Equal access to medicine – A day in the life of a healthcare professional in Brazil (6 min read)

At 4:30am, cardiologist Dr. Fabiana Marcondes-Braga awakens at home in São José dos Campos (SJC), Brazil. Soon after, still in the pre-dawn darkness, she makes a 100-kilometer drive. By 6:30 am, she’s seeing publicly-insured patients, and teaching medical students and trainees, at the Heart Transplantation Unit in Heart Institute, University of São Paulo. Sometime after lunch, Marcondes-Braga drives the 100 kilometers return trip – but she’s not going home yet. Back in São José dos Campos, she will see patients, this time in private practice, for the remainder of the day. During these drives from São José dos Campos to São Paulo and back, she crosses different landscapes and cities; during her work, she sees diverse sectors of the Brazilian healthcare system. She makes this heavy commitment based on principle: “All patients are equal – regardless of their insurance status.” 

‘All patients are equal’ is also the philosophy of the Brazilian National Health System (The “Sistema Único de Saúde,” or SUS), founded in 1990. Today, the SUS is one of world’s largest public healthcare systems, serving more than 75% of the country’s estimated 190 million people. The right to healthcare is something many Brazilians like Marcondes-Braga believe in: thus, the SUS provides comprehensive, free healthcare to any individual in need, with financing by the states and federal government.¹ Since the SUS was created, Brazil’s overall healthcare system has improved, and in some ways, tremendously so. For example, maternal mortality has reduced by 50% (now at a rate of 13 per 1,000 live births), and average life expectancy has risen eight years (to age 74).²

However, like many health systems, the SUS has imbalances – in financing, personnel and resources.³ Wealthier Brazilian states have more funding for medical resources, for example.
In general, says Marcondes-Braga, “there can be significant differences in access to effective care between public and private systems, and between regions.” These differences also result in variations in health outcomes.^{4 5}

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• All patients are equal and should have the same access to healthcare – regardless of their insurance status.

From a heartfelt wish to heart patients

As a specialist for advanced heart failure and heart transplantation, Dr. Marcondes-Braga works daily to help as many people as she can. Since childhood, she wanted to pursue a medical career. “I’ve always wanted to do something professionally that involves helping people. Being a doctor is one way to do this,” she says.
 
Today, at the Heart Transplantation Unit in São Paulo, she often treats patients who are suffering from advanced heart failure disease. In her field, one of the greatest moments, Marcondes-Braga says, is when a patient’s heart transplant is successful. “It’s a real pleasure to be part of this process since we get to see how much the well-being of these patients improves after they received the transplantation.”

But heart transplantation may not be a possibility for many of her patients due to specific medical conditions. Long-term ventricular assist devices are considered the most appropriate treatment for patients with advanced heart failure disease when heart transplantation is contraindicated. However, they are not available for a majority of patients in Brazil.

Accessing prevention - reaching people

To ensure that fewer Brazilians reach a state of chronic illness, prevention measures are crucial, she explains. No matter their income level, an increasing number of Brazilians suffer from the effects of ‘modern lifestyles’ – more sedentary and stressful, less nutritionally-balanced – which show in conditions like “hypertension, diabetes, obesity, or diseases related to smoking and alcohol use,” says Marcondes-Braga, all preconditions for cardiovascular diseases (CVDs). Cardiovascular diseases belong to the category of noncommunicable diseases, which are responsible for roughly 70% of all deaths globally. (Read more on NCDs here)

For some patients, heart transplantation is the last resort. To help prevent chronic cardiovascular diseases, awareness campaigns educate people on the main risk factors.

“On a positive side,” she adds, “the Brazilian government regularly runs awareness campaigns about the factors that promote cardiovascular diseases. Past awareness campaigns have proven successful.” For example, the intervention program ‘Agita,’ designed in 1996, aimed to increase the people’s awareness of how important physical activity is for cardiovascular health. To achieve this objective, the program organized mega-events, specific projects with partner institutions and partnerships with community organizations in São Paulo. This program also changed local communities by increasing the number of walking and bicycling areas, and developing more recreational facilities.

As a result, the Agita program obtained significant media coverage, reaching 21 million Brazilians. The program’s positive health outcomes were even measurable. Annual surveys showed that over five years, the population considered ‘active’ or ‘very active’ increased from about 55 to 62%.⁶ Continuing these nationwide awareness campaigns is key to make all Brazilians realize the risks from an unhealthy lifestyle.

Teaching experts to ensure access

Still, Marcondes-Braga has more measures in mind to change national health outcomes. Lack of access to trained medical experts particularly affects patients in the public health system and those living in rural or low-income areas. “Right now, our public system is focused on solving emergencies and urgent cases,” she continues. “In both sectors we need to expand medical capacity to diagnose and treat conditions before they become chronic. Prevention should be more relevant in the Brazilian healthcare system.”

Working in both the public and private sectors, Marcondes-Braga observes daily a key difference between them. “While patients with private health insurance have good access to medical treatment, in public health, people have great difficulties even to book an appointment with a primary care doctor,” she explains. “This means it may take a long time until they receive the most appropriate therapy.” And patients throughout Brazil, including those with advanced heart failure, can wait months for surgery.

With help of digital tools, treatments for cardiovascular diseases continue to improve. Still, not all patients have access to these new therapies. This is often because of their insurance status.

To improve patients’ outcomes and mitigate the access issues in her country, Marcondes-Braga goes even further than treating patients the best she can. Besides driving 200 kilometers a day, she also teaches medical students and shares with them her motivation. And access to more medical capacity will be needed, she adds, both in Brazil and globally, since the world’s elderly population – who are among the most vulnerable for CVDs – continues to grow. Today, nine percent of the world population is aged 65 and above, whereas in 1960, for example, it was at five percent.⁷ Though she faces a growing patient load with serious illness in her daily work, Marcondes-Braga believes that “everyone who wants to pursue a medical career should follow their call.”

Empathy is a prerequisite

Knowing all of this, Marcondes-Braga makes a point that empathy plays a significant role in improving each patient’s outcome. “For effective treatment, it’s necessary that patients trust their doctors. The welfare of our patients should be the focus in the hospital.” One way Marcondes-Braga demonstrates this is by taking as much time as possible for her patients, whether in a public hospital or private office. “By sitting down with them and meeting them eye-to-eye, they feel they are taken seriously. This is an important prerequisite for their emotional wellbeing, and it affects their overall health.”

Treating all patients with equality and empathy are the cornerstones of Marcondes-Braga’s work as a cardiologist. “Our heart patients need all the support they can get, especially in the public healthcare system. Seeing patients recovering from their pain makes up for all obstacles and all our effort,” Marcondes-Braga adds, getting back into her car. She’s on the way to her next appointment.

References

1. http://www.who.int/bulletin/volumes/88/9/10-020910/en/
2. https://www.theatlantic.com/health/archive/2014/05/the-struggle-for-universal-healthcare/361854/
3. Santos NR. [The Brazilian Unified Health System (SUS), State Public Policy: its institutionalized and future development and the search for solutions]. Cien Saude Colet 2013; 18:273–80.
4. Massuda A, Hone T, Leles FAG, et al. The Brazilian health system at crossroads: progress, crisis and resilience. BMJ Glob Health 2018; 3:e000829. doi:10.1136/ bmjgh-2018-000829
5. Gragnolati M, Lindelow M, Couttolenc B. Twenty years of health system reform in Brazil: an assessment of the Sistema Unico de Saude. World Bank Publications 2013
6. https://www.ncbi.nlm.nih.gov/books/NBK45696/
7. https://data.worldbank.org/indicator/SP.POP.65UP.TO.ZS