Background
Brazil is an upper middle-income country with a population of 190,755,799 inhabitants [
1] and a per capita gross domestic product of USD $ 10,993 (current exchange rate) in 2011. With a land area covering 47% of Latin America [
2], Brazil has marked regional inequalities in terms of climate, social development, income and other indicators.
Following democratisation of the country from 1994 onwards, Brazil has experienced a period of economic growth, which allowed the implementation of social development policies [
3]. This has led to slow but stable improvements in social indicators, particularly reductions in poverty and in regional inequalities. In the 70s and early 80s, Brazil underwent a period of social mobilisation in which people campaigned for basic rights, including universal health care access. The demand for greater decentralisation of public resources led to an increase in the budget of cities and states. These factors contributed to the implementation of the Brazilian Unified Health System (SUS -
Sistema Único de Saúde) in 1990 [
4].
SUS is intended to provide healthcare free of charge to the whole Brazilian population, financed through direct and indirect sources such as tax revenues, social contributions, out-of-pocket spending, and employers’ health-care spending [
5]. It includes primary health care units, hospitals, emergency departments, laboratories and blood centres. In 2006, SUS budget reached around USD $15 billion, which represents 54% of the country’s total health expenses [
6]. Although access has expanded over the years, the increasing demands on SUS have had negative repercussions on the quality of the services delivered and on waiting times in hospitals and emergency departments [
5].
In 2011, 22% of total health expenditure was spent on the payment of private health insurance [
7]. The proportion of out-of-pocket expenses has continued to rise in spite of the implementation of SUS, from 9% in 1981 to 15% in 2003 and 19% in 2008 [
5]. Out-of-pocket expenses are particularly concerning due to the difficulty in accurately predicting these costs [
8] which can lead to catastrophic health spending. This is a problem affecting up to 16% of all Brazilian families [
8‐
11].
Brazil and various other Latin American countries have undergone rapid demographic, epidemiological and nutritional transitions [
12]. Dietary shifts towards low consumption of fiber and heavy consumption of saturated fatty acids and sugar and sedentary lifestyles are key contributors to the incidence of obesity, type 2 diabetes, and other chronic diseases [
13]. Non-communicable diseases (NCDs) have become a major health priority in Brazil with an estimated 74% of all deaths attributable to NCDs in 2010 [
14]. National estimates indicate that people with diabetes experience a 57% greater risk of death than the general population [
15]. Beyond the health burden, diabetes is also responsible for increased use of health services and increased costs. Between 1999–2001, it was estimated that about 7.4% of all non-pregnancy related admissions to hospitals and 9.3% of all hospital costs in Brazil were attributable to diabetes [
16].
In the present study we aimed to: (i) identify existing data sources on the prevalence of diabetes and its complications, as well as the direct and indirect costs of diabetes in Brazil; (ii) describe the prevalence of diabetes and its complications - retinopathy, nephropathy, neuropathy, diabetic foot ulcers, amputation, kidney disease, fundus changes, vascular complications; (iii) report evidence on direct and indirect costs; and (iv) review health policies for the management of diabetes and its complications.
Methodology
A comprehensive literature search was conducted to identify articles containing information on type 2 diabetes in Brazil. The following PubMed search strategy was used: ("diabetes mellitus" [MeSH Terms] OR ("diabetes" [All Fields] AND "mellitus" [All Fields]) OR "diabetes mellitus" [All Fields] OR "diabetes" [All Fields] OR "diabetes insipidus" [MeSH Terms] OR ("diabetes" [All Fields] AND "insipidus" [All Fields]) OR "diabetes insipidus" [All Fields]) AND ("brazil" [MeSH Terms] OR "brazil" [All Fields]). The search was limited to articles published in Portuguese, English or Spanish between 2000 and October 2011, without any restrictions on the study design or the level (national or regional) at which the data were collected.
We included all publications providing information on one or more of the following end-points related to diabetes type 2 in Brazil: prevalence and incidence, management (treatment, access, and inequalities), complications (retinopathy, nephropathy, neuropathy, diabetic foot ulcers, amputation, kidney disease, fundus changes, vascular complications) and direct and indirect costs.
Articles were first screened by title and then by abstract. Full-text of selected publications were retrieved and examined regarding eligibility. Reference lists of the selected articles were scrutinized in order to identify relevant references. Official documents from the Brazilian government and the World Health Organization (WHO) were also examined. In addition, we identified unpublished work in the grey literature through Google, the researchers’ own knowledge and consultations with diabetes experts in Brazil.
Conclusions
According to the latest IDF estimates, the prevalence of diabetes in Brazil was 10.3% in 2012. However, this national level estimate hides important intra-country variation.
In the last few years, the Brazilian Ministry of Health has invested considerably in surveillance systems on NCDs. As a result, our review identified a number of data sources relevant to the study of diabetes covering morbidity (SIH-SUS HiperDia), mortality (SIM), risk factors (VIGITEL, ELSA), access and utilisation of health care services (PNAD, POF). However, it seems that the country is still not capitalising on available national data to produce the necessary evidence to identify gaps and formulate appropriate policy responses.
Data on diabetes costs are patchy and out-of-date. A multicountry study estimated that the total annual costs (direct and indirect) of diabetes in the country were USD $22.6 billion in 2000, representing a direct cost per capita of US $872. A more recent study estimated the direct and indirect costs of diabetes to be USD $ 2,108 per capita in 2007. There is some evidence on hospitalisation costs but no evidence on the cost of various types of complications.
A number of policies and programmes have been introduced by the Brazilian government in an attempt to improve access to diabetes care and reduce the prevalence of the disease. These include a national diabetes screening campaign in 2001, the Brazilian Popular Pharmacy programme introduced in 2004 and preventive efforts addressing risk factors (regulation of the food industry, promotion of physical activity through the health gym programme and anti-tobacco programmes).
Considering the magnitude of diabetes in Brazil, the Ministry of Health has adopted several strategies to reduce the costs of the disease in the Brazilian population, highlighting the interventions to be taken at the primary health care level. Specific programmes were implemented aimed at managing diabetes. However, some of the gaps include weak evaluation of the SUS in providing good quality care for patients with diabetes and lack of data on inequalities in access to medicines and health care services including annual testing for complications.
In conclusion, Brazil has the capacity to address and respond to NCDs due to the availability of federal, state and local integrated health programmes currently in operation. There is funding available for NCDs treatment, control and prevention, as well as health promotion, surveillance, monitoring and evaluation activities. However, these resources need to be used in the right way to be effective.
Competing interests
The authors declare that they have no competing interests. The funding to conduct this study was provided by Novo Nordisk Switzerland. The sponsor had no involvement in the study design, data collection and analysis, and writing. AF received travel reimbursement and speaker fees from Novo Nordisk for delivering two presentations on diabetes in EU5 (France, Germany, Italy, Spain and UK) at national diabetes conferences in Portugal and Spain.