Quality of health care growing awareness in Brazil

International Journal for Quality in Health Care 1999; Volume 11, Number 5: pp. 437 441 Country report Quality of health care growing awareness in Brazil JOSÉ CARVALHO DE NORONHA AND MARIA LUIZA GARCIA ROSA Institute of Social Medicine, State University of Rio de Janeiro, Brazil The World Bank published in 1994 a report on the or- shows tremendous internal disparities. The HDI in the South, ganization, delivery and financing of health care in Brazil. Its Southeast, and Central-West regions places them in the chapter on quality was entitled The forgotten component: upper ranges of human development, whereas the North and quality of care [1]. Tracing back the two decades preceding Northeast regions are at an intermediate level, with the latter its publication no comprehensive programme dealing with region bordering on lower levels of the index [4]. Table 2 quality issues could be identified. Regulatory norms issued shows the differences in life expectancy at birth and infant by the Ministry of Health (MOH) and by professional boards mortality rates in the Brazilian regions in 1991. were identified but only very localized initiatives were detected The Brazilian public health care system, known as the in the fields of quality management, clinical guidelines, ac- Unified Health System, is formed by the federal, state and creditation, consumer satisfaction or defence. Only in the municipal services working in an integrated way, but with early 1990s, more specifically from 1995, did quality of sole authority at each level of government. care initiatives become more and more widely disseminated In 1992 there were 7430 hospitals in Brazil, of which 4433 throughout the country. This report tries to trace this new had no more than 50 beds, 2127 had 51 to 150 beds and environment in Brazil where a growing awareness of quality 870 more than 151 beds. Of these hospitals 72% are private in health care can be detected among consumers, providers, and 28% belong to the public system. Regarding hospital financial planners and government representatives. admissions in the Unified Health System, 40% are to private hospitals, 33% are to non-profit hospitals, 27% are to public hospitals and 10% are to university hospitals. The country Ambulatory care is provided mostly by public and teaching services, the institutional composition varying according to Brazil has an area of 8.5 million km 2 and shares borders with the type of care being offered. all the countries of South America except Ecuador and Chile. Public revenues for health care come from the federal, state Its political and administrative organization includes the three and municipal governments. In 1996, public expenditures branches of government executive, legislative, and judicial amounted to US$ 18.0 billion; 76% came from federal sources, as well as 26 states, 5508 municipios, and the Federal District 13% from state sources and 11.3% from municipal sources. (the seat of government). The total population was a little In addition to the Unified Health System, there is a over 157 million inhabitants according to the 1996 population private sector, consisting mostly of voluntary complementary census. insurance schemes, which covers 20% of the population, The country is divided into five major regions. The North, chiefly in the larger urban centres. In 1996 these plans spent the largest region, occupies 45% of the national territory, but about US$9.0 billion. These complementary schemes provide has only 7% of the population; the Southeast occupies 11% services through their own providers, through contracted of the territory and has 43% of the population. The South providers or by free choice of the customer. Service provision is the smallest region, with 7% of the territory and 15% of includes group medicine, medical co-operatives, private health the population. Each of the other two regions occupies insurance and company-based health services. In 1998 these approximately 18% of the territory, but the Northeast has schemes came under the regulation of the MOH. 29% of the population, and the Central-West has only 6%. Brazil s extreme diversity in social, economic and health Basic indicators of Brazil are given in Table 1. conditions is also reflected in its health care delivery systems. The human development index (HDI) of the United One can find high quality services and facilities side-by-side Nations Development Program applied to Brazilian regions with very poor ones. Places like Rio de Janeiro, São Paulo Address correspondence to J. C. de Noronha, Institute of Social Medicine, State University of Rio de Janeiro, Rua Sao Francisco Xavier 524/70, Rio de Janeiro, RJ 20559 900, Brazil. Tel:+55 21 284 8249. Fax:+55 21 264 1142. E-mail:noronha@vmesa.uerj.br 1999 International Society for Quality in Health Care and Oxford University Press 437

