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Better public health

USP Medical School project encourages training family doctors and looks for ways to improve SUS

EDUARDO CESARFrom the outside, the Jardim Boa Vista Basic Healthcare Unit (BHU), on the edge of the Raposo Tavares highway, is a typical healthcare center on the outskirts of a megalopolis such as São Paulo. The large, greenish building, with its straight lines, has that austere and uninviting architectural design that is typical of public healthcare establishments. Inside, the building is clean and not badly kept, although a touch of paint here and there and small renovations would be welcome. Except for an LCD television set in the entrance hallway, there is no luxury at all. It looks like a simple and decent place, frequented by those who live in this poor part of town, mainly women, children and the aged, who go there in search of a medical consultation, a vaccination or a drug. This in the environment in which the Medical School of the University of São Paulo (FMUSP) is implementing a number of practices and routines designed to make the healthcare provided by SUS, Brazil’s Single Healthcare System, more humane and effective. Since late 2008, the Jardim Boa Vista BHU is one of the healthcare units whose administration the city government has transferred to the medical school, as part of a major project that combines teaching, research and, above all, better medical care.

It all began precisely one year ago, on October 1, 2008, when FMUSP signed a management agreement with the São Paulo City Healthcare Bureau and took over the task of reorganizing the care provided by SUS in part of the western area of the city of São Paulo, a microregion encompassing the districts of Butantã and Jaguaré. The initiative is called West Region Project and aims to transform this area of the city into a model of widespread and hierarchized medical care, promoting the integration of the decentralized work of healthcare centers, outpatient clinics and emergency rooms in the city with better care, that can be provided by the public hospitals, which have a greater structure. “The implementation of SUS in large cities such as São Paulo and Rio de Janeiro has been fraught with difficulties and our initiative can be seen as a laboratory, in this sense,” says Alexandra Brentani, the project’s executive director, an FMUSP administrator specialized in the management of healthcare resources. Alongside the managerial work, the initiative also aims to transform the healthcare services in this area (which encompasses some 420 thousand people or almost 4% of the entire population of Brazil’s largest metropolis) into a valuable platform for training physicians and into the stage for the medical school’s scientific studies. Measures to further this are under way: three disciplines on the medical school course and a residence program for family doctors, a specialization that is yet to have its value properly recognized, are taught by FMUSP in the healthcare centers of Butantã and Jaguaré. Furthermore, the area’s inhabitants have also become the target of a series of medical studies that have just been launched by the university.

The West Region was chosen for the implementation of the project for geographic reasons: FMUSP and the Clinicas Hospital complex, which is managed by the medical school, are within this area, more precisely near Avenida Dr. Arnaldo in the district of Pinheiros. Besides, there is the university campus right in the middle of the district of Butantã, in addition to the Universitário hospital and the Samuel Pessoa School-Health Center. The project, which is meant to last three years but may be extended for an indeterminate period of time, provides for the progressive transfer of the management of the entire network of city medical services in the West Region (14 basic healthcare units, 5 outpatient clinics, 1 outpatient specialtization clinic, 2 emergency rooms and 1 hospital) to FMUSP, through the Medical School Foundation. As the Universitário and Clinicas hospitals (the latter being the public hospital with the greatest structure in the region) are already under USP management, the partnership agreement with the city government is transferring the administration of virtually all the public healthcare services from the West Region to the Medical School. This year, the city government transferred R$47 million for this phase of the project, the management of which has autonomy to decide how best to spend the funds. “All our calculations show that one can have a better healthcare system with the funds available,” comments Alexandra. “With this project, we are turning theory into practice.”

Distortions and SUS
Broadly speaking, the West Region Project, an institutional FMUSP initiative, is derived from two major and correlated distortions, that have become increasingly evident over the last 20 years. The first concerns the difficulty of implementing a more daring model with the broadest coverage, such as SUS, throughout the country. It is no easy task, especially in a country of Brazil’s size and complexity. The United States, the world’s wealthiest nation, has no system similar to SUS, an idea that President Barack Obama is only now attempting to plant in the minds of his fellow countrymen, with great difficulty. The second concerns the discussion of what sort of physician the medical schools should aim at training on their courses. Reflecting a decades-old policy, medical schools today strive to produce specialists in the broadest range of areas, most of whom are trained to work in highly complex hospitals and are overly dependent on expensive procedures and tests. There is no encouragement to train more professionals, such as family doctors, to work in the public healthcare centers and outpatient clinics, which, according to the SUS model, should be the doorway to the system. The profile of illnesses in Brazilian society has changed and new practices are required to respond to the new needs, but the training of physicians continues to focus on hospital care, which is expensive and ineffective under certain circumstances,” comments pediatrician Sandra Grisi, chair of the Governing Board of the West Region Project. “In this context, one must conduct more studies of the population to identify their real health problems.”

Instituted by the Brazilian Constitution of 1988, SUS, at least on paper, reflects major progress relative to the former system. It made healthcare a duty of the State and a right of all citizens. It is an ambitious target. Before its advent, the government had no obligation to provide preventive and curative medical care to all. Only those who were employed, who had proper working papers and, who, furthermore, paid into the governmental social security system had the right to care provided by the old Inamps, the National Institute of Medical Care of the Social Security Department, which had its own medical care network in addition to maintaining agreements with private hospitals. The only alternative left for people with low purchasing power that did not pay into the Inamps system and could not afford a private healthcare plan was to resort to the medical care provided by certain philanthropic entities. The establishment of SUS provided for a new distribution of duties between the federal government, the states and the municipalities in the healthcare field. So-called primary care, provided by the healthcare centers and outpatient clinics, as well as part of secondary care (emergency rooms and less complex hospitals) became the responsibility of the municipalities. The states were put in charge of maintaining highly complex or benchmark reference hospitals (such as the Clinicas hospital in São Paulo). As for the federal government, it is incumbent upon it to transfer the funds required by the entire system and to manage it. This is how SUS is meant to operate, in brief. According to this design, a patient should only change from one care level to the next once treatment options at the preceding level have been exhausted.

