Adequate prenatal care in the SUS has targets not met in 65% of municipalities

Almost two-thirds of Brazilian municipalities (65%) did not meet the target of adequate prenatal care in the SUS, which, among other things, provides that at least 60% of pregnant women have six consultations, the first being up to the 20th week of pregnancy.

More than half of the cities (52%) also did not reach the goal of testing their pregnant women for HIV and syphilis, and 63% did not offer dental care to 6 in 10 pregnant women. In addition, 93% did not offer a Pap smear test for 40% of women aged 25 to 64 years, another goal not achieved.

Data were extracted from Sisab (Health Information System for Primary Care) and refer to the last four months of 2021 (September to December). In all, there are more than 3,600 municipalities that have not met the goals established by the Ministry of Health’s Previne Brasil program.

The alert comes at a time when Brazil has recorded a record number of maternal deaths, making it virtually impossible to reach the UN’s (United Nations) global goal of reducing the mortality rate to 30 cases per 100,000 live births by 2030.

Preliminary data show that in 2021 the mortality rate reached 123.4 per 100,000 live births in Brazil, a rate compared to African countries and four times above the global target. It is estimated that 40% of deaths of pregnant and postpartum women in 2021 are related to the Covid pandemic.

Before the health crisis, Brazil already had a bad rate of 55 deaths per 100,000 births.

According to an analysis by Impulso Gov, a non-profit organization that promotes the use of data and technology in public management, if the failures persist, in addition to the damage to the lives of patients, there will be an impact on the budget of the municipalities.

Previne Brasil was established in 2019, but its start was postponed due to the pandemic. As of January this year, the Ministry of Health began to calculate a part of federal transfers to municipalities according to performance in seven indicators, starting in the first four months with those referring to prenatal care and HIV and syphilis tests in pregnant women.

According to Impulso, if the rules were in effect in December 2021, 36% of municipalities would not have met any target. The volume of funds received would have dropped by 44% (from R$638.9 million to R$282.1 million).

“These results of coverage reductions in the care of pregnant women and children in Brazil are alarming and would require immediate and intensive actions on the part of the federal government”, says doctor Ligia Giovanella, a researcher at Fiocruz and a specialist in primary care.

According to Raphael Câmara, secretary of Primary Care at the Ministry of Health, no municipality will lose resources with Previne Brasil, compared to what it received in 2019. “If you received X already adjusted for inflation and you did a terrible job, you will continue to receive X . Now we are rewarding who is performing better.”

He says that all municipalities had enough time to train in recent years and that they received support from the Ministry of Health.

“We are going to end the month with 27 Previne Brasil workshops in the 27 states. Those who want to work well are working well and will be rewarded for it. There’s no excuse. They had too much time to adapt.”

Still according to Câmara, with the changes, the expectation is that the worsening of the indicators will be reversed. “We cannot continue to pay resources fully to those who are not working well.”

For João Abreu, executive director of Impulso, the low achievement of goals is related to the difficulty of seeking information in the various health systems. Many municipalities are unaware of how many pregnant women have their prenatal care up to date or how many hypertensive and diabetic patients are unattended.

“What we hear most is not that they need three times as many doctors or nurses to meet their goals. They need information,” he says.

He says many small towns have to look at patient file by file to get policy data. “In general, only more organized cities are able to navigate through information systems,” he explains.

The case of Braúna, a municipality in the interior of São Paulo with around 5,700 inhabitants, is an example. According to nurse Márcia Oshiro, from the Family Health Strategy, the city was already informally meeting the goals of Previne Brasil, but the biggest obstacle was in entering data into the ministry’s system.

“We have been actively searching for pregnant women for a long time, monitoring prenatal and postpartum care, including with a nutritionist. We have a lot of production, but we weren’t getting the bureaucratic part right. says Oshiro.

Based on Impulso’s guidelines, the municipality achieved its goals and some of its experiences became a model for other cities.

On the issue of difficulties in accessing information and digitization systems, Câmara says that the ministry has made available around R$ 500 million to computerize health units.

“In the end, do you know how much was spent? Less than 10%. Why? Either the manager did not want to or did not know how to make the purchase. Of course, outside very specific places, in the corners, in the middle of the forest, where there is not even Internet.”

For João Abreu, Previne Brasil created incentives to improve primary care indicators, which is positive, but it did not communicate effectively or create mechanisms to take the policy off the ground.

The institute created a free platform to centralize data and analysis on Previne Brasil and present them in a simple way to municipalities. The initiative was funded by the Behring Foundation, Opy Institute of Health, Dynamo Institute, Sanofi and Novo Nordisk and had institutional support from the National Front of Mayors. The organizations Umane, Artemísia and Instituto Votorantim also supported the initial phase of the project.

According to the rules of Previne Brasil, three criteria are used to determine how much money will be sent to municipalities, including the achievement of targets in seven indicators.

Every four months the ministry evaluates the performance and calculates a score from zero to ten for the city. If she does not reach the goals, the grade drops and she starts to receive a proportional transfer in the following months until the next evaluation. If you improve, you will get more.

The change in the model is criticized by specialists in primary care. For Giovanella, the fact that resource transfers are linked to the number of people registered in the primary care teams, and no longer to the number of residents in the municipality, breaks with the principle of universality of the SUS, because those who are not registered will not have access to the services offered by public health.

The extinction of financial support to municipalities aimed at funding the NAFS (Expanded Family Health Centers), which complemented the teams, was another setback, according to the doctor.

For Giovanella, the low coverage of prenatal care and childhood vaccination pointed out in the survey were aggravated by the lack of national coordination by the Ministry of Health during the Covid-19 pandemic.

Câmara, however, says that municipalities have never had so many resources for primary care, especially for maternal and child health, and that many of them, due to management problems, were unable to spend the emergency funds allocated during the pandemic.

In the secretary’s assessment, the criticisms in relation to Previne Brasil are not justified. He says many health managers who once criticized the program now apologize.