J. C. de Noronha and M. L. G. Rosa Table 1 Basic indicators of Brazil 1 Area 8 547 403 km 2 Population (1996) 157 079 573 Gross domestic product (1995) 2 688.1 billions US$ Gross domestic product per capita (1995) 2 5400 PPP$ 3 Median age (1996) 23.2 years Mortality rate (1994) 5.77 per 1000 Life expectancy at birth (1995) 2 67 years Infant mortality rate (1994) 40.0 per 1000 live births Adult literacy rate (1994) 82.7% Urban population (1996) 78.4% Physicians (1996) 13.04 per 10 000 inhabitants Hospital beds (1992) 3.2 per 1000 inhabitants 1 Data from [2]. 2 Data from [3]. 3 Purchasing Power Parity dollars (the number of units of a country s currency required to buy the same amount of goods and services in the domestic market as US$1 would buy in the USA). Table 2 Life expectancy at birth and infant mortality rates per 1000 live births, Brazilian regions, 1991 There are many regulatory processes related to quality of health care in Brazil: norms for licensure of health facilities set by the MOH; Region Life expectancy Infant mortality... hospital accreditation under the federal hospital re- Central-West 63.45 32.46 imbursement system; Northeast 60.56 82.45 North 61.78 50.98 private payer systems for accrediting services; Southeast 64.50 32.17 South 65.67 29.04 norms for infection control set by the MOH; Brazil 63.29 49.49 licensing of schools for health professionals; and Porto Alegre play host to the most recent and advanced forms of medical technology and the most qualified medical and other health professionals; on the other hand physicians can hardly be found in some municipalities of the Northeastern states. The same is true of quality initiatives in this large and diverse country. One will find well-structured programmes in hospitals such as the Heart Institute of the State University of São Paulo, the Institute of Hematology of Rio de Janeiro or the Hospital Mãe de Deus in Porto Alegre. Yet one reads in the newspapers about infant deaths in an overcrowded nursery in the public maternity hospital of the city of Rio, or receives a report on the lack of tuberculosis chemotherapy agents in a municipality of the State of Pernambuco, and learns of a 100% Caesarean section rate in a maternity hospital in the State of Parana. The only possible approach to quality issues in places like Brazil is the concept of Continuous Quality Improvement (CQI). Dissemination of the idea that improvements in the quality of care can and must be pursued whatever the setting of care and wherever it is located is absolutely crucial. In the same way it is crucial that educational activities be developed based on the concept that a systematic approach to this issue is possible. licensing for professional practice (medicine, nursing, pharmacy etc.); norms and standards of practice set by medical societies and councils. However the purpose of the present report is to trace initiatives related to quality improvement actions. As reported previously by Malik [5] and by Noronha and Pereira [6], the Brazilian MOH tried such an approach when it started a national programme for quality in health care in 1995. The programme was called the Five Tracks Strategy : (i) moving towards the use of outcomes indicators. As indicators of undesired outcomes can function as flags for quality improvement efforts, indicators should be defined both at the level of services (e.g. hospital mortality rates) and at the community level (e.g. infant mortality rates); (ii) setting a national accreditation programme. The process of accreditation should be distinct from regular legal licensing procedures and should be conducted by independent non-governmental agencies; (iii) emphasizing quality improvement tools. Use of tools such as Total Quality Management or CQI should be encouraged among health care providers; 438

Quality of health care in Brazil resulted in decreases in the still very high rates observed in Brazil [5]. Research in academic settings is still scarce but has begun in some academic institutions and mainly since 1990. De Gouvea et al. [7] studied the quality of care analysed through the sentinel event approach, and examined the occurrence of avoidable deaths during hospital admissions. Silva and Russomano [8] described the development of an information system in perinatal care designed for research into ef- fectiveness, including analysis of the relationship between process and outcome and for quality assurance purposes. Bastos et al. [9] tested and confirmed the hypothesis that availability of technology, levels of staffing and diagnostic diversity in an intensive care unit are associated with the ability to decrease hospital mortality. (iv) establishing basic clinical guidelines. Basic