Brazil
The Americas
Brazil
Emergency medicine in Brazil
Keywords: Emergency health care, Public/private Health care, Medical insurance, Competency standards
The major cause of death in Brazil today is cardiovascular disease, followed by cancer, respiratory disease, and trauma. In general, patients in developed urban areas of Southern Brazil suffer from lifestyle diseases similar to those in developed countries. Trauma from motor vehicle collisions and interpersonal violence is a major problem and the leading cause of death in persons aged 15-60 years.
Many penetrating trauma injuries occur in the poorly policed and impoverished favelas. Problems of particular concern in the favelas include alcohol and substance abuse and tuberculosis. A number of tropical diseases are endemic in rural and tropical areas of Brazil. These include helminth infestations, dengue fever, yellow fever, biharzia, American trypanosomiasis(Chagas disease), filariasis, and onchocerciasis. Chloroquine-resistant falciparum malaria is prevalent in some areas of the Amazon basin.
1 Health care economics
Both public and private sectors finance health care in Brazil. The federal government funds universal medical care through the Sistema Unico de Saude (SUS)program, which was passed into constitutional law in 1988. SUS funds public hospitals in Brazil and contracts for medical care at individual private hospitals. Because Brazilians are not required to qualify or register for SUS,any person in Brazil can receive free medical care at any hospital with a SUS contract. Although the federal constitution guarantees universal health care to all Brazilians through SUS, the actual delivery of this care is limited by insufficient government funding. Brazilian health care also is funded by private medical insurance, which both complements and, in some cases, competes with SUS. Certain national corporations and government entities provide employees’medical insurance, which is valid only at specified hospitals.
2 Health care system
The health care system in Brazil is divided into public and private sectors,operating in parallel. Accordingly, Brazil has both public and private medical schools, hospitals, and pre-hospital care services. Even private hospitals with SUS contracts often divide their emergency departments (EDs) into separate areas for patients with private medical insurance and patients with SUS, creating an often jarring disparity between modern, well-equipped areas for the insured and often overcrowded, ill-equipped areas for patients with SUS.
Brazilian hospitals may specialize in specific areas of medicine such as trauma or cardiology. Trauma hospitals provide care for patients with virtually any type of trauma, including orthopedic or hand injuries, but may refuse to admit patients with medical disease. Conversely, a hospital providing internal medicine care may transfer a patient with simple orthopedic injuries.
Physicians are widely specialized in Brazil, with 63 officially recognized medical specialties, compared to 24 specialty boards in the US. Emergency medicine (EM) per se is not yet an officially recognized medical specialty.
Although the health care systems in different regions of Brazil are based on similar law and organizational framework, facilities in Southern Brazil are usually much better equipped and physicians are better trained than in Northern and Amazon regions. As in the US, physicians are poorly distributed, with an overabundance of physicians in the metropolitan areas and a shortage of physicians, especially specialists, in the poorer rural areas.
3 Emergency medical services
The various services that comprise EMS in Brazil can be grouped into three categories, as follows:
- 1.
the public service represented by the Servico de Assistencia Medica Urgente(SAMU) and the fire department (bombeiros);
- 2.
privatized highway services; and
- 3.
fully privatized (non-highway) ambulance services.
Recently, the trend has been for Brazilian federal and state governments to regulate and coordinate these diverse EMS. In the 1990s, the Federal Council of Medicine and the Ministry of Health established pre-hospital care standards for EMS. The Franco-German model of EM has influenced these systems, with physicians frequently riding in ambulances.
Paramedics do not exist in Brazil because Brazilian law precludes non-physicians from performing intubation, defibrillation, and other advanced life support (ALS) procedures. Brazilian law recognizes the public SAMU service as having the authority to set EMS standards and to coordinate all public and private services. No standards govern qualifications of EMS physicians, except that they must hold a valid state license to practise medicine.
SAMU is free to all citizens and is supported by SUS, mostly through municipal funds. SAMU was established in 1995 following an agreement between Brazil and France to exchange technical information. A major characteristic of the SAMU system is the evaluation or screening of emergency calls (medical regulation) by a physician at the communication or dispatch center. Medical regulation may result in medical advice to the caller, basic life support (BLS)ambulance dispatch, or ALS ambulance dispatch. ALS dispatches generally are performed with a physician dispatched to the scene, either in the responding ambulance or in a separate automobile. The public accesses SAMU by calling 192. Fire departments and military police occasionally have had their own ambulance systems and public access numbers. Absorption of these services into SAMU is the trend.
In regions where the highway system is privatized, an ambulance system may exist specifically for auto accidents and other highway emergencies. The guiding philosophy of these services is to transport patients as rapidly as possible to previously selected trauma hospitals. Highway tolls fund this service. Like the SUS-supported SAMU service, patients are not charged directly for these services.
Several private ambulance services operate in Brazil, especially in the South. Patients usually pay a monthly insurance premium for private ambulance service. Uninsured patients also may access private ambulances but, of course,must pay for this service. The physicians who provide care in these ambulances usually are moonlighting residents or other physicians with no training in emergency care.
Many emergency physicians feel that an inappropriate number of seriously ill medical patients are brought to EDs by taxi or private vehicle. Suggested reasons for this state of affairs are the public’s general lack of awareness that SAMU can be accessed for conditions other than trauma and the prohibitive cost of private ambulances for non-insured patients.
4 Future of emergency medicine in Brazil
Public demand for state-of-the-art medical care is growing in Brazil, and this includes emergency medical care. Establishing the Hospital de Pronto Socorro EM residency in Pôrto Alegre represents an essential step towards the development of EM as a specialty. Historically, in countries where EM has developed as a specialty, a core of EM specialists has been integrally involved in its evolution. The following challenges in development of EM as a specialty lie ahead:
development of more EM residency training programs;
establishment of a specialty organization for emergency physicians;
creation of a board-certification process; and
official recognition of EM as a specialty by Conselho Federal de Medicina.
Challenges for law and policy development include the following:
development of minimal competency standards for physicians practising in EDs and ambulances;
development of law governing interfacility transfers; and
development of policy and law that address the disparity between and duplication of public and private health care systems.
Author: Ross D. Tannebaum MD, FACEP, Clinical Assistant Professor of Emergency Medicine, University of Illinois College of Medicine at Chicago.
More information at: www.emedicine.com
