Innovation and achievement for primary care in Brazil: new challenges

Brazil occupies half of the South American landmass, and is the fifth largest country in the world. The current population estimate is 207 million.1 Demographic and epidemiological changes, as well as nutritional transition, have affected mortality and morbidity in the country. The leading causes of disability-adjusted life years (DALYs) in 2010 were ischaemic heart disease, interpersonal violence, lower back pain, stroke, and road injury.2 

The main principles of the Brazilian National Health System (SUS), are universal access, comprehensive care, and equity of actions. The SUS model has emphasised the rapid scaling-up of community-based care in order to provide comprehensive primary health care (PHC). Among a number of important initiatives undertaken to develop this approach are the introduction of lay health workers ( agentes comunitarios de saude ), and an increased focus on community empowerment. These are both examples of important innovations in the public health system.

The PHC has …


Introduction
Last summer our small medical team visited the Calais 'Jungle'. Since that time much has changed and the camp is being demolished and by the time this article is read, it will probably be long gone. Some youngsters are finally being brought to the UK under the 'Dubs' amendment. However, once this camp is cleared it will not solve the ongoing flight of refugees from war torn areas: other camps are already appearing.

July 2016
A young Afghan man caught his finger on a sharp point while trying to cross a barbed wire fence. The finger was partially degloved. He attended the local hospital, where they placed a few sutures, but now, 2 weeks later, the skin is necrotic and the underlying tissue looks infected. He is in danger of losing his finger.
A middle-aged Sudanese man has been having rigors and is generally unwell. He says it is similar to when he last had malaria.
A young Ukrainian woman complains of lower back pain and urinary frequency. The paths of these three people may never have crossed; yet here they are, denizens of the Calais Jungle. They turn up to a makeshift primary care 'clinic' that we set up in the heart of the unofficial refugee camp one weekend in July 2016.
With only basic medical supplies, we are immediately challenged by what we see. How can we arrange secondary care for the young Afghan in danger of losing his finger? We try to persuade him to return to the original local hospital, but he is reluctant. It was not a good experience for him the first time round.
With the other two patients, it is easier. They can attend the Salam clinic run by a local association during weekdays. Later, we receive word that malaria has been confirmed in our Sudanese patient.
More people arrive, presenting with scabies, rat bites, tinea, chest infections, and wheezing from inhaling smoke from fires lit to cook and keep warm in their tents at night. We examine a severely malnourished 2-year-old boy. We meet several of the camp's 600 unaccompanied children, at grave risk of sexual exploitation. We learn that there is inadequate safeguarding in place to protect them. A young Eritrean man comes in worried about his eye. He has sustained direct ocular trauma from a rubber bullet, and will never see normally again out of that eye. We see haematomas from police batons, and hear about children being exposed to tear gas again and again ( Figure 1).

The reality
These are no ordinary patients. They have travelled far from home to escape war, poverty, and misery. They have endured personal odysseys to get here, experienced untold hardships, and suffered unimaginable privations. Many have survived the loss of their families, torture, and rape. Their journeys over, for the moment at least, they must make their homes in the Calais Jungle. Their new shelters are in many cases mere tarpaulin covers, and their new beds just rugs on the ground. They own next to nothing. There is little for them to do, besides use their ingenuity to cross the English Channel in search of a better life. They are vulnerable to exploitation, crime, injury, and disease. Potentially violent clashes with local police, with other ethnic groups resident in the Jungle, or local far The effect of Dr Google on doctorpatient encounters in primary care: a quantitative, observational, crosssectional study Noor Van Riel, MD 1 , Koen Auwerx, MD 2 , Pieterjan Debbaut, MD 3 , Sanne Van Hees, MD 4 , Birgitte Schoenmakers, MD, PhD 5 * Method: Patients were recruited by social media for the quantitative study. This was followed by a qualitiative study of GPs who were questioned in focus groups. Two questions were addressed: What is the effect of searching online health information on the behaviour of the patients? How does the GP handle this information?
Results: Almost half of all responders (total n = 963) usually went to the doctor after the online information search but two-thirds were not reassured by the internet search. More than half of responders had more confidence in their GP after searching online. The older the responders, the more they went to the doctor after their internet search and the younger the responders, the more they were worried. The more frequently people consulted the internet for specific complaints, the more likely they reported reassurance.
Discussion: Patients usually made an appointment with their GP after the internet search. New symptoms are rarely noticed and the search usually did not lead patients to distrust their GP. The majority of GPs described positive effects of the online search behaviour on the consultation.

