According to the Brazilian Institute of Geography and Statistics (IBGE), the total population of Brazil in February 2019 was of 209,575 thousand people, of which 48.90% were men and 51.10% were women.  Around 21.35% of the population are aged 14 years old or less, 69.43% are aged between 15 and 64 years old, and around 9.22% are aged 65 and over (Brazilian Institute of Geography and Statistics, 2019f). It is important to point out that these proportions vary among the five geographic regions in Brazil (North, Northeast, Central-west, South and Southeast). For example, in 2012 the proportion of people aged 65 and over was 4.5% in the Northern region, 7.2% in the North-Eastern region, 8% in both Southern and South-Eastern regions, and 5.8% in the Central-West region (Brazilian Ministry of Health, 2019o).

References:

Brazilian Institute of Geography and Statistics. (2019f). Population projections.

Brazilian Ministry of Health. (2019o). TabNet Win32 3.0: População Residente—Brasil. http://tabnet.datasus.gov.br/cgi/tabcgi.exe?ibge/cnv/popuf.def

Brazil’s geography is mostly continental, with a few small islands that are economically and geographically closely connected with the mainland. The five geographic regions in the country are different in terms of demography. For instance, while the southeast region (that covers 11% of the Brazilian territory) accounts for 43% of the population and 56% of the gross domestic product; the north region (containing most of the Amazon forest) is the second poorest region, after the northeast region, and has the lowest population density (3.9 people per Km²) (Paim et al., 2011). In general, Brazil has a population density of 24.66 inhabitants per square kilometre. Around 76% of the Brazilian population live in urban areas which correspond to 26% of the municipalities; whereas about 60% of the municipalities are considered rural and encompass 17% of the population (Brazilian Institute of Geography and Statistics, 2012).

References:

Brazilian Institute of Geography and Statistics. (2012). Nova proposta de classificacao territorial mostra um brasil menos urbano. https://agenciadenoticias.ibge.gov.br/agencia-noticias/2012-agencia-de-noticias/noticias/15007-nova-proposta-de-classificacao-territorial-mostra-um-brasil-menos-urbano

Paim, J., Travassos, C., Almeida, C., Bahia, L., & Macinko, J. (2011). The Brazilian health system: History, advances, and challenges. The Lancet, 377(9779), 1778–1797. https://doi.org/10.1016/S0140-6736(11)60054-8

The Brazilian official language is Brazilian Portuguese. Despite having a single language spoken around the country, there are around 305 geographically isolated indigenous groups speaking 274 different languages (Ethnologue, 2019). According to the Brazilian Institute of Geography and Statistics, the skin colour or race in Brazil are classified as white (45.2%), black (8.9%), yellow (Asians) (0.5%), mixed race (45.1%), and indigenous (0.4%) people (Azevedo, 2015; Brazilian Institute of Geography and Statistics, 2019k).

References:

Azevedo, A. L. M. dos S. (2015). IBGE – Educa | Jovens. IBGE Educa Jovens. https://educa.ibge.gov.br/jovens/conheca-o-brasil/populacao/18319-cor-ou-raca.html

Brazilian Institute of Geography and Statistics. (2019k, June 17). Popuação residente, por cor ou raça, segundo a situação do domicílio. https://sidra.ibge.gov.br/Tabela/3175

Ethnologue. (2019). Languages per country.

Population projections between 2010 and 2060 show that the proportion of people aged 14 years and below will decrease from approximately 25% to 15%. In the age-group 15-64 years, this proportion will also diminish from around 68% in 2010 to 60% in 2060. Differently, among people aged 65 and over, the proportion will increase from around 7.3% in 2010 to 25.5% in 2060. However, such figures are remarkably different across the country’s regions (more older people tend to be located in the southern areas and fewer older people tend to be located in the northern areas) due to socioeconomic and health conditions that significantly affect life expectancy rates (see next item about life expectancy) (Brazilian Institute of Geography and Statistics, 2019g). In 2019, the growth rate in Brazil was 0.79% per year. (Brazilian Institute of Geography and Statistics, 2019d).

The total dependency ratio in Brazil means the ratio of the population assumed as economically dependent (those under 15 years old and those over 60 years old) and the age segment assumed to be productive (those between 15 and 59 years old) among a population living in a specific geographical area, in a specific year. High values indicate that the “working-age population” must sustain a large proportion of dependents. (RIPSA, 2019). In other words, this measure is used to show differences in the size of population groups that are assumed not to be in engaged in the labour market and those who are. Currently, the total dependence ratio in Brazil is of around 44.29 (2020) and it is expected to increase to 67.23 by 2060. In people aged 65 and over, the dependency ratio is of 14.18, which is expected to reach 42.62 by 2060 (Brazilian Institute of Geography and Statistics, 2019c).

References:

Brazilian Institute of Geography and Statistics. (2019c). IBGE | Projeção da população. https://www.ibge.gov.br/apps/populacao/projecao/index.html

Brazilian Institute of Geography and Statistics. (2019d). IBGE divulga as estimativas da população dos municípios para 2019. https://agenciadenoticias.ibge.gov.br/agencia-sala-de-imprensa/2013-agencia-de-noticias/releases/25278-ibge-divulga-as-estimativas-da-populacao-dos-municipios-para-2019

Brazilian Institute of Geography and Statistics. (2019g). Population projections.

RIPSA. (2019). Razão de Dependência.

The total fertility rate in Brazil in 2019 was 1.77 and this is expected to decrease to 1.68 by 2050. The crude natality and mortality rates in Brazil in 2019 were 14.20 and 6.51, respectively. By 2050, mortality rate is expected to increase to 10.69% and natality rate is expected to decrease to 9.89%. In 2019, mortality rate in children under 2 years old was 11.94%, and this is expected to reduce to 7.24% by 2050 (Brazilian Institute of Geography and Statistics, 2002, 2019f).

The ageing index in Brazil is defined as the number of people aged 60 years and over per every 100 people under 15 years of age, in a population living in a geographical space in a determined year. Advanced values for this index indicate the population is at advanced stages of the demographic transition. The ageing index in Brazil is expected to increase over the years, from 29.55 in 2010 to 173.47 in 2060 (Brazilian Institute of Geography and Statistics, 2020; Interagency Health Information Network, 2008). The median age of the population in 2000 was 24.2 years (23.5 years for men and 24.9 years for women). By 2018, median age raised to 32.6 years (the highest median age was in Rio Grande do Sul (35.9), and the lowest in was in Acre (24.9) (Brazilian Institute of Geography and Statistics, 2002, 2019f).

Life expectancy at birth is also increasing in Brazil, with this being 73.3 for men and 80.2 for women in 2020. By 2060, these are expected to reach 77.9 for men and 84.2 for women. However, life expectancy rates are remarkably different across the country’s regions. For example, the life expectancy for both males and females were 79.6 in Santa Catarina (in the South of Brazil) in 2018 and are expected to increase to 84.5 years in 2060. Differently, in 2018 life expectancy at birth for both genders in the state of Maranhão (in the Northeast of Brazil) was 71.1 and is projected to be 78.2 years in 2060 (Brazilian Institute of Geography and Statistics, 2002, 2019f).

