Country update - Latin America

• Guidelines in Brazil
• Colombia: moving towards evidence based healthcare model
• Mexico: Coordinated production of clinical practice guidelines in the Public Health System

Brazil

Data about Brazil

Area: 8,547,403 sqKm

Population: 189.6 million (2008 estimate) It is the fifth largest country in the world. With a population of 190 million, Brazil is also the fifth most populous country and fourth largest democracy.

Gross national income per capita (PPP international $): 8,700

Life expectancy at birth m/f (years): 68/75

Healthy life expectancy at birth m/f (years, 2003): 57/62

Probability of dying under five (per 1 000 live births): 20

Probability of dying between 15 and 60 years m/f (per 1 000 population): 230/121

Total expenditure on health per capita (Intl $, 2006): 765

Brazil invests about 8% of its PIB in the health sector. In recent decades, the cost has grown tremendously.

Figures are for 2006 unless indicated. Source: World Health Statistics 2008

Guidelines in Brazil

For years doctors have been using international guidelines to support quality of care at their clinical practice, although there is a growing trend to base the practice on the national guideline developed by the specialty.

With the goal of offering the population a free comprehensive health program, the Brazilian National Health System (SUS) was created by Organic Health Law no. 8.080/1990. However, ensuring universality and comprehensiveness in a country with inequalities and scare budgetary and financial resources is an arduous task.

Private health care sector has been growing in Brazil. The number of insured has increased in recent years, and medical care plans have increased by 5.3% from 2008 to 2009.

There are several public and private initiatives that reinforce the importance of development and implementation of guideline in Brazil. The Brazilian Medical Association has set a priority agenda with a view to equipping actors in both public and private health care systems with the tools necessary for qualification of clinical practice and better care for the health of their participants.

The Brazilian Medical Association and the National Agency for Supplementary Health –have joined GIN, and there is a need to network with other experiences, such as the workshop that was held in Rio de Janeiro. The workshop was held entitled “The Implementation of Clinical Guidelines in Health Care: international experiences and the issue of private health insurance in Brazil,” with the support of the Pan American Health Organization (OPAS). It was an important step for all countries present – Brazil, Chile, Colombia and Portugal – and at the same time showed that the organization and use of clinical guidelines remains a challenge.

The Iberoamerican Guideline Network has been a very helpful to support the development and implementation of guidelines in the region. In the Lisbon Conference there was a meeting from the board of both organizations in order to improve liaison between GIN and the Iberoamerican Guideline Network.

Trajectory in Brazil

In Brazil, the process of developing national clinical guidelines based on evidence was triggered by the Brazilian Medical Association and the Federal Council of Medicine, called Project Guidelines. This project started from a meeting in December 1999 in Brasilia, bringing together all directors of the AMB and regional advisers of CFM, in which all voted unanimously in favor of the partnership between the two sides, outlining a policy of joint action. Subsequently, the following year the strategic planning carried out by the two entities ratified in detail the key objectives and action areas. There are seven guidelines books issued and in 2009. Brazilian Medical Association (AMB) is developing clinical practice guidelines with the Specialties Societies, coordinated by a technical evidence based committee. Until now about 400 clinical practice guidelines were developed.

The Brazilian Medical Association and the National Agency for Supplementary Health have started to issue guidelines which is available free of charge on the site: www.projetodiretrizes.org.br. The National Agency of Supplementary Health (ANS) established a collaboration term with the Brazilian Medical Association (AMB) to develop guidelines and monitor their implementation. A priority-setting process was implemented to identify the high priority topics for the guidelines and it were based on the participation of representatives of health insurance companies and medical specialty societies, and it was mediated by the regulatory agency in Brazil. ANS and AMB did some workshops with these representatives intended to find out what were their highest priority topics. Its principal goal was the improvement of private health assistance by stimulation of taking health decision based on scientific evidences, the implementation of effective actions of promotion of health and prevention of illnesses and the rational use of techniques and medical technologies.

It were established stages of planning with well defined goals, as: definition of priorities; construction of scientific methodology, standardization of the guidelines; sensitization (support/discussion) by means of workshops with representatives of health insurance companies, medical specialty societies, AMB and ANS. Medical coordinators trained by the AMB did technical validation and ANS did the validation of implementation and monitoring. Moreover, the project includes the accomplishment of activities directed to health professionals, aiming at dissemination and adjustment of the use of guidelines.

