Schmidt et al

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60135-9/abstract

Reviewed by PDV

This article develops a comprehensive and critical review of chronic NCDs and related health policies in Brazil.  Efforts to tackle the NCD-burden led to important progress over the last decades. The
Brazilian experience confirms three key elements for NCD-strategies: First, the development of broad prevention strategies. Second, a health care system with universal access to quality services. In Brazil, the setup of the Unified Health System has played a major role. Finally, the importance of tackling social inequities. Brazil remains one of the countries with dramatic socio-economic contrasts. Measures to decrease this gap are essential to effectively influence the course of NCD prevention, morbidity and mortality.

NCD challenges are important for Brazil, as 72% of all deaths in 2007 were attributable to chronic diseases (compared to 10% to infectious and parasitic diseases and 5% to maternal and child health disorders). While the crude NCD mortality increased by 5%  between 1996 and 2007,  age-standardized mortality declined by 20%. This was mainly due to the decline of cardiovascular diseases (31%) and of chronic respiratory diseases (38%). Main factors for this success were the implementation of some successful prevention policies, leading to e.g. decreases in smoking, and the expansion of access to primary health care.

Nevertheless, prevalence of hypertension and diabetes is rising. Cardiovascular disease remains the principal cause of death, with mortality rates of 286 per 100.000 in 2004, higher than those reported for most North American and European countries. But while cardiovascular diseases continuously declined as cause of death, for diabetes the picture is more complicated. As underlying cause of death it rose 11% from 1996 to 2000, and then declined 8% to 2007. This might be explained by a combination of an increasing prevalence of diabetes, with an improved diagnosis and treatment (besides changes in reporting practices).

Brazil has progressively implemented a comprehensive plan of action and a surveillance system for NCDs and their risk factors. Since the 1980s, the control of smoking has been a prominent success. While the important risk factor of smoking declined from 34.8% in 1989 to 22.4% in 2003 in the 18+ population, still 13.6% of all adults deaths for 2003 were attributable to smoking.

But a growing concern is the overweight epidemic. Between 1975 and 1989, the prevalence of adolescents with overweight doubled for boys and girls, and it more than doubled between 1989 and 2003 for boys while stabilizing for girls. During the second period, an increased shifting towards poor people was seen. For adults a similar pattern exists, with a shifting to the poor in both periods. A broad
health promotion plan on all risk factors was set up in 2006. Nevertheless, much has to be done.  The unfavorable trends for most major risk factors pose an enormous challenge to inter-sectorial preventive action, but also to cost-effective chronic health care.

In the provision of chronic disease care, the setup of the Unified Health System has played a major role, as it dramatically improved universal access at all levels of care. The 2001 national plan of  diabetes and hypertension care led to the detection and incorporation into the health system of 320 000 people with diabetes. Diagnosis and treatment at the first line were scaled up. Nevertheless,
important care gaps remain. Essential aspects of the chronic care model are only now beginning to be incorporated. Prevention should be reinforced at the first line care level. The initiative of ‘walk-in’ specialist clinics needs to be integrated with the Family care program, to avoid competing entry points to the system. Other important challenges are the elimination of long waiting lists for specialized ambulatory care, diagnostic services and surgeries, and the transfer of treatments of acute flares of chronic conditions from hospital emergency rooms to outpatient care settings.

Maybe the most important (and in this article not really analyzed) problem for Brazil is the avoidable social inequity in the distribution of NCD risks. Brazil remains one of the countries with dramatic socio-economic contrasts. Measures to decrease this gap are essential to effectively influence the course of NCD prevention, morbidity and mortality. The recommendations of Brazil’s National Commission on social Determinants of Health are to become an essential part of the country’s NCD-strategy.

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