References:

Brazilian Institute of Geography and Statistics. (2002). Tendencia demográfica.

Brazilian Institute of Geography and Statistics. (2019f). Population projections.

Brazilian Institute of Geography and Statistics. (2020). Tabela 4492: Pessoas de 18 anos ou mais de idade que referem diagnóstico médico de diabetes, total, percentual e coeficiente de variação, por condição em relação à força de trabalho na semana de referência e situação do domicilio. SIDRA. https://sidra.ibge.gov.br/tabela/4492

Interagency Health Information Network (Ed.). (2008). Indicadores básicos para a saúde no Brasil: Conceitos e aplicações (2a edição). Organização Pan-Americana da Saúde, Escritório Regional para as Américas da Organização Mundial da Saúde. http://tabnet.datasus.gov.br/tabdata/livroidb/2ed/indicadores.pdf

With regards to within country migration, in 2010, around 35% of the population did not live in the city where they were born, and 14.5% (26 million) lived in another state. The number of migrants is bigger in Southern areas, whilst most people in Northern areas are originally from there. São Paulo (19.4%), Rio de Janeiro (13,1%), Paraná (16.3%) and Goiás (26.6%) had the highest proportions of people who were not originally from there. Minas Gerais (18.4%), Bahia (22.1%), São Paulo (5.8%) and Paraná (21.1%) had the largest number of people who emigrated to another state (Brazilian Institute of Geography and Statistics, 2010b, 2010a).

With regards to international migration, in 2010, Brazil had received around 268,500 migrants from other countries, 86.7% more than in 2000 (143,600). Of the total of international migrants, 174.6 thousand (65.0%) were Brazilians returning to Brazil. Most of the migrants were coming from the United States (51.9 thousand) and Japan (41.4 thousand). (Brazilian Institute of Geography and Statistics, 2010b, 2010a).

Until 1980, outmigration in Brazil used to be rare, with more people emigrating to Paraguay. In the recent years, outmigration from Brazil has become more common, frequently occurring to the United States (around 750,000 people), Paraguay (350,000), and Japan (250,000). Other countries receiving Brazilians are Portugal (circa of 65,000 people), Italy (65,000), Swiss (45,000), and the UK (30,000). Around other 500,000 Brazilians are living abroad in Europe and other continents (Committee on foreign affairs and national defense, 2004).

References:

Brazilian Institute of Geography and Statistics. (2010a). Proporcao de migrantes entre grandes regioes, UFs e municipios. https://brasilemsintese.ibge.gov.br/populacao/proporcao-de-migrantes-entre-grandes-regioes-ufs-e-municipios.html

Brazilian Institute of Geography and Statistics. (2010b). Vamos conhecer o Brasil. Nosso povo: Migracao e deslocamento.

Committee on foreign affairs and national defense. (2004). Brasileiros no Exterior. Portal da Câmara dos Deputados.

Risk behaviours

In 2017, around 10.1% of the adult population (≥18 years old) smoked tobacco, of which 2.6% were classified as heavy smokers (≥20 cigarettes/per day) and 6.7% were passive smokers in the work environment. Around 54% of people were classified as being overweight (IMC≥35) and 18.9% were obese (≥30). About 14.6% consumed sugary drinks five or more days per week and 19.1% regularly consumed alcohol to excess. Around 13.9% of both men and women (≥18 years old) were physically inactive. There was a greater difference among sex in the age group between 18 and 24 years where 21% of the women and 9% of men were physically inactive. Besides, physical inactivity was increased among people with fewer years of schooling (Brazilian Ministry of Health, 2017b).

Diabetes

The prevalence rate of diabetes in Brazil varied from 8 to 9%, and 8.1% when adjusted by age, according to the Brazilian Society of diabetes in 2017 (Brazilian Society of Diabetes, 2017). Between 2006 and 2016, the number of people with diabetes grew by 61.8%, amounting to 8.9% of the population (9.9% in women and 7.8% in men) (Ministry of Health, 2017). In 2017, estimates from the Brazilian Ministry of Health based on data from 27 large cities (people aged 18+) showed that the prevalence of diabetes in the urban population was 7.6% for both genders. However, this rate tended to increase with age and was higher among those with lower education levels (up to eight years of education) (Brazilian Ministry of Health, 2017b). Estimates from the National Health Research 2013 revealed that the prevalence of diabetes was 4.6% in people aged 18 years and over in the rural population of Brazil (Brazilian Institute of Geography and Statistics, 2020).

High Blood Pressure

The prevalence of high blood pressure in the population aged 18 and over is about 24.3%, being higher in women (26.4%) than in men (21.7%). In both genders, prevalence rate tended to increase with age and was higher in those with low levels of education (up to 8 years of education) (Brazilian Ministry of Health, 2017b).

Obesity

The prevalence of being overweight is about 54%, being higher in men (57.3%) than in women (51.2%). Women who were older were more likely to be overweight, while those who were more educated were less likely to be overweight. No specific pattern was observed for men. The prevalence of obesity was 18.9% for men and women. The frequency of obesity was lower among more educated women, but no particular pattern was observed among men (Brazilian Ministry of Health, 2017b).

Mental disorders

Between 1999 and 2016, Alzheimer’s disease was one of the ten leading causes of age-standardised years of life lost (YLL) rate in Brazil. This condition was also among the main causes of years of life lived with disability (YLD) in 2016 together with depressive, bipolar and anxiety disorders (GBD 2016, 2018). According to a WHO report, the prevalence of depressive disorders in Brazil was 5.8% and of anxiety disorders was 9.3% in 2017 (World Health Organization, 2017). We could not find any report document ‘mental disorders’ more generally.

References:

Brazilian Institute of Geography and Statistics. (2020). Tabela 4492: Pessoas de 18 anos ou mais de idade que referem diagnóstico médico de diabetes, total, percentual e coeficiente de variação, por condição em relação à força de trabalho na semana de referência e situação do domicilio. SIDRA. https://sidra.ibge.gov.br/tabela/4492

Brazilian Ministry of Health. (2017b). Ministry of Health Report on Surveillance of Risk Factors.

Brazilian Society of Diabetes. (2017). Atlas da diabetes no Brasil.

GBD 2016. (2018). Burden of disease in Brazil, 1990-2016: A systematic subnational analysis for the Global Burden of Disease Study 2016. The Lancet Neurology, 392. http://dx.doi.org/10.1016/S0140-6736(18)31221-2

Ministry of Health. (2017). Ministry of Health Report on Surveillance of Risk Factors.