Conclusion:
The emerging use of the internet for searching health information, commonly referred to as 'Dr Google', is not seen as a threat by GPs and leads to a better mutual understanding of symptoms and diagnosis.

How this fits in
More patients are searching the internet before consulting their GP and they not only search for an online answer to symptoms but also to prepare for a consultation. GPs believe that this does not undermine the doctor-patient encounter and well-informed patients contribute in a positive way to the consultation. The effect of Dr Google on doctorpatient encounters in primary care: a quantitative, observational, crosssectional study Noor Van Riel, MD 1 , Koen Auwerx, MD 2 , Pieterjan Debbaut, MD 3 , Sanne Van Hees, MD 4 , Birgitte Schoenmakers, MD, PhD 5 * Method: Patients were recruited by social media for the quantitative study. This was followed by a qualitiative study of GPs who were questioned in focus groups. Two questions were addressed: What is the effect of searching online health information on the behaviour of the patients? How does the GP handle this information?
Results: Almost half of all responders (total n = 963) usually went to the doctor after the online information search but two-thirds were not reassured by the internet search. More than half of responders had more confidence in their GP after searching online. The older the responders, the more they went to the doctor after their internet search and the younger the responders, the more they were worried. The more frequently people consulted the internet for specific complaints, the more likely they reported reassurance.
Discussion: Patients usually made an appointment with their GP after the internet search. New symptoms are rarely noticed and the search usually did not lead patients to distrust their GP. The majority of GPs described positive effects of the online search behaviour on the consultation.

Conclusion:
The emerging use of the internet for searching health information, commonly referred to as 'Dr Google', is not seen as a threat by GPs and leads to a better mutual understanding of symptoms and diagnosis.

How this fits in
More patients are searching the internet before consulting their GP and they not only search for an online answer to symptoms but also to prepare for a consultation. GPs believe that this does not undermine the doctor-patient encounter and well-informed patients contribute in a positive way to the consultation. The effect of Dr Google on doctorpatient encounters in primary care: a quantitative, observational, crosssectional study Noor Van Riel, MD 1 , Koen Auwerx, MD 2 , Pieterjan Debbaut, MD 3 , Sanne Van Hees, MD 4 , Birgitte Schoenmakers, MD, PhD 5 * technology, as a way to support and improve the diagnosis and management of conditions that can be dealt with at the primary care level, is essential in order to have a more effective health system, and is one of the greatest challenges in terms of innovation for PHC throughout the country. Studies of its effectiveness using robust methodology are required in order to ensure it is being used in the best possible ways. The Brazilian Ministry of Health has recently produced guidance for health technology assessment for PHC in order to identify the types and characteristics of studies that should be developed to improve decision making at this level of care, such as the rapid appraisal of new technologies, the use of systematic reviews, and evaluation of budget impact. This guidance is in press and will be published in 2017. 11

Challenges
The health system faces the challenge of implementing quality PHC throughout a large country with many socioeconomic differences and serious inequities in access to health care. The number of health professionals, including GPs, who have adequate qualification, are insufficient to provide universal coverage in every part of the country. The challenge also includes the delivery of effective interventions in remote areas, which are culturally and socially sensitive, and the coordination of long-term care between the primary and specialised care sectors, a challenge that is increased by the rapid ageing of the Brazilian population.
There has been an increase in PHC investment, but it is still insufficient. Programmes, such as the FHS, appear to be cost-effective; however, due to the current economic and political situation in the country, the achievements in PHC, and the remarkable health system reform in Brazil over the last two decades, are under threat. Strengthening PHC in Brazil, through these and other initiatives, is essential to guarantee the SUS principles of universal access, comprehensive care, and healthcare equity.