guidelines should be established after appropriate identification of priority problems based on frequency, costs and social relevance. Local professional bodies should develop and monitor these initiatives and develop appropriate continuing education programmes; (v) enhancing community control. Community control is crucial for adequate quality improvement. Consumer satisfaction surveys may be useful but are insufficient to promote change. New methods of evaluation such as consumer audits may prove useful and should be developed and tested. Community councils, consumer protection initiatives and other forms of health ad- vocacy would help communities to monitor adequately and to press for good care. Using outcomes indicators Accreditation Since the early 1990s the use of outcomes indicators in The basic accreditation proposal was for the establishment hospital and community care has been increasing in Brazil, of a voluntary programme distinct from the existing licensing however there is no overall accounting of these initiatives. requirements set by the MOH and other governmental agen- A very good example of the use of outcome indicators is cies. The first initiatives in this field go back to 1986 when provided by the Program of Community Health Workers the Brazilian College of Surgeons, considering the training and certification of new surgeons and the quality of the sponsored by the MOH and conducted by local governments hospitals, created the Special and Permanent Committee for and communities in the poorest parts of the country, par- Qualification of Hospitals. ticularly in the Northeastern states. The programme prioritizes In 1990, the State of São Paulo Medical Association and maternal and child care and employs a number of outcomes the Regional Council of Medicine of the State of São Paulo indicators. Examples of these are the number of mothers commenced a programme called Controle da Qualidade exclusively breast feeding 4 months after delivery, the pro- Hospitalar CQH (Control of Quality of Hospitals) [10]. portion of undernourished children < 1 year of age, the About 120 hospitals in the State of São Paulo participated proportion of low weight births, neonatal mortality rates and in the programme in 1997. About 20 were awarded a Seal infant mortality rates and the proportion of deaths among of Quality. women aged 10 49 years. Approximately 3700 families are Other initiatives in this field were the result of a programme followed by the community health workers and data are of the Pan-American Health Organization (PAHO) on the collected regularly. The data allow corrective actions to be Accreditation of Hospitals established by an agreement with taken in due time, and so far the families covered achieved the Latin-American Federation of Hospitals. At the end of an average yearly decrease of about 10% in their infant 1995 a manual became available for testing. Up to now it mortality rates. has been applied to about 40 hospitals and a new application Other localized initiatives have been reported. In the City manual has recently been developed. The State Secretariat of of Rio de Janeiro a programme Right to be born right was Health of the State of Paraná also developed a programme introduced in 1995 by the City s Department of Health. This utilizing the standards proposed by the PAHO [11]. programme regularly monitors maternal and perinatal deaths In 1997 the MOH started a process to establish a national in municipal maternity centres. After 3 years a regular yearly agency for accreditation. A technical group was set up to decrease of about 10% in perinatal deaths was achieved when review the manual on standards for hospitals. A final version corrective measures were adopted by the outlier centres. In of this manual was published by the end of 1998 and is the harbour city of Santos (state of São Paulo), a High-Risk available on the Internet [12]. It is structure oriented as can Newborn Surveillance System was set up by the Municipal be deduced from its list of chapters: Secretariat of Health seeking to provide special care to highrisk pregnancies. Perinatal mortality rates are thoroughly Organization of medical care, including inpatient unit, ammeasured to evaluate the successes of the programme. Since bulatory care, etc.; 1997, the State of Pernambuco in the Northeastern Region has Diagnoses and therapy, including clinical laboratory, blood been developing a special training programme for physicians, transfusion services, rehabilitation services etc.; nurses and midwives that includes techniques of monitoring Technical support, pharmacy, food and nutritional services outcomes to evaluate the impact of their actions on mother etc.; and child care. Follow-ups of Caesarean section rates have Processing and supplies, linen and laundry services, materials been conducted by some Departments of Health and have processing and sterilization; 439