World Health Organization. (2017). Depression and Other Common Mental Disorders: Global Health Estimates. https://apps.who.int/iris/bitstream/handle/10665/254610/WHO-MSD-MER-2017.2-eng.pdf;jsessionid=F9B8AE77F2B1D3698E01577B2AFCBC03?sequence=1

HIV/AIDS

From 1980 to June 2018, 926,742 HIV positive cases were identified in Brazil, with an annual record of 40,000 new cases. In 2012, detection rate was 21.7 cases per 100 thousand inhabitants, whereas in 2017, detection rate was 18.3, representing a decrease of 15.7%. In four years, there was also a decrease of 16.5% in the mortality rate from the disease, from 5.7 per 100 thousand inhabitants in 2014 to 4.8 deaths in 2017.  Around 73% of new HIV infections occur among males, 70% of whom are aged between 15 and 39 years (Brazilian Ministry of Health, 2018f). Such decline might be related to more accessible treatment for all, better diagnosis rates, reduced time between diagnosis and start of treatment, and better access to testing (Brazilian Ministry of Health, 2018f).

Tuberculosis

In 2017, 69,569 new cases of tuberculosis were reported in Brazil. Incidence rate equalled 33.5 cases per 100 thousand inhabitants. From 2008 to 2017, this coefficient showed an annual average decrease of 1.6%. In 2016, 4,426 deaths from tuberculosis were recorded, resulting in a mortality rate equal to 2.1 deaths per 100 thousand inhabitants, reflecting an annual average decrease of 2.0% from 2007 to 2016. The distribution of both indicators was heterogeneous by regions, states, and capitals. However, the tuberculosis situation in the capitals of the country requires attention, since 70.4% of them (19 capitals) had an incidence rate higher than that recorded in the entire country. The highest mortality rates in 2016 were recorded in the north and northeast cities -in Recife (6.4 per 100 thousand inhabitants), Belém (5.3 per 100 thousand inhabitants) and Manaus (4.7 per 100 thousand inhabitants) (Brazilian Ministry of Health, 2018c), possibly given to lower socioeconomic status in these cities. In 2017, 13.347 relapse cases/treatment were registered in the country, equivalent to 16.1% of total cases reported in the period. The states with the highest proportion of retreatments were Rio Grande do Sul (23.3%), Rondônia (19.9%) and Paraíba (19.5%). This result is similar to that observed in the capitals, among which the highest proportion of retreatment was recorded in Porto Alegre (31.2%), Campo Grande (25.8%), João Pessoa (23.8%) and Porto Velho (23.3%) (Brazilian Ministry of Health, 2018c).

Dengue /Zika Virus/ Chikungunya

Brazil faces epidemic levels of mosquitoes-transmissible diseases (e.g. Aedes aegypti), such as dengue, zika virus, yellow fever and chikungunya, all of which take a great proportion of financial and human resources in the primary, secondary and tertiary care sectors in Brazil, in both private and public health services. According to a report published in March 2019 by the Ministry of Health comparing the epidemiological situation of dengue, chikungunya and zika in 2018 and in 2019, the number of cases with such diseases has increased considerably, as per information below (Brazilian Ministry of Health, 2019f).

Dengue: In 2019 (up to week 11), there were 229,064 probable cases of dengue in the country, with an incidence rate of 109.9 cases per 100 thousand inhabitants. In the same period of 2018, there were 62,904 probable cases. The South-Eastern region had the highest number of probable cases (149,804 cases, 65.4%) in relation to the country rates, followed by the Midwest (40,336 cases, 17.6%), the North (15,183 cases, 6.6%), the Northeast (17,137 cases, 7.5%) and the South (6,604 cases, 2.9%). The incidence rate of probable dengue cases (per 100 thousand inhabitants) up to week 11 of 2019 shows that the Centre-West and Southeast regions had the highest incidence rates: 250.8 cases per 100 thousand inhabitants and 170.8 cases per 100 thousand inhabitants, respectively (Brazilian Ministry of Health, 2019f).

Chikungunya: In 2019 (until week 11), there were 12,942 probable cases of chikungunya in the country, with an incidence rate of 6.2 cases per 100 thousand inhabitants. At the same week of 2018, 23,484 probable cases were registered. In 2019, the Southeast region had the highest number of probable cases of chikungunya (8,536 cases, 66.0%) in relation to the total of the country. The North (2,139 cases, 16.5%), the Northeast (1,786 cases, 13.8%), the Central Region (293 cases, 2.3%) and the South (188 cases, 1.5%). The incidence rate of probable cases of chikungunya in 2019 shows that the North and the Southeast regions had the highest incidence rates: 11.8 cases per 100 thousand inhabitants and 9.7 cases per 100,000 inhabitants, respectively (Brazilian Ministry of Health, 2019f).

Zika virus: In 2019 (until September 9), 2,062 probable cases of Zika were registered in the country, representing an incidence rate of 1 case per 100 thousand people. During the same period of 2018, 1,908 probable cases had been registered. In 2019, the northern region has had the highest number of probable cases (912 cases, 44.2%) in relation to the country’s total figures – the Southeast: 584 cases, 28.3%; the Midwest: 176 cases, 8.5%; the Northeast: 343 cases, 16.6%; the South: 47 cases, 2,3 %. The incidence rate of probable Zika cases shows that the Northern region has had the highest incidence rate: 5 cases per 100 thousand inhabitants. Among the UFs, Tocantins (47 cases per 100 thousand inhabitants) and Acre (9.5 cases per 100 thousand inhabitants) have had the highest numbers (Brazilian Ministry of Health, 2019f).

Yellow fever: With regards to yellow fever, between January and May 2019, 68 cases were confirmed in the state of São Paulo, 12 in Paraná and one case in Santa Catarina (total=81 cases). The majority of the cases were among rural workers and/or among people with higher exposure to the mosquitos, of which 72 (88.9%) were males, aged between eight and 87 years. Among the confirmed cases, 14 led to death (17.3%). The total number of human cases recorded in the same period of 2018 was 1,309, showing an important decrease in the number of cases in the country (Brazilian Ministry of Health, 2018d).

Influenza: Brazil has also epidemic periods of influenza, which the country has been trying to control through vaccination and education (e.g. hand washing). It affects mostly vulnerable populations such as babies, pregnant women, older adults, health professionals, carers, bed-bound people, and people with potentially compromised immune systems – HIV, cancer, lupus, etc.). Brazil has a national online system for compulsory registration of Influenza cases (SINAN, 2019).

References:

Brazilian Ministry of Health. (2016b). Panorama da tuberculose no Brasil: A mortalidade em números.

Brazilian Ministry of Health. (2018c). Implantação do Plano Nacional pelo Fim da Tuberculose como Problema de Saúde Pública no Brasil: Primeiros passos rumo ao alcance das metas (Vol. 49).

Brazilian Ministry of Health. (2018d). Monitoramento do Período Sazonal da Febre Amarela Brasil – 2017/2018 (Issue Figura 1).

Brazilian Ministry of Health. (2018f). Pará está entre os estados com redução de óbitos por AIDS. Ministério Da Saúde.

Brazilian Ministry of Health. (2019f). Monitoramento dos casos de arboviroses urbanas transmitidas pelo Aedes (dengue, chikungunya e Zika) até a Semana Epidemiológica 11 de 2019 (Vol. 50, Issue Tabela 1).

