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INEBRIA 2009 Newcastle upon Tyne

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1 INEBRIA 2009 Newcastle upon Tyne
Brazilian alcohol and drugs policy of the Ministry of Health and SBIRT implementation Erikson F. Furtado, MD, PhD – Assist. Prof. USP – University of São Paulo FMRP – School of Medicine of Ribeirão Preto Dept. Neuroscience and Behavior EFF/PAI-PAD/USP-RP-2009

2 Objective To present an overview of the present developments of the Brazilian public policy for alcohol and drugs and its relation to SBIRT implementation in the public health system. EFF/PAI-PAD/USP-RP-2009

3 Brazil: Country Profile
Population (2009) – 191 millions (mostly urban) Federative Republic, 5 regions, 26 States (01 FD) Municipalities - 5,564 Territory: 8.5 mln sq km (aprox. 22 inh/sqkm) GNP (2008) US$ 1,991 bi Per capita GNP (2008) - US$ 10,325 HDI Rank (2006) - 70th (0.807) This is a brief introduction to Brazil. As the slide states, Brazil is a federal republic with approximately 185 million inhabitants, making it the world’s fifth most populous country. At the end of 2008, it had an estimated GNP per capita of roughly US$10,000. Such numbers, however, hide the persistence of huge income inequalities as well as the deep regional disparities that exist within Brazil. EFF/PAI-PAD/USP-RP-2009

4 Health Policy – Challenges
Health Policy in Brazil Health Policy – Challenges Epidemic diseases – Dengue, Tuberculosis, Aids-STD Neonatal deaths Chronic diseases - risk factors Cancer, cardiovascular diseases, diabetes Obesity Violence and vehicle accidents Alcohol and Drug abuse Health costs Community participation Management of health services and health system. EFF/PAI-PAD/USP-RP-2009 4 4

5 Human Development Index

6 Health Policy in Brazil
Health Budget and Expenditures Total Health Budget in R$ Billions – Federal, State and County. Brazil, EFF/PAI-PAD/USP-RP-2009 6 Brasil, Ministério da Saúde. Painel de Indicadores do SUS, Brasília. Ano I, No. I, agosto 2006 6

7 Health Policy in Brazil
Context: Epidemiologic Transition - Violence Standardized Mortality Rate by Violence (Assault and Homicide) per habitants, Region, Brazil, Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Saúde Brasil 2006 : uma análise da situação de saúde no Brasil. Brasília : Ministério da Saúde, p. : il. – (Série G. Estatística e Informação em Saúde) EFF/PAI-PAD/USP-RP-2009 7 7

8 Per Capita Alcohol Consumption

9 Alcohol and Injury in Emergency Departments

10 Alcohol and Car Accidents
53% car crash victims attending the emergency room – HC-Sao Paulo (mostly, young ya males) Mortality due by fatal car accidents responds for 28% of all external causes (about 30,000 deaths/year) High BAC found among 96.8% of necropsies of fatal victims (IML-SP) About 50% positive AUDIT in ER Source: Report of the Brazilian Ministry of Health EFF/PAI-PAD/USP-RP-2009

11 Prevalence of alcohol dependence

12 Alcohol abuse among university students from a medical school
20,00 15,00 10,00 5,00 0,00 Score total AUDIT 80 60 40 20 Frequency Mean = 4.8 SD = 4.4 N = 464 Cut-off point Audit ≥ 8 23.5% Binge Drinking 33.3% EFF/PAI-PAD/USP-RP-2009

13 Liver disease – Males (Cases / 100.000)
State Region of Ribeirão Preto = 75,5 EFF/PAI-PAD/USP-RP-2009

14 Mortality by TB and comorbidities
Condition N TB treatment p None (n;%) Some (n;%) Diabetes 44 23(52.3) 21(47.7) .05 Cancer 6 4(66.7) 2(33.3) COPD 39 23(59) 16(41) HIV 15 11(73.3) 4(26.7) .005 Smoking 64 39(60.9) 25(39.1) Alcoholism 142 82(57.7) 60(42.3) .01 Lindoso et al., Rev Saude Publica 42(5), 2008 COPD Chronic Obstructive Pulmonary Disease 71% Smoking & 64% Alcoholism 64% EFF/PAI-PAD/USP-RP-2009

15 Alcohol use by pregnant women
Health professionals don't assess risk patterns of alcohol use Patients with problematic alcohol use are discriminated Risk groups are not routinely assessed N = 450 N = 100 (22%) Only 9% identified By GO clinicians Fabbri , Laprega & Furtado , Rev Saude Publica 41(6), 2007. EFF/PAI-PAD/USP-RP-2009