The priorities were some subjects in the clinical specialty for development the guidelines, such as immunology, cardiology, endocrinology, gastroenterology, geriatrics, internal medicine, medical genetics, obstetrics and gynecology, oncology (breast, colon and rectal, female genital tract), ophthalmology, pediatrics and psychiatry. As a result, efforts have been unnecessarily duplicated and opportunities for standardization of care. We have elaborated a list of 80 guidelines and the collaboration will support the development and implementation of them. The new process improves transparency on the development and implementation of the guidelines and seeks to improve the quality of health care by promoting systematic development of clinical practice guidelines and their application into practice. To ensure that future guidelines on healthcare problems are useful, it is imperative that policy makers take the problem definitions of potential users for the Brazilian National Health Care System.

Thanks to Airton Tetelbom Stein and Wanderley Marques Bernardo for their contribution with this piece.

Colombia: moving towards evidence based healthcare model

In Colombia, benefit plans are being updated by pathology prioritization along with the simultaneous development of management tools in order to attain a greater level of comprehensive care and coverage one of these being Clinical Practice Guidelines (CPG), designed to improve the quality of care while efficiently rationalizing health expenditures.

The overall strategy of the Colombian Health Ministry for changing and improving the benefits of healthcare plans is comprised of:

• Updating the prioritization of health problems.
• Reviewing and updating the contents of the plans in light of scientific evidence and the CPG.
• Responding to epidemiological and demographic changes of the Colombian population, i.e. Changes in their habits, the effect of increased life expectancy and the slow aging of the population
• Developing economic evaluations of the prioritized pathologies and the financial impact of imposing the recommendations on the UPC.

This strategy empowers CPG’s as an instrument that gives conceptual clarity to health insurance in Colombia and the UPC as a conduit for directing financial incentives.  CPG would not only be a means of improving quality, but also an efficient rationalization of health expenditures.

While Colombia has had a fruitful experience in the development of Guidelines, the proposal of the Ministry of Health is to strengthen the component of evidence-based Guidelines, economic studies and resulting financial impact as a pragmatic solution in the absence of better alternatives

The development of Evidence-Based Guidelines has been the initiative of academic groups based out of research universities or institutes. In developing its strategy, the Ministry proposes to promote the development of evidence-based guidelines for prioritized pathologies, including health economic studies and an actuarial analysis of its impact on the UPC. The objectives are strengthening the quality of care, and controlling the costs and increasing expenditures related to healthcare.

Some challenges must be addressed: the poor practice of information and record keeping, the availability of health economists with expertise in the models required by the guidelines, as well as actuaries able to sequentially address the guidelines that are part of the strategy. Finally, ignorance as to the true level of acceptance for the guidelines and barriers of implementation.

However, it is worth mentioning that the Ministry recognizes the value and importance of evidence-based guidelines and interprets this tool as a method not only for improving quality and cost containment, but also as a central element in the reform of the mandatory healthcare plan for today’s Colombia.

Thank to Rodrigo Pardo Turriago for its contribution with this piece.

Mexico: Coordinated production of clinical practice guidelines in the public health system

The Mexican Ministry of Health, through the Innovation and Quality Vice Ministry instructed the National Center for Health Technology Excellence (CENETEC), to coordinate the development of Clinical Practice Guidelines (CPG) in the Health Sector aiming mainly at establishing a national benchmark to support clinical decision making and management recommendations based on the best evidence available. This in turn would reduce the use of unnecessary or ineffective interventions and facilitate the treatment of patients with maximum benefit, minimum risk and acceptable costs.

The strategy devised to accomplish this challenge was to establish collaboration among all the institutions comprising the Public Health Sector for the adoption of CPG with a common methodology and to create a CPG Master Catalog, all under the coordination of CENETEC. This proved to be a task of great magnitude that has required a complex coordination and sustained efforts from all the participants in order to standardize and harmonize methodology, editorial format and other criteria for the construction of the CPG.

The effort has also proven to be fruitful and since from May 2008 to November 2009 one hundred and fifteen CPG were produced and incorporated to the Master Catalog as a result of the coordinated effort of more than 1,500 people. Themes were selected according to the Health Systems needs starting with primary care and following with specialty themes; they are all based on the best available evidence and aim at improving the quality and safety of medical assistance.

Thanks to María de Lourdes Dávalos Rodríguez, Maria Luisa González Rétiz and Esteban Hernández San Román for their contribution with this piece.