SINAN. (2019). Sistema de Informação de Agravos de Notificação. http://www.portalsinan.saude.gov.br/

According to a map of violence produced by the Institute for Applied Economic Research (IPEA) and the Brazilian Forum of Public Security (FBSP), the homicide rate in Brazil was 30 times higher than that in Europe in 2016 (62,517 murders). Considering only the last decade, 553,000 Brazilians lost their lives through violent death (153 deaths per day). Such deaths represent almost 10% of all deaths in the country and affect mainly young men: 56.5% of the deaths of Brazilians aged between 15 and 19 are from violent deaths. Young victims represent 53.7% of the total number of deaths in the country (that is, 33,590 deaths), 94.6% of whom are males. The number of violent deaths also reflects great racial inequality: 71.5% of the people murdered are black or mixed race (Institute for Applied Economic Research, 2018).

Despite the alarming numbers at the national level, the disparity between the Federation Units draws attention. There was a reduction of homicide rates in the last decade in states such as São Paulo (-46.7%), Espírito Santo (-37.2%) and Rio de Janeiro (-23.4%), and a growth in others, such as Rio Grande do Norte (256.9%), Acre (93.2%), Rio Grande do Sul (58.8%) and Maranhão (121.0%). By 2016, the homicide rate per 100,000 inhabitants had reached almost 45 in the states of the Northeast and the North. In the Southeast, on the other hand, the value was in the 20’s, slightly below the 25 reached by the Southern states (Institute for Applied Economic Research, 2018).

Most homicides in Brazil are caused by fire guns: from 1980 to 2016, almost one million Brazilians lost their lives because of fire guns. A total of 71.1% of homicides was committed with the use of fire guns (a rate that grew for decades until 2003, the year of the creation of the disarmament statute) (Institute for Applied Economic Research, 2018). Currently the Brazilian new government is starting to allow more sectors of the population to have a fire gun.

References:

Institute for Applied Economic Research. (2018). Atlas da violência.

According to the World Bank metrics, Brazil is an upper middle-income country and one of the biggest economies in the world. In 2017, the GDP per capita (PPP – current international $), was 15,553.4 – representing a total economic turnover of 2,056 trillion USD. Comparatively, Mexico has 1.15 trillion USD and Argentina has 637.6 billion. Brazil has experienced a remarkable growth in the last decade, which made  the country become the fifth largest economy in the world (The World Bank, 2019).

References:

The World Bank. (2019). The World Bank Data. https://data.worldbank.org/indicator/NY.GDP.PCAP.PP.CD

Brazil’s GDP in 2018 was US$1.6 trillion. The country’s economy is composed of services (the main productive sector), followed by industry (e.g.: textiles, shoes, chemicals, cement, lumber, iron ore, tin, vehicles etc.); and agriculture (e.g.: coffee, soybeans, wheat, rice, corn, sugarcane, cocoa, citrus and beef) (Brazilian Institute of Geography and Statistics, 2019i, 2019h).

References:

Brazilian Institute of Geography and Statistics. (2019h). Produto Interno Bruto—PIB | IBGE. https://www.ibge.gov.br/explica/pib.php

Brazilian Institute of Geography and Statistics. (2019i). SIDRA – Tabela 1846: Valores a preços correntes.

The total public debt in Brazil (aggregating the national, state, and municipal governments) was 77.6% of the national GDP in 2018. The public debt can be separated into internal debt (approximately 70% of the GDP) and external (less than 10% of the GDP) (Central Bank of Brazil, 2019). We could not find information about private debt.

References:

Central Bank of Brazil. (2019). Estatísticas fiscais. Estatísticas fiscais. https://www.bcb.gov.br/estatisticas/estatisticasfiscais

The country has experienced an increase in the number of people living in extreme poverty (from 6.6% in 2016 to 7.4% in 2017; that is from 13.5 million to 15.2 million people). There was also an increase in the proportion of people living below the poverty line (income of up to $5.50 a day). In 2017, this number stood at 26.5%, compared to 25.7% the year before. Such rates represent a change from 52.8 million to 54.8 million people. Most of people affected —over 25 million — live in the North Eastern region of the country (Brazilian Institute of Geography and Statistics, 2018c). The GINI index in Brazil was reported at 51.3 in 2015 (Trading Economics, 2019). With regards to gender equality, national figures (2016) reveal gender inequality across the country. For example, women devote about 73% more hours to domestic and/or household chores than men (18.1 hours versus 10.5 hours). The greatest inequality in the distribution of hours dedicated to these activities is in the Northeast Region, where women dedicate about 80% more hours than men, reaching 19 more hours a week. Black or mixed-race women are the ones that dedicate themselves the most to the care of people and/or household chores, with a record of 18.6 hours per week in 2016. Such figures vary little for men when considering ethnicity or region of residence (Brazilian Institute of Geography and Statistics, 2018b, 2019b).

References:

Brazilian Institute of Geography and Statistics. (2018b). Estatísticas de Gênero Indicadores sociais das mulheres no Brasil.

Brazilian Institute of Geography and Statistics. (2018c). Síntese dos Indicadores Sociais, uma análise das condições de vida da populção brasileira.

Brazilian Institute of Geography and Statistics. (2019b). Gender Statistics—Social indicators of women in Brazil. IBGE.

Trading Economics. (2019). Brazil—Gini Index. https://tradingeconomics.com/brazil/gini-index-wb-data.html

Brazil was the only country in the Americas that is among the world’s ten countries with the highest number of people affected by disasters between 1995 and 2015. Most incidents are related to rain/flooding-related disasters (Federal University of Santa Catarina, 2013). From 2008 to 2013, 40.9% of Brazilian municipalities suffered at least one natural disaster. Around 2,376 cities were affected by gradual flooding, abrupt floods and/or landslides in that period. Gradual flooding alone left 1,406,713 people homeless or displaced. Almost 50% of the 5,570 city councils around the country had no resources to deal with these occurrences (Brazilian Institute of Geography and Statistics, 2019e). In the last four years, two large environmental accidents happened in the state of Minas Gerais, which were associated with crime. The first was in 2015: a dam disruption in the city of Mariana led to 19 deaths, communities were destroyed, rivers were polluted and the vegetation was devastated (Brazil Agency (EBC), 2018). A little more than three years later, another dam disruption occurred in the same state, but in the city of Brumadinho. This disaster led to 179 accounted deaths and 134 people disappeared. A “muddy sea” invaded the region destroying communities and the entire city of Brumadinho and put forest areas at risk of contamination. Both environmental disasters were under the responsibility of a company called Vale do Rio Doce (Brazil Agency (EBC), 2019).

References:

Brazil Agency (EBC). (2018, November 5). Tragédia Mariana. Agência Brasil. http://agenciabrasil.ebc.com.br/geral/noticia/2018-11/tragedia-de-mariana-completa-3-anos-veja-linha-do-tempo

Brazil Agency (EBC). (2019, February 25). Tragédia em Brumadinho. Agência Brasil. http://agenciabrasil.ebc.com.br/geral/noticia/2019-02/tragedia-em-brumadinho-completa-um-mes-com-134-desaparecidos

Brazilian Institute of Geography and Statistics. (2019e). Perfil dos municípios brasileiros 2013. IBGE. https://biblioteca.ibge.gov.br/visualizacao/livros/liv86302.pdf

Federal University of Santa Catarina. (2013). Atlas brasileiro de desastres naturais 1991 a 2012.

