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.
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5. Human Development Index
EFF/PAI-PAD/USP-RP-2009

6. Health Policy in Brazil
Health Budget and Expenditures
Total Health Budget in R$ Billions – Federal, State and County. Brazil,
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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)
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8. Per Capita Alcohol Consumption
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9. Alcohol and Injury in Emergency Departments
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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
EFF/PAI-PAD/USP-RP-2009

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
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Datasus Tabwin/Access

20. CAPS-AD Distribution – 2009
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21. Cumulative number of CAPS by year
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22. Health Policy in Brazil Family Health Care Program
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Brasil, Ministério da Saúde. Painel de Indicadores do SUS, Brasília. Ano I, No. I, agosto 2006 22

23. Family Health Teams – PHC level
EFF/PAI-PAD/USP-RP-2009

24. Urgency AOD Policy Plan
EFF/PAI-PAD/USP-RP-2009

25. New AOD beds in general hospital wards
EFF/PAI-PAD/USP-RP-2009

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
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27. BRASILIA DECLARATION ON ALCOHOL PUBLIC POLICIES, 2005 - PAHO Recommendations
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

28. BRASILIA DECLARATION ON ALCOHOL PUBLIC POLICIES, 2005
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
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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
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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.
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