,6 3,6 7,7 15,4 18,8feminino 0,3 1,0 2,3 9,3 15,4 21,8

18-24 25-34 35-44 45-54 55-64 65 e +

Diabetes Melitus prevalence (auto-refer)f ifor regions

NORTH REGION NORTHEAST REGIONNORTH REGION3,8% - 333.171

NORTHEAST REGION5,3%-1.633.991

CENTRAL WEST REGION

SOUTHEAST REGION

CENTRAL WEST REGION4,0%-367.051

5,7% -3.035.117SOUTH REGION5 5% 1 029 7005,5%-1.029.700

Prevention and Care of Hypertension and Di b tDiabetes

Prevention

SurveillanceEducation (profissionals ,patients and families)

Care

05 Integrated areasResearch

Care

Actions of care are in primary units especially in family care teamsDM type 1 in especialized centersDM type 1 in especialized centers

PAHO Proposal for the Prevention and Management of Diabetes and Obesity in theManagement of Diabetes and Obesity in the

Americas

Population-based and individual approaches to the prevention and management of di b t d b it ith 05 t t idiabetes and obesity with 05 strategic areas :

Primary Prevention of Obesity and DiabetesScreening for Diabetes and Prediabetes Including Identification of Overweight or Ob iObesityImproving Management of Obesity and DiabetesDiabetesSecondary Prevention of ComplicationsSurveillance and MonitoringSurveillance and Monitoring

Chronic Care ModelChronic Care ModelMacColl Institute for Healthcare Innovation (USA)

COMMUNITY Health Care Organizations

HEALTH SYSTEM

ClinicalInformation

Self-Management Resources &

Policies

COMMUNITY Health Care Organizations

Delivery System Design

DecisionSupport

SystemSupportPolicies

ProductiveInteractionsProductiveInteractions

Prepared,Proactive

Informed,Empowered InteractionsInteractions Proactive

Practice Team

I d O t

EmpoweredPatient

Improved Outcomeswww.improvingchroniccare.org

HIPERDIA-Backgroud:R i ti f th C fRe-organization of the Care of

Hypertension and Diabetes (MoH, 2001)

• National health system-SUS (1988)i 2001 i d it i f di b t d- in 2001, reorganized its primary care for diabetes and hypertension

First structured approach to prevention and care diabetes andFirst structured approach to prevention and care diabetes and hypertension in primary attention

• A centerpiece of this reorganization was a national screening campaign at primary care centers to enhance awareness stakeholders and

i i d bili i l f h h l hcommunities and mobilize various elements of the health system

Brazilians aged 40 or older-22,069,905 fingersticksBrazilians aged 40 or older 22,069,905 fingersticks Those positive were instructed to follow-up at their primary care clinic

It was estimated 320 000 new cases of diabetes initiated treatmentIt was estimated 320,000 new cases of diabetes initiated treatment

Diabetes Comittments

United Nations General Assembly Resolution 61/225 - World Diabetes Day

"Encourages Member States to develop national policies for theEncourages Member States to develop national policies for the prevention, treatment and care of diabetes in line with the sustainable development of their health care systems, taking into account the internationally agreed development goals including the Millennium Development Goals; "agreed development goals, including the Millennium Development Goals;…

Brazil:Law nº 11.347 -set 2006

Assures free distribuition of medication , materials for application and for glicemic monitoring to people with diabetes enrolled in d ti leducational programs

HIPERDIAPrevention and integrated care to

Hypertension and Diabetes

Guidelines Continuing education and training for health profissionalspPharmaceutical assistance Clinical Information SystemClinical Information SystemHealth education for self-care for patients and families Advocacy , information to community and paternshipsContinuous monitoring and evaluation Management of network attention

Guidelines for primary care (phisicians and nurses)(p )

www.saude.gov.br/dab

Public Pharmaceutic AssistanceIn Primary Care Units: ESSENCIAL MEDICINE LIST for Hypertension and

Diabetes and CV prevention (RENAME 2008)

Diabetes:Glib l id 5 Gli id

Hypertension and CVD :Alf tild 250 f• Glibenclamida 5mg ; Glicazida

(80) 30mg • Metformina 500 e 850mg

• Alfametildopa 250mg –for pregnhancy

• Anlodipino 5 mg e 10 mg• Metformina 500 e 850mg • Insulin R e Insulin NPH 100UI

Insulin analogs in some states

od p o 5 g e 0 g• Captopril 25 mg; Enalapril 5, 10 e

20 mggin especial cases (by protocol)

• inputs for diabetes: capillary glucose strips syringes with

• Propranolol (cloridrato) 40 mg ; Atenolol 50 mge 100 mg; Metoprolol 50 e 100 mgglucose strips, syringes with

attached needle for application of insulin

p g• Hidroclorotiazida 12,5 e 25mg• Losartan 50 mg • Digoxina 0,25 mg HD• Sinvastatina 40 mg

Insulin distribution in public h lth i t SUShealth sistem-SUS

(MoH buys annually and distributes to all states each 3 months elther R and NPH i li t t / i i liti b i t i d i )

Evolução nº de frascos 10 ml de insulina, Brasil, 2003-2008

NPH insulins; states/municipalities buy insums-strips and seringes)

ç , ,

9.768.900

10.882.748

l ins

ulin

a

10.300.000

7.661.048

scos

10

ml

5 467 160

7.039.800

Nº d

e fra

sc

5.467.160N

0 2.000.000 4.000.000 6.000.000 8.000.000 10.000.000 12.000.000

2003 2004 2005 2006 2007 2008

People's Pharmacy ProgramThe Federal Government created in 2004 the People's

Pharmacy Program in Brazil to expand access to medicines for most

People s Pharmacy Program

Pharmacy Program in Brazil to expand access to medicines for most common diseases among the citizens.