Government data published in May 2019 showed that 12.7% of the population are currently unemployed, with the highest concentration among young people, women, black, and mixed-race individuals. The unemployment rate in the age group 14 to 17 years reached 44.5%. Among those aged 18 to 24 years, the proportion of unemployed reached 31.9% in the Northeast region. However, the largest proportion of unemployment is concentrated among the population aged 25-59 (57.2%), followed by people aged 18 to 24 (31.8%), adolescents (8.3%) and people aged 60+ (2.6%). Women made up the majority (52.6%) of the unemployed population and the population outside the workforce (64.6%). Among men, the unemployment rate was 10.9% in the first quarter 2019, while among women it was 14.9% (Brazilian Institute of Geography and Statistics, 2019j).

References:

Brazilian Institute of Geography and Statistics. (2019j, April 30). Desemprego sobe para 12,7% com 13,4 milhões de pessoas em busca de trabalho. IBGE – Agência de Notícias. https://agenciadenoticias.ibge.gov.br/agencia-noticias/2012-agencia-de-noticias/noticias/24283-desemprego-sobe-para-12-7-com-13-4-milhoes-de-pessoas-em-busca-de-trabalho

In 2019, we identified the highest proportion  of people having informal jobs (these are jobs without constitutional work rights, without formal job contract): 41.4% (Brazilian Institute of Geography and Statistics, n.d.). Data from a National Survey from 2015 (PNAD), showed that among the private sector, 20.6% of the workers were informal workers (that means without formal job contract) (Brazilian Institute of Geography and Statistics, 2015b).

References:

Brazilian Institute of Geography and Statistics. (n.d.). Desemprego cai para 11,8% com informalidade atingindo maior nível da série histórica. Retrieved December 3, 2019, from https://agenciadenoticias.ibge.gov.br/agencia-noticias/2012-agencia-de-noticias/noticias/25534-desemprego-cai-para-11-8-com-informalidade-atingindo-maior-nivel-da-serie-historica

Brazilian Institute of Geography and Statistics. (2015b). Pesquisa Nacional por Amostra de Domicílios—2015. https://biblioteca.ibge.gov.br/visualizacao/livros/liv98887.pdf

Education is a constitutional right in Brazil and is offered freely through state schools, from nursery to post-graduate levels (Fortuna, 2018). From nursery to high school, education can be either full time or part time and includes free meals. State schools/universities are funded through the Federal, State or Municipal governments. However, given the low quality of education up to the end of high school in most areas of the country, many Brazilian citizens with the available means end up paying for private education. Around 21.7% of all schools in the country are private. Whilst state-funded schools represent the majority, only 36% of all students attending state schools end up going to university, whereas this rate reaches 79.2% in the private sector (self-funded). Whilst 51% of white students went to university in 2017, only 33.4% of black and mixed-race minority groups had the opportunity. In the private sector, though black and mixed-race people continue to be disadvantaged, the difference between the two groups reduced by 10%. Those who go to university are also the richest – the largest proportion of students in higher education come from families who are among the richest twenty five per cent of the country (Brazilian Institute of Geography and Statistics, 2018a).

Brazil has a system by which people from state schools and ethnic minorities have a small advantage when applying to state universities and might be entitled to scholarships to attend private universities. The government also provides loans for those who do not fit the criteria to the latter. Data from 2016 shows that among the population aged 15 years and over, the illiteracy rate is 7.2% (11.8 million people) (Ferreira, 2017). In people aged 60+, this index is almost three times higher (20.4%). The Northeast is the area with the highest illiteracy rate in Brazil: 14.8%. The lowest index is registered in the Southern region, with an illiteracy rate of 3.6%. Again, more black people are illiterate in comparison to white people (9.9% vs. 4.5%, respectively). Males are slightly more illiterate than females (7.4% vs. 7.0%, respectively). Besides the 7.2% of illiterate people, 21% of Brazilian people are ‘functionally illiterate’ (people who are considered to be educated but who are unable to interpret day-to-day information, including the costs of products in the supermarket, for example). Altogether, there are almost 30% of people in Brazil who are unable to understand basic texts and numbers (INAF, 2018).

References:

Brazilian Institute of Geography and Statistics. (2018a). Escola privada coloca o dobro de alunos no ensino superior em relação à rede pública. https://www1.folha.uol.com.br/educacao/2018/12/escola-privada-coloca-o-dobro-de-alunos-no-ensino-superior-em-relacao-a-rede-publica.shtml

Ferreira, P. (2017). Brasil ainda tem 11,8 milhões de analfabetos, segundo IBGE. https://oglobo.globo.com/sociedade/educacao/brasil-ainda-tem-118-milhoes-de-analfabetos-segundo-ibge-22211755

Fortuna, D. (2018). MEC divulga dados do Censo Escolar da educação básica. Correio Web.

INAF. (2018). INAF BRASIL 2018. https://www.correiodopovo.com.br/notícias/ensino/brasil-tem-cerca-de-38-milhões-de-analfabetos-funcionais-1.268788

The Single System of Social Assistance (Sistema Único de Assistência Social – SUAS) is a public system that organises and provides social assistance services in Brazil. These are organised into two main groups; the first is called Basic Social Protection, aimed at preventing social and personal risks by offering programs, projects, services and benefits to individuals and families in situations of social vulnerability, such as poverty and disability. The second is called Special Social Protection, it is aimed at families and individuals at risk and those whose rights have been violated by experiences, such as the occurrence of abandonment, mistreatment, sexual abuse, and drug use. The most popular policy of the first group is a conditional cash transfer program called ‘Bolsa Família’, which seeks to provide a minimum level of income for those who are below the poverty line. In return, these families need to ensure that their children and young people are attending school and are regularly seen by the primary health care teams  (Brazilian Ministry of Citizenship, 2019).

There are also social protection schemes in place to protect those regularly contributing to the Social Security System (Sistema de Seguridade Social) through formal work from events such as unemployment or illness. Benefits include disability allowance, sick allowance and restrain allowance (to the family of those who are arrested whilst contributing to the Social Security System) (Brazilian Ministry of Citizenship, 2019; Brazilian Ministry of Economy, 2016).

A total of 77,467,360 people subscribed to social protection schemes in September 2019, which represents approximately 38% of the Brazilian population. The aforementioned Bolsa Família programme reached 13,537,137 families during this same period (Brazilian Ministry of Citzenship, 2019).