J. C. de Noronha and M. L. G. Rosa Administrative support, building documentation, electrical systems, general maintenance, etc. care providers. The most important is the National Quality Prize [13], but there are two important prizes in the state of Rio Grande do Sul and Rio de Janeiro. Since 1994 hospitals have begun to be awarded mentions and medals although no health care organization has won a prize so far. Another example of these quality initiatives is the case of the National Institute of Metrology and Industrial Normalization [14]. Until very recently it used to have activities only with industries. In 1996, the Institute established a norm for good practices of laboratories. In an effort to stimulate consumer awareness, it developed a project of verification of sphyg- momanometers that showed important problems of cal- ibration. In 1997 a survey was conducted by the MOH among consultant firms and State Secretariats of Health in order to identify hospitals that have engaged some sort of quality management initiatives. Eighty-two hospitals in 13 states were identified. Since 1994 a number of hospitals and other health services have been seeking International Standards Organization certification and by 1998 more than 20 had achieved it. In August 1994 the National Academy of Medicine, the Brazilian College of Surgeons and the State University decided to create the Programa de Avaliao e Certifição de Qualidade em Saúde or PACQS (Programme for the Evaluation and Quality Certification of Health Services) as the first step towards the organization of an accrediting agency. More recently, as further development of this programme, the Brazilian College of Surgeons created a Permanent Commission for the Accreditation of Hospitals. In July 1997 the Cesgranrio Foundation, a foundation established by the universities of the State of Rio de Janeiro for evaluation of educational processes, joined this programme. In 1998, the four organizations mentioned above formed the Brazilian Consortium for Accreditation of Health Care Systems and Services, the CBA. Assistance was sought from the Joint Commission International Accreditation and a set of standards was established based on the Joint Commission for Accreditation of Healthcare Organizations standards for hospitals and on the effort of the Joint Commission Task Force for the Development of International Standards. A manual was finished by March 1999. This set of standards has been in use since August 1998 to evaluate seven federal hospitals in the City of Rio de Janeiro. The two main teaching hospitals in Rio and the five hospitals administered by the State Department of Health are due to apply the same methodology. The standards are organized as two groups of functions: those focused on the patients and those focused on the organization. Patient-focused functions are: patients rights, organizational ethics and education; access and continuum of care; assessment of patients; care of patients. Organizationfocused functions are: quality improvement; leadership; environment of care; medical staff, nursing and human resources management; management of information; surveillance, prevention and control of infection. This functional approach seems best suited to places like Brazil where a very significant diversity of health care settings exists. Hospital Albert Einstein, in the State of São Paulo is preparing itself for accreditation by the Joint Commission International Accreditation. Quality improvement tools In 1990, the Brazilian Congress passed a law on consumer rights and protection. At the State levels offices of consumer rights solicitors were set up. Many cases relating to health care began to be presented to these offices, most of them consisting of complaints against private health plans [15]. However, Brazil has nothing similar to the malpractice litigation observed in the USA. Activities in the field of consumer protection are not yet well developed. In 1997 the government proposed a law to regulate private health plans in the country. In 1988 the Instituto Brasileiro de Defesa do Consumidor (IDEC; Brazilian Institute for Consumer Protection), a voluntary organization, was created in São Paulo. In 1990 IDEC conducted a survey on quality compliance of contraceptives. Since 1995 it has been conducting many surveys on products and services more directly related to health care, such as pregnancy tests (July 1996), baby pacifiers (August 1996), male contraceptives (November 1996), clinical laboratories (April 1997), and ampicillins (November 1997). IDEC spon- sors a monthly journal where it publishes articles on consumer In Brazil, quality management issues began to be discussed in industry in a