The reality, however, is different. The three SUS levels have not been duly integrated, the population tends to be suspicious of the efficiency level of the healthcare centers and, even when people have a mere headache, they prefer to skip stages and go directly to the highly complex medical centers, such as the Clinicas hospital, which, as a result, become overloaded. In this distorted logic, complex and expensive tests, such as a CAT scan, may sometimes be requested to uncover easily diagnosed problems that could be treated at a healthcare center. “In the city of São Paulo there was a factor that further aggravated this situation,” explains Sandra Grisi. “The implementation of SUS was delayed by eight years by several city administrations.”

From diagnosis to action
After having diagnosed the situation of the entire municipal medical structure in the city’s West Zone, the project started to intervene directly in the system, so as to redesign it based on the size and characteristics of the local population. For the time being, while work on this is still at an early stage, FMUSP has taken over the management of three basic healthcare units (Jardim Boa Vista, Vila Dalva and São Jorge), which are in charge of providing simple medical services, typical of healthcare centers, to a population of some 48 thousand individuals, largely with very little money. By the end of the year, another two units (Jardim D’Abril and Paulo VI), two outpatient clinics (Vila Nova Jaguaré and Jardim São Jorge) and two municipal emergency rooms (Lapa and Butantã) are to be transferred to the medical school. The timetable for the incorporation of all of the city’s medical structures into the project extends to October 2011. “Our target is to cover all of the basic needs of people at the healthcare centers and to create an integrated system,” states infectologist and FMUSP director, Marcos Boulos. “Only 3% of sick people should be sent to an upper-tier care hospital such the Clinicas.” Other USP academic units, such as the Schools of Dentistry, Pharmacy, Public Health and Psychology, are also taking part in the West Region Project. “It will tend to become an initiative of the entire university and not only of the USP medical school,” comments Boulos.

When it starts to manage a basic healthcare unit directly, the project team has almost complete autonomy over it. Besides being able to choose who will run it and the staff, FMUSP can also pay higher wages than the city’s average and determine the unit’s working guidelines. Thus, it tries to draw better-qualified professionals into the initiative. To date, the medical school has hired some 300 employees for the healthcare centers. One of the chief priorities of this reformulation is to set up family healthcare teams attuned to the population’s needs. This should lead to the establishment of a relationship of trust between the healthcare center’s staff and the area’s inhabitants, causing the latter to go to the basic healthcare unit to take care of their medical problems. “For us to determine the human resources and equipment structure for a basic healthcare unit, we have to know the profile of the inhabitants that use the system,” states Alexandra. In the three healthcare centers under the project’s administration, 19 family healthcare teams have been set up. Each team consists of one doctor, one nurse, two nursing assistants and six community agents (recruited from among the region’s inhabitants). “The care we provide took a quantum jump in quality with the arrival of USP,” says Ana Emilia Bagueira Leal, a nurse and the manager of the Jardim Boa Vista basic healthcare unit, which has a staff of about 90 people and sees to 300 people a day. “We are integrating the work of our six family health teams with healthcare surveillance and with the four dentists that work here.”

Of the three basic healthcare units under FMUSP management, the Jardim Boa Vista one is where the project has advanced the most. All the houses in the catchment area of the unit, where some 17 thousand people live, have been visited by its teams. The profile of the inhabitants was entered into a database and associated with their residence, the precise location of which can be checked on Google maps. One of the project’s main challenges is creating online medical records of the people cared for in the basic healthcare units in the West Region in such as way that any physician in the city’s SUS system can gain access to them. The Healthcare Bureau has an electronic system that may prove adaptable. The other alternative is to adopt a system currently being tested by Duke University in the United States. The services provided by this and by other healthcare units within the project are further reinforced by the frequent presence of medical school students and residents. This enables the unit to offer certain special services, such as occupational therapy for the physically handicapped and, in the near future, psychological counseling. Today, the undergraduate FMUSP students have to take three subjects (Primary Healthcare I, II and III) at the healthcare centers of the municipality, and the medical school offers 16 residencies in Family and Community Medicine. “Many students are still prejudiced and some aren’t even aware that this specialty exists,” says Flavia Cardoso, a third-year medical student. “I don’t know whether I’m going to continue in this area, but I have always felt that healthcare should be a collective asset.”

In the scientific research field, the project has not been under way long enough to produce any results. However, more than 20 scientific studies have been initiated, focusing on the catchment area of the three basic healthcare units that came under FMUSP management one year ago. The research studies are conducted by professors plus graduate and undergraduate students from several departments of the medical school and other USP schools, such as the School of Public Health, the Psychology Institute and the School of Nursing. The São Camilo University Center and Paulista University (Unip) are two private educational institutions that are also conducting research under the project’s umbrella. The studies are financed by several promotion agencies, such as FAPESP and the CNPq (the National Council for Scientific and Technological Development) and the Ministry of Health. In general, the research themes center on issues of the family healthcare program. The living conditions of women, in particular pregnant women, children and the elderly are also topics that are often studied in detail. “In another year or two, we will be able to conduct epidemiological studies with this São Paulo city population,” foresees Alexandra Brentani.