References:

Brazilian Ministry of Citzenship. (2019). Relatórios de Informações Sociais. https://aplicacoes.mds.gov.br/sagi/RIv3/geral/index.php?file=entrada&relatorio=153#

Brazilian Ministry of Economy. (2016). Seguro-Desemprego. http://trabalho.gov.br/seguro-desemprego

Brazil is a federative republic with a political system composed of three levels of independent government (federal government, 26 states and one federal district, and 5,563 municipalities). The government is led by a president (executive branch), bicameral legislature (chamber of deputies and senate house) and several political parties. Brazil is a democratic nation, governed by means of an independent judiciary, with national and subnational (mandatory voting) electronic elections every four years (Paim et al., 2011). It is a young democracy, still with many contradictions.

References:

Paim, J., Travassos, C., Almeida, C., Bahia, L., & Macinko, J. (2011). The Brazilian health system: History, advances, and challenges. The Lancet, 377(9779), 1778–1797. https://doi.org/10.1016/S0140-6736(11)60054-8

Brazil was colonised by Portugal from 22 April 1500 to 7 September 1822, when the country proclaimed independence. Brazil moved from monarchy to a republic on 15 November 1889. The country had a large influence (culturally, economically, socially, etc.) from African people who were made slaves by Europeans and were brought to Brazil to work on (mainly) coffee plantations. When slavery was abolished in Brazil (13 May 1888), Brazil received hundreds of thousands of Europeans immigrants who came to work (voluntarily) in the plantations.

Brazil had a national election in October 2018, in which the current president (named Jair Bolsonaro) was elected. He is in post since January 2019. In September 2020, state and municipal elections will take place, and the new election for president will take place at the end of 2022.

Transparency International (a global coalition against corruption) ranks corruption among 180 countries by using a scale from 0 to 100, where 0 is highly corrupt and 100 is very clean. In 2018, Brazil presented a score of 35 in that scale and was ranked 105th out of 180 countries (Transparency International, 2018).

References:

Transparency International. (2018). Corruption Perceptions Index 2018—Transparency International. https://www.transparency.org/cpi2018

Political stability index (-2.5 weak; 2.5 strong): the average value for Brazil between 1996 and 2017 was -0.15 points, with a minimum of -0.41 points in 2017 and a maximum of 0.33 points in 2002 (The World Bank, 2019).

References:

The World Bank. (2019). The World Bank Data. https://data.worldbank.org/indicator/NY.GDP.PCAP.PP.CD

The Brazilian health system is comprised of a complex and interconnected mix of public-private service providers and purchasers. The system provides healthcare through three sub-sectors: 1) the public – Unified Health System (Sistema Único de Saúde – SUS) – in which services are financed and provided by the state at the three levels of governance (federal, state, and municipal); 2) the private (for-profit and non-profit) in which services are funded by public and private funds; and 3) the private health insurance sub-sector. People may use services in any of these sub-sectors according to their ability to access and pay for them (Paim et al., 2011).

References:

Paim, J., Travassos, C., Almeida, C., Bahia, L., & Macinko, J. (2011). The Brazilian health system: History, advances, and challenges. The Lancet, 377(9779), 1778–1797. https://doi.org/10.1016/S0140-6736(11)60054-8

The SUS was implemented in 1990. It is state-funded, it provides health services free of charge to the entire population, and it is one of the largest and most complex health systems in the world (Paim et al., 2011). In 2017, it accounted for 8.3% of national revenue, meaning 1.8% of the Brazilian Gross Domestic Product (GDP) in that year  (Brazilian National Treasure, 2018). The SUS provides a range of health services and interventions spanning the whole life-course (from the gestational period to the end of life). These include the primary, secondary, and tertiary levels of care; urgency and emergency systems; hospital care; health and environmental surveillance; and a pharmaceutical assistance program (Brazilian Ministry of Health, 2019k). The system is the major source of healthcare for low-income groups and those without access to private health insurance (Castro et al., 2019). According to the latest published version of the National Health Survey – 2013 (Pesquisa Nacional de Saúde – PNS), around 70% of the Brazilian population do not have private health insurance and therefore benefit from services provided by SUS or pay directly for private health services (Brazilian Ministry of Health, 2013a). The SUS is informed by local, municipal, state, and federal councils that aim to embed the population’s voices and needs into policy.

References:

Brazilian Ministry of Health. (2013a). Pesquisa Nacional de Saúde 2013: Acesso e Uitlização dos Serviços de Saúde, Acidentes e Violências. https://biblioteca.ibge.gov.br/visualizacao/livros/liv94074.pdf

Brazilian Ministry of Health. (2019k). Sistema Único de Saúde (SUS): Estrutura, principios e como funciona. http://www.saude.gov.br/sistema-unico-de-saude

Brazilian National Treasure. (2018). Aspectos Fiscais da Saúde no Brasil. https://sisweb.tesouro.gov.br/apex/f?p=2501:9::::9:P9_ID_PUBLICACAO:28265

Castro, M. C., Massuda, A., Almeida, G., Menezes-Filho, N. A., Andrade, M. V., Noronha, K. V. M. de S., Rocha, R., Macinko, J., Hone, T., Tasca, R., Giovanella, L., Malik, A. M., Werneck, H., Fachine, L. A., & Rifat, A. (2019). Brazil’s unified health system: The first 30 years and prospects for the future. Lancet Health Public. https://www.abrasco.org.br/site/wp-content/uploads/2019/07/PIIS0140673619312437.pdf

Paim, J., Travassos, C., Almeida, C., Bahia, L., & Macinko, J. (2011). The Brazilian health system: History, advances, and challenges. The Lancet, 377(9779), 1778–1797. https://doi.org/10.1016/S0140-6736(11)60054-8

The private health sector has been an important part in the provision of care in Brazil and is spread across the country. The private healthcare sector connects with the public sector by providing services contracted-out by the SUS, out of pocket hospital, and ambulatory services, drugs, and through private health plans and insurance. Private healthcare services are financed both by the SUS and private sources. Data from the report “Fiscal Aspects of Health in Brazil” state that 55% of the total expenditure in health comes from private expenditure/sources and 45% comes from public expenditure/sources (Brazilian National Treasure, 2018; OPAS/OMS, 2019).

It is important point out that over 70% of the total population do not count on private insurances for their healthcare needs (>190 million people) (Brazilian Ministry of Health, 2013a). A survey conducted in 2018, commissioned by the Credit Protection Service (SPC Brasil) and by the National Confederation of Store Owners (CNDL), showed that, of the 70% who do not hold a health insurance, nearly 45% report to use SUS whenever they need it, while the remaining proportion reports to pay in cash for their healthcare whenever they need it (Agencia Brasil, 2018). Mostly due to the long waiting time for consultations, some people pay for it privately and then do the exams requested by the clinician through the public health system, for example. Also, most people get their vaccinations done through SUS, and may get their medication free of charge also out from the primary healthcare services (Agencia Brasil, 2018).

By the end of 2018, according to the National Regulatory Agency for Private Health Insurances and Plans (Agência Nacional de Saúde Suplementar – ANS), around 23.3% of the Brazilian population had a private health care insurance (National Regulatory Agency for Private Health Insurances and Plans, 2019b). Main users of private health plans are employees from public and private companies that offer private health coverage. The insurances vary in quality and amenities according to socioeconomic and occupational status of the demanders. Within one company, employees may have different levels of health care coverage depending on occupational hierarchy. Even though people with private health care insurance might benefit from more “premium” health plans, they often receive vaccines, high-cost, and complex services through SUS (Paim et al., 2011).