The program has its own network of pharmacies(2008: 521 pharmacies own units in 405 municipalities -107 items -950 thousand ppeople/month)

Here is the People's Pharmacy :p ypartnership with the private network pharmacies to

offer three types of medicine: diabetes, hypertension and birth control - in this case the drugs are provided by privatebirth control in this case the drugs are provided by private laboratories.

Built in 2006, co-payment model, offers subsidized medicines up to 90% by the Federal Government and themedicines up to 90% by the Federal Government, and the citizens pay only 10% of the reference value.( 2008: 7.292 accredited pharmacies-1.6 million calls a

th U$ 175 illi )month-U$ 175 million)

Attention Network( levels of attention)( levels of attention)

SIS-HiperdiaSystem for registration and monitoring ofSystem for registration and monitoring of patients with hypertension and diabetes in

Primary CarePrimary Care

Number of registered patients with Diabetes and Hypertension In Primary

DM: 2.069.675 HA 5 887 085

g p yp yCare (Jan2001 till Oct2009):

HA: 5.887.085

SIS-Hyperdia is not mandatoryyOnly in Primary Public Health Units: almost 40% of patients were registeredwere registered

Continuing education and gtraining for health profissionalshttp://www.telessaudebrasil.org.br/http://www.telessaudebrasil.org.br/

•National and local tutorsE L i•E-Learning

•Educational materials : printed, CDs and id d i t t ( it )videos and internet (site)

•Educational second opinion •Conference clinic discussion on line•Conference clinic discussion on line •Local workshops with tutors •Virtual library•Virtual library• Virtual comunities to share experiences

Diabetes Education Via Internet and with materials and

workshoppings for the family teamsTeaching and training local health profissionals in primary care to informe, estimulate and empower people with diabetes and comunities to create autonomy to self care in diabetes and health in generalto self-care in diabetes and health in general

A network with national and localA network with national and local tutors -1000 local tutors

E-learning M i l i dMaterials to patients and

community-folders, videos(DVD) , site and by internetsite and by internet

www.telessaude.org.brwww.sead.sc.br

Paternshipsp

• The brasilien public health system called Unified Health• The brasilien public health system called Unified Health System-SUS, is a sharing network with states and municipalitiesmunicipalities

OthOthers:• Scientific societs• Research Institutes• Universities• Patients associations• Internationals entities : OPAS OMS World Diabetes• Internationals entities : OPAS,OMS, World Diabetes

Foundation•• …………

Some examples of partnerships:Some examples of partnerships:

PROCED: Capacity Building and Community Diabetes Awareness Project for Brazilian States and Portuguese Speaking Countries

Diabetes treatment expertise dissemination in Brazilian towns and villages - a replicating model for multi-professionals (2007 – 2010)

Nationwide net for prevention of chronic diseases in childhood

PROCED: Capacity Building and Community Diabetes Awareness Project for Brazilian States and Portuguese j g

Speaking Countries

CEDEBA (Diabetes and Endocrinology Referral Center of the State of Bahia, Brazil) a publicReferral Center of the State of Bahia, Brazil) , a public health supported center, has been training primary care professionals using Staged Diabetes Management (SDM–IDC USA) customized protocolsIDC–USA) customized protocols

50 health professionals(13 physicians ,27 nurses,5 social workers,5 dietitians) from , 7 States of B il d 2 Af i t i t i d t CEDEBABrazil and 2 African countries, were trained at CEDEBA and participated in the diabetes education community event

+Ministry of Health and WDF

Diabetes treatment expertise dissemination in Diabetes treatment expertise dissemination in ppBrazilian towns and villages Brazilian towns and villages -- a replicating a replicating

model for multimodel for multi--professionalsprofessionals20072007 201020102007 2007 -- 20102010

Nationwide net for prevention of chronic diseases in childhooddiseases in childhood

Crist, the Redeemer-Rio Unite for Diabetes

Diabetes World Day-2008Brazil in blueBrazil in blue

Maracanã Stadium-RioMaracanã Stadium-RioLacerda elevator-Salvador

Rosa Sampaio Vila-NovaNational Diabetes and Hypertension Coordinatoryp

Ministry of HealthBrazil

rosa.sampaio@saude.gov.br@cnhd@saude.gov.br

www .saude.gov.br/hipertensão-diabetes

Telefones: (55) 61 - 9227-3177