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Public health

Wider spectrum

Program diversifies to bring researchers closer to the problems faced by SUS, the Brazilian National Health System

milton michida, wikimedia commons and gilberto marquesOn March 9, the Programa de Pesquisa para o Sistema Único de Saúde em São Paulo/ PPSUS-SP research program will announce a new bid for projects.  This bid will include a new feature in comparison to the bids announced from 2005 to 2007. This time, the research projects will not be restricted to topics related to the system´s operating matters or improvements, such as the management or evaluation of health care technologies.  “The range of the program will be much broader.  It will be possible to analyze projects involving diseases that affect an extensive part of the population, such as diabetes, heart diseases, infectious diseases, and cancer, all of which have a unique impact on the SUS system”, says Mário Saad, a professor at the Medical School of the State University of Campinas/Unicamp and representative of FAPESP on the program’s management committee.  Broadening the scope was the result of the restricted number of projects submitted in previous years. “Specifically in regard to the bid in 2007, the response from the academic community was lower than we had expected. We need to attract more researchers and raise the awareness of São Paulo’s scientific community to interact with public health authorities and investigate issues related to the health of the population”,  says Luiza Heimann, director of the Instituto de Saúde de São Paulo, Health Institute of the São Paulo, State Health Secretary, which participates in the program, together with FAPESP, the Conselho Nacional de Desenvolvimento Científico e Tecnológico/CNPq, National Scientific and Technological Development Council and the Ministry of Health.

The bid announced that R$ 6 million will be granted for research projects on six broad issues:  infectious diseases, non-infectious diseases, mother-child mortality, infant mortality, external causes, health and the environment, and management and administration of the SUS public health care system. The topics were defined on the basis of public health priorities as defined by the State Health Care Plan and by the Pacto pela Vida program, a set of sanitation commitments undertaken by the federal, state and local governments.  In the case of diseases, the criterion has a high incidence among the population. In the case of cancer, for example, the priority is research on gastro-intestinal, breast, prostate, lung and cervical tumors. Registration for the São Paulo State PPSUS, which is part of FAPESP’s Program for Public Policies, will be open for 60 days and will close at the beginning of May. The PPSUS is a nationwide program and involves agreements between the Ministry of Health, the state secretaries of health, and state research funding agencies, responsible for announcing the bids.

In spite of the narrower focus, the first two bids announced by the PPSUS contemplated a consistent set of projects.  The Instituto Butantan, for instance, was granted funding for two projects.  One of the projects, initiated in 2006, was the development of a swine-based lung surfactant and the creation of a plant for the production of the medical drug, crucial to save lives of newborn babies afflicted with the so-called infant respiratory distress syndrome (see Pesquisa FAPESP nº 147). The second project, initiated in 2008, involves clinical essays conducted in Brazil to test a vaccine for four types of virus strains that cause dengue fever (see Pesquisa FAPESP nº 147). For both projects, the Butantan Institute also obtained funding from FAPESP’s Programa Pesquisa Inovativa em Pequenas Empresas/Pipe, Program for the Support of Innovative Research by Small Businesses.

Another project funded by the program is led by researcher Hiro Goto, from the University of São Paulo’s Tropical Medicine Institute.  She heads a team that is working on faster-acting serological tests to detect leishmaniasis-caused infections in dogs, the main target of the transmission control of the agent that causes visceral leishmanaiasis.  “At present, the existing test uses cultivated parasites and the result depends on the reading under a fluorescent microscope, which implies a subjective evaluation, in addition to the time this takes”,says the professor. The studies are focused on finding an alternative similar to the Eliza type test, the reading of which is automated.

A project concluded by the Hospital das Clínicas teaching hospital at the Medical School of Ribeirão Preto/FMRP-USP proposes alternatives for a traditional bottleneck that exists in the operating activities of the SUS. A research study sponsored by PPSUS compared the data on health care services on two dates:  in 2001, when the hospital itself conducted the screening of patients (and was overburdened by having to deal with simple cases which , according to the SUS philosophy, should have been dealt with at the local health care centers and decentralized hospitals), and in 2005, after such screening had been eliminated and the hospital had established a quota of services for each region, delegating to the Regional SUS Centers/DRS the task of selecting the more complex cases for referral to the teaching hospital  One of the problems of the organization of the SUS became evident after the research study had been concluded:  although the patients’ screening had been delegated to the DRS, there was no drop in the number of patients who were not seriously ill and should have been referred to the local health care centers or regional hospitals rather than to the teaching hospital. In addition, the result of the study showed that health care services at the local centers were underused, for two reasons: the DRS did not refer enough cases to fill up the schedule and many patients who had scheduled medical appointments failed to show up.

The proposed solution was to improve the system by resorting to information technology, rather than to go back to the old system. The inadequate referral of patients is improving, thanks to a simple measure:  physicians and employees who work at the DRS must fill out all the items in the on-line form to refer a patient to the Hospital das Clinicas teaching hospital – the referral is not processed unless all the items on the form are filled in. This also improved the pace of the medical services. “Normally, when a patient arrives at the hospital, he or she has to go through a battery of tests, and this can delay treatment”, says Marcos Felipe Silva de Sá, director of the medical school and coordinator of the project. “Now the DRS are instructed to have patients go through the tests and take the test results with them when they go for appointments at the teaching hospital; this saves time”, he adds.

Another important study was coordinated by Luciane Cruz Lopes, a professor at the University of Sorocaba/Uniso. Her group conducted an analysis of the court decisions ordering the SUS to supply seven expensive drugs for cancer treatment. She verified that there were distortions in this kind of service, such as the lack of scientific evidence for the use prescribed by the physicians. “Some court orders obliged the SUS to provide a specific drug for the treatment of pancreatic cancer, and that drug was not the proper one to treat this kind of neoplasia”, says Luciane. “The judge who hands down the decision bases his decision on the principle that the SUS is obliged to provide the drug and does not question the physician’s prescription”, she states. According to the study, the losses undergone by the SUS system as a result of providing drugs whose prescriptions had no scientific basis came to R$ 6.8 million. More than 50% of the lawsuits had been filed by the private sector and are concentrated in the hands of a few physicians and lawyers. “This result is enough to justify an audit in order to investigate the relationship between the physicians prescribing the drugs and the lawyers in the pharmaceutical industry”, she states.