[music] Here we are now in the final week on health for all through primary health care. And I wanted to give you a sense of what can be achieved at scale through the development of primary health care services. And I am calling this part of the lecture On the Road in Brazil to Achieving Health for All Through Primary Health Care. And what I want to do here is to first give an overview of Brazil's primary health care system, and how it's evolved over the last 40 or 50 years. And then share with you some of the remarkable achievements in coverage of services and reduction of inequalities that have been achieved in Brazil. And then, finally Share with you some of the very impressed results that Brazil shows now is a result of these investments. Brazil back in the 1940's and 50's was a very poor country on the par of countries in Africa. And during that time it created a special service for public health that was focused on improving the public health in rural isolated areas giving priority to immunizations, maternal and child health, and improving water and sanitation. And there was a very sparse Distribution of health centers that were created as part of this. But interestingly enough, early on, I don't know exactly how this all came about. It would be nice to know. But there was a program of home visitation by community health workers at that time. Called Visitadoras Sanitarias, and even though this program, Servicio Especial de Saude Publica, even though it had minimal resources it was a program that was well administered and the staff who worked in it were well paid, it had a goog management structure. And this carried down as well to the community health workers who themselves were well paid and well supervised and as we've heard previously in this course unfortunately that is not often the case in many developing countries that have tried to implement community health workers at scale. But in the late 1980's Brazil made a major transition. From what it been a dictatorship type of government into a democratic society with a new constitution and this lead to the creation of the Sistema Unica de Saude, the Unified System of Health which expresses the new enthusiasm within the country for democracy and health for all. Health as a right of all citizens. And so this health system was developed and implemented, and included in it were very fundamental concepts of strong community participation and shared financing among different levels of government. Not only the federal or national government, but the state governments and the local municipalities. And ingrained in the Constitution was the idea that states and municipalities with new taxation authority would be spending at least 10% of their revenue for health. And that has now expanded as you see here on the slide to 12% for states and 15% for municipalities. So they were required to spend >> Significant amount of money for health and unfortunately, in many very poor countries this just doesn't exist. And at the same time in 1991 as part of this transition to a unified health system for the country the. Community health worker who had then a part of the[UNKNOWN] systems for many decades the Visitadora Communitaria. Her name was changed and was called Agentes de Saude or community health agent and during this time immediately after the transition to democracy this program expanded and reached in a short period of time a 40% of the population. Mostly in rural areas and among the very poor of the society. And this program underwent another evolution in the early 1990's to the Programa Saude de Familia, the Family Health Program. And at this time the health care services expanded further to cover the great majority of the population and the community health work. [inaudible] had an increasingly strong role in the, as you see here in the year 2002 they became officially recognized as professionals and the whole health center concept continued to expand and the municipalities gradually took on an ever stronger role both for financing the management of this primary health care system. System and there was a strong engagement of civic society in the development of these health services through what are called Municipal Health Councils. And all of these services were provided free on the basis of revenues generated through taxes in Brazil. And so By 2006, the Brazilian government expenses for health for all kinds of health for all levels, were $252 per capita which for a very poor company that's a lot of money of course Brazil is the middle income country, but, in terms of what developed countries spend for health today which is more ten $7,000 per capita. This is still a very small amount of money. And one of the fundamental elements of this natural health system is the concept of the family health team. Brazil has a 33000 of these family health teams and a team is generally composed of 1 doctor, 1 nurse, 1 auxillary nurse. And four to six community health agents for every 1,000 families. And each of these health teams is based at a health center and the staff work in the health center, but they're also in and out of the community. And the community health workers are spening virtually all of their time making home visits. And they visit on the average about 150 families per month. And these teams provide a wide range of services from promotive to preventive to curative and then rehabilitative services just as the declaration of Alma Ata called for back in 1978. And so at the present time, this program and these family health teams are reaching 120 million people. [unknown] about 2 3rds of Brazils population of almost 200 million people. And the cost for the family healthcare component of this program is about $42 to $50 per person per year which Is roughly about a fifth of what the government health care expenditures are for so. Even though it's a substantial amount of money, it's still a very modest amount compared to what some of the other countries have. And at the present time in Brazil there are 236000 of these community health workers. This makes Brazil community health worker program the second largest one in the world second only to India And it continues as it did in the very early days to have a strong supervision by nurses back up referal to facilities when they are needed. And these people are relatively well paid $200 a month, which is still an attractive salary. And Brazil for this type of work. So what has this primary health care system achieved? Well, here are a few figures that have come from a report that was published in 2012. Called Countdown to 2015: Maternal, Newborn and Child Survival. And these are data for Brazil and it shows that 93% of the demand for family planning is been satisfied. That means that. Of all the women who do not want to have a child in the next two years, 93% of these women are using a modern form of family planning. 