Health ‘forgives’ municipalities that failed to meet hypertension and diabetes control goals

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Without meeting diabetes and hypertension control goals, almost 5,000 Brazilian municipalities managed, on the eve of the second electoral round, to extend the deadline for this charge by the Ministry of Health by four months and, thus, avoid a discount of R$ 117 million in resources. intended for primary care.

The goal in the second quarter of this year, completed at the end of August, was that 50% of diabetics had taken a glycated hemoglobin test at least once a year, but only in 11% of the municipalities this occurred. Blood pressure should have been measured in half of the patients every six months, but only 12% of the cities met the goal.

In terms of vaccination coverage against poliomyelitis and pentavalent (against diphtheria, tetanus, whooping cough, hepatitis B and haemophilus influenza type B bacteria), only 9% met the objective of vaccinating 95% of children. Also, only 9% met the coverage target of the Pap smear (pap smear) for the prevention of cervical cancer, which would reach 40% of women between 25 and 64 years of age.

The decision to extend compliance with the goals was announced on Thursday night (20), at a meeting of the CIT (Tripartite Intermanager Commission), which brings together representatives of the Ministry of Health, Conass (National Council of Health Secretaries) and Conasems ( National Council of Municipal Health Departments).

The goals are set out in Previne Brasil, a Ministry of Health program created in 2019 that changed the logic of funding primary health care. A part of the federal transfers to the municipalities started to be calculated according to the performance in indicators and the number of users registered and monitored in the SUS primary care.

According to Mauro Junqueira, president of Conasems, the request for extension was made by the municipal secretaries and answered by the Ministry of Health. “This gives the possibility of not having the discount of R$ 117 million to the municipalities. Due to the pandemic and other factors, we were not able to move forward [no cumprimento das metas]”, he says.

For Érico Vasconcellos, founder of UniverSaúde, a startup that trains SUS managers, the measure sets a serious precedent for “changing the rules of the game in the middle of the game”. “There is a clear political motivation. If the argument is the damage caused by the bad results of the indicators, why didn’t the Ministry of Health consider this review sooner?”

Raphael Câmara, secretary of primary care at the ministry, says that the request for an extension came from the leaders of Conasems, and not from the portfolio. “As we have a very special affection for the municipalities in Brazil, we accepted. Giving another four months, we hope that the municipalities can adapt.”

For him, the fact that this happened ten days before the elections is a coincidence. “On October 10th, we released the results [do desempenho dos municípios no segundo quadrimestre, finalizado em agosto]. The media always wants to find something [errada] behind, but it doesn’t.”

In the first four months of the year, the municipalities had already failed to receive R$ 143 million for not reaching established goals for the monitoring of pregnant women in prenatal care. As of October, they would begin to receive resources related to performance in seven indicators, including diabetes and hypertension.

Hisham Hamida, CFO of Conasems, explains that, although the performance indicators are “theoretically simple” to achieve, the municipalities faced many problems, such as instability in the information systems of the Ministry of Health.

“Sometimes, the data does not arrive and, when it arrives, it is wrong. There is an estimate by Datasus that about 30 million doses of vaccines were applied by the municipalities but they are not yet accounted for [pelo ministério]. They’re on the way. These are adjustments that need to be made.”

Another problem, according to him, is that the Ministry of Health has used overestimated numbers to calculate the number of chronic patients in each municipality. These data are mostly based on the National Health Survey.

“We have regions where the ministry’s denominator says that I have to measure the pressure of a certain population of hypertensive patients and I have much less. Even in smaller municipalities, which have better control, they cannot reach [a meta] because the population [de crônicos] is overrated,” he explains.

Hamida also says that there are municipalities with a high rate of residents who have health plans, which may have better coverage of chronic monitoring and exams to prevent cervical cancer, for example, but private data do not speak to the public.

He also recalls that many municipalities face structural difficulties, with family health teams lacking due to the lack of doctors. “If São Paulo has difficulty finding a medical professional, imagine the rest of the country, the interior.”

In the opinion of Érico Vasconcellos, the Ministry of Health has been, since the beginning of Previne Brasil, transferring responsibility for the loss of financial incentives to municipal managers. “Nobody cares about the problems that teams are facing, especially from the point of view of managing information through systems,” he says.

For Isabel Opice, co-founder and director of operations at Impulso Gov, a non-profit organization that works to promote the use of data and technology in the SUS and that created a platform for managers to monitor Previne Brasil information, the indicators have shown improvements, but they are still far from the goal.

For example, the average result for hypertension, whose goal is to have 50% of the target population with consultation and blood pressure measured in the semester, was 30% in the last four months. For diabetes, with the same goal, 24% of patients went through a consultation and had their glycated hemoglobin measured.

According to her, in many municipalities, health teams are not aware of the real population with hypertension and diabetes and, therefore, are unable to carry out adequate monitoring. “It is important that the postponement is accompanied by measures of support from the ministry to municipalities, such as communication of program rules, data recording and transparency of performance calculations, which continue to generate doubts among managers and primary care professionals.”

Raphael Câmara says that there may be instability and other problems in the ministry’s information system, which are already being resolved, but “in no way” has this harmed the performance of the municipalities.

For him, the number of hypertensive and diabetic patients is not overestimated, as reported by Conasems. “There is indeed an underestimation of the municipalities. The pressure is only measured by those who go to the post. And even so, those who go with a complaint of hypertension and diabetes. There is no active search.”

In relation to “rich municipalities”, with a high rate of residents with health plans and who can follow up with private doctors, Câmara says that there may be damage to the results of Previne Brasil because this assistance is not computed. “For now, we have no way of forcing these doctors to notify.”

Câmara says that the ministry held workshops to train municipalities in all regions of the country on Previne Brasil, but that it is also the role of the states to help them achieve the goals.

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