References:

Agencia Brasil (EBC). (2018, November 5). Tragédia Mariana. Agência Brasil. http://agenciabrasil.ebc.com.br/geral/noticia/2018-11/tragedia-de-mariana-completa-3-anos-veja-linha-do-tempo

Brazilian Ministry of Health. (2013a). Pesquisa Nacional de Saúde 2013: Acesso e Uitlização dos Serviços de Saúde, Acidentes e Violências. https://biblioteca.ibge.gov.br/visualizacao/livros/liv94074.pdf

Brazilian National Treasure. (2018). Aspectos Fiscais da Saúde no Brasil. https://sisweb.tesouro.gov.br/apex/f?p=2501:9::::9:P9_ID_PUBLICACAO:28265

National Regulatory Agency for Private Health Insurances and Plans, M. (2019b). Caderno de Informação da Saúde Suplementar: Beneficiários, operadoras e planos. Março 2019. https://www.gov.br/ans/pt-br/arquivos/acesso-a-informacao/perfil-do-setor/dados-e-indicadores-do-setor/informacoes-gerais/total-cad-info-jun-2019.pdf

OPAS/OMS. (2019). OPAS/OMS Brasil—Países estão gastando mais em saúde, mas pessoas ainda pagam muitos serviços com dinheiro do próprio bolso. https://www.paho.org/pt/noticias/20-2-2019-paises-estao-gastando-mais-em-saude-mas-pessoas-ainda-pagam-muitos-servicos-com

Paim, J., Travassos, C., Almeida, C., Bahia, L., & Macinko, J. (2011). The Brazilian health system: History, advances, and challenges. The Lancet, 377(9779), 1778–1797. https://doi.org/10.1016/S0140-6736(11)60054-8

The primary care system is conceptualized for acting as a gatekeeper system. This is one of the aims in the provision of health care in Brazil. The primary care model is in line with the provision of universal access and comprehensive healthcare, it aims to coordinate  the access to specialist and hospital care, and it promotes actions for health promotion and disease prevention (Paim et al., 2011). Investments and organisational strategies, such as the establishment of the Community Health Agents Programme and the Family Health Strategy – FHS, have been carried out and have been helpful to reorganize primary care clinics to focus on the community and to integrate medical care with health promotion and public health actions (Brazilian Ministry of Health, 2019d; Paim et al., 2011).

In addition, more investments in decentralized and computerized regulatory systems have been made by municipalities. These result in the possibility of monitoring of waiting lists for specialized care, increase of service supply, introduction to clinical guidelines, and use of electronic medical records. These strategies end up integrating primary healthcare with the network of specialised services (Paim et al., 2011). According to a study conducted in four Brazilian capitals, referrals to secondary care services that come from family health care teams are usually more effective and have shorter waiting times (Almeida et al., 2010). Although all these advances have been achieved, it is necessary to remember that the primary care system in Brazil may be circumvented by people willing to pay out-of-pocket to access services immediately.

References:

Almeida, P. F. de, Giovanella, L., Mendonça, M. H. M. de, & Escorel, S. (2010). Desafios à coordenação dos cuidados em saúde: Estratégias de integração entre níveis assistenciais em grandes centros urbanos. Cadernos de Saúde Pública, 26(2), 286–298. https://doi.org/10.1590/S0102-311X2010000200008

Brazilian Ministry of Health. (2019d). Estratégia Saúde da Família (ESF).

Paim, J., Travassos, C., Almeida, C., Bahia, L., & Macinko, J. (2011). The Brazilian health system: History, advances, and challenges. The Lancet, 377(9779), 1778–1797. https://doi.org/10.1016/S0140-6736(11)60054-8

Yes, universality is one of the principles of SUS. The SUS is based on three doctrinal principles: universality (any Brazilian citizen has the right to access health services in Brazil – this right is well stablished by the Federal Constitution, 1988), equity (aims to diminish health inequalities), and integrated care (regarding person-centred care) (Brazilian Ministry of Health, n.d.-b).

Potential barriers for universal access to health are geographical (related to distance and transportation costs to health care units), financial (the more expensive the services are, the less accessible they become), managerial (quality of personal, waiting lists etc.), and informational (related to education, self-perception of health etc.).

Access to health services is more problematic in some areas, such as riverside communities and in the countryside. Difficult access to these remote areas, in  addition to poor working conditions discourages health professionals to work in such places (Brazilian Society for Medical Clinic, 2019). As an attempt to overcome this barrier, the government developed strategies such as the fluvial family health strategies (where family health teams go to riverside communities by boat) to expand access in places like Amazonia. In addition, the National Policy for Primary Care expands the coverage of health services provision through the creation of UBSs (Basic Care Units) and emergency care units (UPAs) (Brazilian Ministry of Health, 2012). Access to health services is also problematic among indigenous people due to difficulties regarding geographical access, cultural aspects etc. Therefore, the Ministry of Health put together a specific unit responsible for delivering health services for indigenous people (Brazilian Ministry of Health, 2019p).

References:

Brazilian Ministry of Health. (2012). Política Nacional de Atenção Básica. http://189.28.128.100/dab/docs/publicacoes/geral/pnab.pdf

Brazilian Ministry of Health. (2019p, June 20). Secretaria Especial de Saúde Indígena. https://www.gov.br/saude/pt-br/assuntos/sesai_noticias/secretaria-da-sesai-acompanha-mutirao-na-casai-de-goiania

Brazilian Ministry of Health. (n.d.-b). Princípios do SUS. Retrieved December 3, 2019.

Brazilian Society for Medical Clinic. (2019). Médicos para as áreas remotas. Sociedade Brasileira de Clínica Médica. http://www.sbcm.org.br/v2/index.php/artigo/2802-medicos-para-as-areas-remotas-

The Brazilian health system is financed through taxes, social contributions (taxes for special programmes), out-of-pocket spending, and employers’ healthcare contributions (Paim et al., 2011). The financing of the SUS is funded by the public sector through three levels of governance (federal, states, and municipalities) and it is guaranteed by the Federal Constitution of 1988 (Presidency of Republic of Brazil, 1988). Funding for the SUS comes from tax revenues and social contributions of the federal government, and from state, and municipal budgets (Paim et al., 2011). The federal government is the main financing body and follows a calculation based on GDP that reveals the percentage to be invested in SUS per year (Presidency of Republic of Brazil, 2012, p. 141).

According to the Law N. 141 (2012), states and municipalities must invest a minimum of 12% and 15% of their revenue in SUS, respectively (Presidency of Republic of Brazil, 2012). However, funding for the SUS has not been enough to ensure adequate or stable financial resources for the public system (Paim et al., 2011). The private health sector is financed both by the SUS (via services contracted-out by the public health system) and by private sources such as individuals who make out-of-pocket payments for private health services and employer’s healthcare contributions. Data show that in 2017, private health services accounted for 66.8% of families’ health-related expenditure (Brazilian Institute of Geography and Statistics, 2019a).