91% of women who have given birth recently have had four more antenatal visits during their pregnancy. 97% of. The women who have given birth recently in Brazil had their delivery attended by someone with proper medical training. About 40% of women are exclusively breastfeeding during the first six months of life. So that's a challenge, but compared to virtually all other low and middle income countries, this is a very good level. Although, of course, it could be better. And then 99% of children have been immunized against Measles. And you see here in the next slide that it's not only Measles immunization, but other immunizations that have achieved virtually universal coverage within the entire national population. It's an extraordinary achievement for a low and middle income country. And in the following slide we see that the number of women who are HIV positive, who receive antiretroviral medication to prevent transmission of that infection tot their offspring is virtually a 100% which again is extra ordinary achievement for a . Country that's not well developed. So, as a result of all of these activities, and of course there's been economic development and improvement in education, so there are other reasons to explain this, but you can see that over the past two decades there's been a dramatic decline in under five mortality. And it has made it possible for Brazil to achieve it's millennium development goal target of 20, more than five years ahead of schedule. And they're very few countries in the world that have made that kind of a progress. The next slide gives a little broader view of that dramatic decline of under five mortality going back to 1960. And we express this under five mortality as a number of deaths per 1,000 live births. So you see back in 1960 Under five mortality was 180. So that meant that roughly 18% of all children who were born died before they reached the age of five. And you can see over the 50 year period the very dramatic change and the improvement and mortality rates that have occurred in Brazil. And, it's interesting to compare Brazil's progress with some countries in Africa that had essentially the same, under five mortality, rate that Brazil had at that time in 1960. And here you can see I have compared Brazil to Congo, Kenya, and Lesotho. And there's a dramatic difference in the greater decline that has been achieved in Brazil compared to these other countries. And of course we recognize that Brazil has made stronger economic progress, than have these African countries. But still given the nature of their primary health care system I think it's hard to argue that, that didn't make an important contribution. In fact Brazil has had the Fourth most rapid decline in under five mortality of all the countries of the world for that period of time between 1990 and 2006. Thailand and Vietnam and Peru lead the pack on this and in Brazil the average annual decline was 6.5%. But what's also very impressive about the Brazilian situation is how inequities in health have been reduced as well and here I have two examples that demonstrate that. This slide that you see shows how the prevalence of stunting among children under five has changed between the period 1989 and 2007. You see the red line at the top which is 1989 and at that time, the poorest 20% of the population had a prevalence of stunting which was almost 40 percent, while the richest 20% had a prevalence of stunting which was only about 5%. So there was a dramatic difference in the problems of stunting depending on the socioeconomic status of the child. But you see in 1996 that difference in stunning by the socioeconomics status of the child began to decline, but by 2007 it's virtually gone. So the A level of malnutrition among the poorest quintile of the population is almost the same as it is among the richest quintile. It's, they're very, very few countries that have anything close to that. And then the improvement in[INAUDIBLE][UNKNOWN] in health services is shown in this slide which compares the percentage of the population who when giving birth, had that birth attended to by someone who had been trained. And you see in 1996 there was a fairly dramatic difference depending on the income quintile of population so the poorest quintile Had a much lower coverage of skilled attendance at birth compared to the richest quintile but by 2007 that socioeconomic difference had pretty much disappeared. So I think this is an exciting example that shows that investing in a strong primary health care program similar to the one envisioned in Alma Ata can really be important part of improving the health of a population at scale. This is a primary health care system that has integrated services is called for at Alma Ata. The services are readily accessible and there's a strong home visitation component that delivers services down to the household when possible. It's integrated by a promotion of health education, prevention, methods such as immunizations, curative care, and assisting those who have been disabled to become as functional as possible. And built into the primary health care system is a very strong element of community participation at the local municipal level. So, I think it is safe to say that the strong primary health care program in Brazil is an important factor that has made these results possible. And we are now entering a time in which we're beginning to think about and talk about within the next generation. Ending preventable child deaths. And I'll mention this just a little bit more in the closing video, but the idea of this is that we want to live in a world by 2035, in which the under five mortality. Of children in all countries and in sub-populations of those countries is 20 or less. And so we can see here that on a national basis Brazil has already achieved that. Although I'm sure there are sub populations in Brazil still today where the under 5 mortality may be greater than that. But I think it's safe to say that Brazil is very well long down that path towards ending preventable child deaths. Which is going to be one of the Great challenges of your lifetime to see this happen. And its also interesting to note that South Africa has decided to adopt the Brazilian model for primary health care and is now in the planning stage of developing this system of for application throughout its country. So I think Brazil is a convincing case that health for all can be achieved through primary health care at a readily affordable cost And hopefully Brazil and its primary health care system will become a model, not only for South Africa, but for many other countries that are currently troubled by weak health systems have a high burden mortality and limited resources. So I hope that you've enjoyed this final week's lecture, and we'll have a wrap up video that I'll try to bring all this together coming next. [music]