16 Americas: Alcohol – risk factor Nr. 01
Source: Monteiro, M. G. Alcohol y atencion primaria de la salud. OPS, 2008

17 Frequency of inpatient admissions
Alcohol Dependence 57,789 Alcoholic Liver Disease 14,188 Total 71,977 EFF/PAI-PAD/USP-RP-2009

18 Structure CAPS-AD Emergency Room Outpatient MH Clinics
Basic Care (PHC) AOD Health Care System CAPS-AD Emergency Room Outpatient MH Clinics General Hospital Family Health Program Psychiatric Hospitals Detoxification GH EFF/PAI-PAD/USP-RP-2009

19 AOD Psychosocial Centers
About 50 th people can be assisted every month in AOD Centers. Short hospitalization wards: 4 EFF/PAI-PAD/USP-RP-2009 Datasus Tabwin/Access

20 CAPS-AD Distribution – 2009

21 Cumulative number of CAPS by year

22 Health Policy in Brazil Family Health Care Program
EFF/PAI-PAD/USP-RP-2009 22 Brasil, Ministério da Saúde. Painel de Indicadores do SUS, Brasília. Ano I, No. I, agosto 2006 22

23 Family Health Teams – PHC level

24 Urgency AOD Policy Plan

25 New AOD beds in general hospital wards

26 AOD Policy - Chronology
2003 – Basic Guidelines for a National Public Policy for Alcohol and Drugs, Prevention, Treatment and Health Promotion First insertion of Brief Interventions EFF/PAI-PAD/USP-RP-2009

Preventing and reducing alcohol consumption-related harms be considered a public health priority for action in all countries of the Americas. Regional and national strategies be developed, incorporating culturally appropriate evidence-based approaches to reduce alcohol consumption related harm. These strategies are supported by improved information systems and further scientific studies on the impact of alcohol and the effects of alcohol policies in the national and cultural contexts of the countries in the Americas. EFF/PAI-PAD/USP-RP-2009

Alcohol policies whose effectiveness has been established by scientific research are implemented and evaluated in all countries of the Americas. Priority areas of action need to include: heavy drinking occasions, overall alcohol consumption, women (including pregnant women), indigenous peoples, youth, other vulnerable populations, violence, intentional and unintentional injuries, underage drinking and alcohol use disorders. EFF/PAI-PAD/USP-RP-2009

29 Recent Brazilian effectiveness studies
SBIRT among ER patients: Segatto, Rev Psiq Clínica, 2008. SBIRT among Firemen periodical health evaluation: Ronzani, Est Psicologia (Natal), 2007. SBIRT among university students: Kerr-Côrrea, Alcohol Alcohol, 2008 SBIRT among adolescents attending a community health clinic: De Micheli, Rev Assoc Médica Bras, 2004 SBIRT among imprisoned adolescents : Andretta, Est Psicologia (Campinas), 2008

30 Implementation Process

31 Trained Health Professionals
PAI-PAD: Trainings Network Supervision Evaluation EFF/PAI-PAD/USP-RP-2009

32 Stigma is a barrier 69(7): , 2009 EFF/PAI-PAD/USP-RP-2009

33 Changing attitudes after training
SBIRT knowledge after training correlates with reduction of alcohol expectancies N = 185; r = 0.215; P < 0,005 EFF/PAI-PAD/USP-RP-2009

34 Implementation process
2008 Ministry of Health, three metropolitan areas pilot project for SBIRT implementation in the Family Health Program and the matricial support teams. 2009 Annual plan, Alcohol and Drugs Coordination, State of São Paulo Extending the PAI-PAD couverture of SBIRT training for all 17 regional health departments, reaching the total population of the state (~41mi). EFF/PAI-PAD/USP-RP-2009

35 References Brasil. Ministério da Saúde. As Causas Sociais das Iniqüidades em Saúde no Brasil. Relatório Final da Comissão Nacional sobre Determinantes Sociais da Saúde (CNDSS). Brasília Brasil, Ministério da Saúde. Painel de Indicadores do SUS, Brasília. Ano I, No. I, agosto 2006. Cornwall, A., Shankland, A. Engaging citizens: Lessons from building Brazil’s national health system. Social Science & Medicine 66 (2008) 2173 – 2184. Barreto, ML, Aquino, R. Recent Positive Developments in the Brazilian Health System. American Journal of Public Health. January 2009, Vol 99, No. 1. Camargo, KR. Celebrating the 20th Anniversary of Ulysses Guimarães’ Rebirth of Brazilian Democracy and the Creation of National Health Care System. American Journal of Public Health. January 2009, Vol 99, No. 1. EFF/PAI-PAD/USP-RP-2009 35 35

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