Country Speech

Conferência Ministerial sobre Tuberculose e Desenvolvimento Sustentável Amsterdã - Holanda - 22 a 24 de março de 2000

Financing and Sustainable - China, India, Nigeria and Brazil

Brazil is investing, annually, around US$ 23 million in actions of tuberculosis control, what means a per capita investment of US$ 0.13, value superior to what is preconized by WHO, which is US$ 0.10. The crescent allocations of financial resources and efforts that has been applied in the quality of its management indicates that the country will maintain the National Tuberculosis Programme (NTP) sustainability, redefined in October 1998, with a basic purpose to maximize its benefits and to avoid eventual wastes. Considering the problem magnitude, the possibilities and advantages of its control, the excellency in resources and actions management are fundamental matters to reach the goals established in the National Programme.

For the Brazilian government the tuberculosis control aims special attention, been introduced to its Annual Plan, which defines the national priorities and is object of a specified management system. This Plan involves, for 2000-2003, the amount of R$ 1.113 billion (around US$ 636 million), which more than half for social development (US$ 318 million). Each established priority in this Plan compose a programme and has got a specific manager, who respond by the execution of fixed goals. In health area are defined 29 priorities, tuberculosis control included.

One of the fundamental measures for disease control is an integration with other strategies driving at the basic attention reorganisation, specially by the family agent and community health agent programmes, adopted in Brazil for the redirection of the model of health attention. By these strategies, we'd like to organise the services, reorganising the entrance door of health system, with a good quality of basic attention services, resoluble and humanised, from the familiar centre.

The health family teams are composed, at least, by physicians, nurses, nurses assistance and health community agents, prepared to the total basic attention and to the ...... in order to an attending specialised and or hospitalar eventually required. Nowadays are more than 100 thousand community agents integrated to the 4,405 health family teams, distributed in 1693 Brazilian cities. Each team attend, at most, 1,000 families or 4,500 people that lives or works in the territory of each health unit responsibility, now denominated "Unidade Básica de Saúde da Família" (Basic Unit of Health Family). The goal is to establish, still this year, 6000 teams; for 2002, the goal is 20,000 teams, enough for the attendance of half Brazilian population, more than 80 millions people.

The results already observed in the whole country and the potential of PSF (Health Family Programme) made the Ministry of Health to reflect its priority in the budget: in 1998 the health family programmes and community agents received a budget of US$ 124,571,000; in 1999 this amount raised to US$ 217,142,000; end for this year is expected the amount of US$ 388,571,000.

These programmes represents fundamental instruments for the Brazilian health system - the Unique Health System (SUS) - consolidation, defined by the Federal Constitution in 1988, who consecrate the ideals of the process of sanitary reform. This movement was initiate a few decades ago, aiming, among other objectives, the overcoming of dichotomy between health public actions and assistance medical-hospitalar, as well as the promotion for the universal access and even-minded to the services. Therefore, the Brazilian Constitution defines as principals of the System the universality of access to the services; the equity in offer and access; the integrally of attention, understood as integrated prevented and curative actions, individual and social; and social participation. As organisation goals are, for example, the System management decentralisation, toward in each field of government; the gathering of Union, States and Cities resources to structure and health services offering.

Along these principles and goals, the new National Tuberculosis Programme established in 1998 has defined the needs and measures to be adopted according to the diseases specifications. One of the specifications identified regards to the need to keep an appropriate balance between an action integration and a definition of functions in each government level, including those who must be kept in the central level, as establishment of national norms, acquisition of medicines, valuation and monitoring of the Programme. An important purpose in its elaboration was the changing of old models or vertical models for those integrated, which execution is assumed in the basic health net. It is, at last, a net performance that doesn't work only in the spontaneous demand to the services and in punctual initiatives.

In the whole of measures established in the National Programme, its worth to detach the treatment supervisioned by, procedure recommended by WHO, being applied in all the 27 States. Many States Units are in the expanding phase in this kind of treatment, heaving effect the introduction as São Paulo, Pernambuco and Ceará States. In the country the treatment abandon ratio has droped from 14% to 12%; note that this dropping ratio changes from city to city, as Cuiabá, which drop was from 50% to 4%.

Another Programme detach refers to the diagnosis, make essentially by baciloscopy. In 1996, the baciloscopy month average for diagnosis was 13,000; in October and November 1999, reached, respectively, 15,366 and 36,624. At the moment the country is promoting the enlargement of lab net with control of quality. The substantial improvement in the drugs supplying system and the beginning of Sistema de Informações de Agravos Notificáveis (SINAM) - Surveillance System.

The Programme resolution has been favoured by the concession of a bonus to the services on cases of tuberculosis treated and cured. This bonus is around US$ 85.71 or US$ 57.14 depending if had a supervisioned cases. Today, 23 of the 27 Brazilian States have this bonus programme. In the beginning of its implementation was distributed 283 bonus/month; last November was distributed 5,957 bonus.

To the possible impacts in the health sector reform about the tuberculosis situation , the expectation is to maintain and increase the advantages and opportunities registered. Among these, detaches the integrally of attention, through the Programme Actions integration with the others developed, essentially by health family strategies and community agents, supporting not only the expansion of specific measures but also its complementarily. Another important advantage is the programme management decentralisation, because the proximity between power of decision and population who demands the services enable a bigger effectivity on resources application, making easy the supervisioned treatment. Besides, supports the community participation, relevant to control disease activities, because helps to make known about the problem to cases discoveries and adhesion to the treatment.

On the other hand, about eventual risks, the priority character maintenance, on local level, makes a challenge, considering the enormous number of cities in Brazil - 5,506 - with management capacity differential. Such characteristic demands an exact monitoring, in order to avoid the control national norms detour and the lost of cases treatment uniformity, making the emersion of multidrugs resistant bacillus, which social and economic cost is enormous, requiring the development of high costs programmes. Concerning the actual demands the big necessity is human resources training with lab net with control of quality, being implanted already.

The favourable aspects, challenges, opportunities and identified needs analysis indicates that are positive the perspective of tuberculosis control in Brazil. The National Programme has changed the logical of resources repass to the Brazilian cities, in order to finish the systematic bureaucracy and increasing the incentive to search for cases, increasing the amount to baciloscopies, what encouraged its execution, also increasing the discovering and detection of cases. The measures and results that has being reached shows the real possibility to reach the goals defined helping to implement and maintain the National Programme in 100% of Brazilian cities. The detection in 2002 of 92% of estimated cases. The cure at least of 85% of detected cases, reduction in 2009 of 50% incidence and mortality reduced to two thirds.

The tuberculosis in Brazil has being object of special attention, full explained considering that is a public health problem, with a strong influence in the profile social-economic: is simultaneous cause and efect of this profile, plus the fact that presents interrelations with AIDS epidemiological. Besides the specific technical measures, such attention has understood the permanent search of new partners in the fight (ou struggle) against the decease, the larger social involvement and the responsibility of medical schools, nurses schools and health in general, such as professionals in particular.