systematic way around the 1970s. In 1990 the Federal Government created the Brazilian Programme of Quality and Productivity oriented mainly to quality processes in industrial settings. In 1996 greater amplitude was given to the programme enlarging the concept and scope of quality initiatives. Four macro-priorities were defined, including quality of life and within this, a special project on quality of blood was launched. There are also quality prizes that are now attracting health Clinical guidelines Basic guidelines for dealing with endemic diseases in the country had been written for many years by the MOH. From 1994 some medical societies began to publish guidelines in an effort to diminish practice variation and improve care. The cardiology, paediatrics and pulmonary diseases societies have been the leaders in this field with guidelines already produced on the management of common childhood dis- orders, hypertension, post-myocardial infarction, asthma and many others. Consumer protection 440

Quality of health care in Brazil protection and the results of its product evaluations. It also 5. Malik, AM. Quality Improvement Issues in Brazil. Joint Com- has a series of books on the subject and a site on the Internet mission J Qual Improve 1997; 23: 55 59. [16]. 6. Noronha, JC, Pereira, TR. Health care reform and quality As a requisite of the decentralization process, health couninitiatives in Brazil. Joint Commission J Qual Improve 1998; 24: 251 263. cils are being organized at state and municipal levels. By 7. De Gouvea CS, Travassos C, Fernandes C. Service delivery and 1997, almost every state had its council and over 1000 quality of hospital care in the State of Rio de Janeiro, Brazil municipalities also had their health councils. Consumers 1992 to 1995 (in Portuguese). Rev Saude Publica 1997; 31: voices are very active in many of these councils. 601 617. Since 1995, the MOH has made available on the Internet 8. Silva LK, Russomano FB. Underreporting of maternal mortality data concerning all activities financed by the Ministry [17]. in Rio de Janeiro (in Portuguese). Bol Oficina Sanit Panam 1996; Consumers, members of legislative branches, advocacy and 120: 36 43. professional groups are making growing use of these data. 9. Bastos PG, Knaus WA, Zimmerman JE et al. The importance of technology for achieving superior aoutcomes from intensive care. Brazil APACHE III Study Group. Intensive Care Med 1996; Conclusions 22: 664 669. 10. Silveira JA. Conference at the Symposium Accreditation of hospitals and quality improvement in health care (in Portuguese). There is a growing awareness concerning quality of health Anais da Academia Nacional de Medicina 1994; 154: care in Brazil. The size and diversity of the country does not 203 204. allow the establishment of a single strategy for improving 11. Instituto Paranaense de Acreditação em Servios de Saúde (Parana Institute for Accreditation of Health Services): http://www.sau health care quality. The five tracks approach gives room to de.pr.gov.br/acreditacao.htm find what combination of initiatives is best suited to the 12. Novaes, HM. Brazilian Manual for the Accreditation of Hosparticular local facilities or organizations. The strict regulatory pitals (in Portuguese). Brasil: Ministério da Saúde, 1998. activities have proved insufficient to produce improvements 13. Fundao Prmio Nacional da Qualidade (National Quality Prize in the quality of care. Mobilization of the community, health Foundation) http://www.fpnq.org.br care providers and financiers and different levels of govhttp://www.inmetro.gov.br 14. National Institute of Metrology and Industrial Normalization: ernment in a continuous effort for improvement is crucial. 15. Governo do Estado do Rio de Janeiro, Secretaria de Estado de Justiça e Interior, Programa de Orientação e Proteção ao References Consumidor - PROCON (Government of the State of Rio de Janeiro, State Secretariat for Justice and Internal Affairs, Program for Consumer Protection and Orientation): http://www.al 1. The World Bank: Brazil. The Organization, Delivery and Financing ternex.com.br/~proconrj/saude.htm of Health Care in Brazil: Agenda for the 90s. Report No. 12655-16. Instituto Brasiliero de Defesa do Consumidor (Brazilian Institute BR. Washington: World Bank, 1994. for Consumer Protection): http://www.idec.org.br 2. Ministry of Health, Brazil. Indicators (in Portugese). http:// 17. Brasil. Ministério da Saúde, Departamento de Informática www.saude.gov.br/indica.htm DATASUS (Brazilian MOH, Department of Informatics 3. The World Bank. World Development Report 1997. Washington DATASUS): http://www.datasus.gov.br DC: World Bank, 1997. 4. Pan American Health Organization. Health in the Americas. Washington, DC: PAHO, 1998: p. 108, Vol. 2. Accepted for publication 5 March 1999 441