References:

Brazilian Institute of Geography and Statistics. (2019a). Conta-satélite de saúde: Brasil: 2010-2017. https://biblioteca.ibge.gov.br/index.php/biblioteca-catalogo?view=detalhes&id=2101690

Paim, J., Travassos, C., Almeida, C., Bahia, L., & Macinko, J. (2011). The Brazilian health system: History, advances, and challenges. The Lancet, 377(9779), 1778–1797. https://doi.org/10.1016/S0140-6736(11)60054-8

Presidency of Republic of Brazil. (1988). Federal Constitution of Brazil. http://www.planalto.gov.br/ccivil_03/constituicao/constituicao.htm

Presidency of Republic of Brazil. (2012). Lcp 141. http://www.planalto.gov.br/CCIVIL_03/LEIS/LCP/Lcp141.htm

Projeto de Lei do Senado n° 74, de 2014. (2014). https://www25.senado.leg.br/web/atividade/materias/-/materia/116394

We could not find precise estimates about that. However, based on data from the National Regulatory Agency for Private Health Insurances and Plans (ANS – Agência Nacional de Saúde Suplementar), we estimated that by the end of 2018, around 77% of the population were not covered by private health insurance (National Regulatory Agency for Private Health Insurances and Plans, 2019b).

References:

National Regulatory Agency for Private Health Insurances and Plans, M. (2019b). Caderno de Informação da Saúde Suplementar: Beneficiários, operadoras e planos. Março 2019. https://www.gov.br/ans/pt-br/arquivos/acesso-a-informacao/perfil-do-setor/dados-e-indicadores-do-setor/informacoes-gerais/total-cad-info-jun-2019.pdf

Brazil is undergoing a socio-political and economic transition. Since 2018, Brazil is under a new government, which has been adopting austerity measures that are likely to affect the SUS. Some estimates show impacts that might be linked to these measures on healthcare of the population, such as: increased infant mortality, worsened regional disparity regarding infant mortality, increased inequalities regarding the Family Health Strategy (FHS) coverage and among mothers who regularly attend antenatal care centres. Changes in FHS coverage are likely to affect smaller municipalities disproportionately, given the stronger dependence of small municipalities on primary healthcare (Castro et al., 2019). So far, no comprehensive plan for the future exists. While the Constitutional Amendment Proposal Number 241 (PEC 241), approved in 2016, limits public expenditures and consequently affects the SUS, the Ministry of Health has strengthened the Primary Healthcare by expanding the number of working hours and the quantity of primary healthcare units. However, it is still too early to assess possible changes in the financing of the health system.

References:

Castro, M. C., Massuda, A., Almeida, G., Menezes-Filho, N. A., Andrade, M. V., Noronha, K. V. M. de S., Rocha, R., Macinko, J., Hone, T., Tasca, R., Giovanella, L., Malik, A. M., Werneck, H., Fachine, L. A., & Rifat, A. (2019). Brazil’s unified health system: The first 30 years and prospects for the future. Lancet Health Public. https://www.abrasco.org.br/site/wp-content/uploads/2019/07/PIIS0140673619312437.pdf

The Ministry of Planning (Ministério do Planejamento, in Portuguese) (International Budget Partnership, 2018).

References:

International Budget Partnership. (2018). Defining and managing budget programs in the Health Sector: The Brazilian Experience. https://www.internationalbudget.org/wp-content/uploads/case-study-health-budget-programs-in-brazil-ibp-2018.pdf

The Constitution of 1988 defines the key planning and budgeting instruments as: (a) the Pluriannual Plan (Plano Plurianual – PPA), which is formulated over the first year of a presidential mandate and covers a period of 4 years; (b) the Law of Budgetary Guidelines (Lei de Diretrizes Orçamentárias – LDO) to be passed every year to define the key parameters and policy directives that will orient budget formulation; and (c) the annual Budget Law (Lei Orçamentária Anual – LOA). The PPA is meant to define objectives and targets for national, regional, and sectoral government plans and programs, while LDOs and LOAs are supposed to translate these into yearly priorities and activities. The Ministry of Planning reviews and updates the budget for health as part of the process for formulating the PPA. At the beginning of each PPA cycle, the ministry of planning defines the programs that outline the government’s agenda for each area of public policy, including health policies (International Budget Partnership, 2018). 

References:

International Budget Partnership. (2018). Defining and managing budget programs in the Health Sector: The Brazilian Experience. https://www.internationalbudget.org/wp-content/uploads/case-study-health-budget-programs-in-brazil-ibp-2018.pdf

The budget to be spent on health follows a “transfer system” and priorities are set independently by each of the different government levels (federal government, states and municipalities) (Brazilian Ministry of Health, 2019m).

References:

Brazilian Ministry of Health. (2019m). Sobre o FNS. http://portalfns.saude.gov.br/sobre-o-fns

The National Fund for Health (Fundo Nacional de Saúde) transfers the budget to the federal government (Ministry of Health), states and municipalities, according to the Pluriannual Plan, Law of Budgetary Guidelines and the Annual Budget Law. It is considered a decentralized system in which each level of government can decide how the money will be spent. The amount of money to be transferred to each level is set by law (Brazilian Ministry of Health, 2019m; International Budget Partnership, 2018). In theory, the budget should not be dispersed through geographical areas as there is transfer according to the three levels of governance in Brazil. However, as each level is responsible for managing and setting priorities for spending the budget, it is not rare to find geographical areas with different levels of investment depending on regional or local management.

References:

Brazilian Ministry of Health. (2019m). Sobre o FNS. http://portalfns.saude.gov.br/sobre-o-fns

International Budget Partnership. (2018). Defining and managing budget programs in the Health Sector: The Brazilian Experience. https://www.internationalbudget.org/wp-content/uploads/case-study-health-budget-programs-in-brazil-ibp-2018.pdf

The Ministry of Health works with large budgetary actions within a unique program. This strategy makes shifting resources between various programme areas easier to the Ministry of Health to manage (International Budget Partnership, 2018).

References:

International Budget Partnership. (2018). Defining and managing budget programs in the Health Sector: The Brazilian Experience. https://www.internationalbudget.org/wp-content/uploads/case-study-health-budget-programs-in-brazil-ibp-2018.pdf

Data from the National Regulatory Agency for Private Health Insurances and Plans showed that around 23% of the population of Brazil purchased private health care insurance by the end of 2018 (National Regulatory Agency for Private Health Insurances and Plans, 2019a).

References:

National Regulatory Agency for Private Health Insurances and Plans. (2019a). Agência Nacional de Saúde Suplementar. https://www.gov.br/ans/pt-br

Yes. There is the National Regulatory Agency for Private Health Insurances and Plans (Agência Nacional de Saúde Suplementar – ANS), that is linked to the Ministry of Health and is in charge to regulate the private health insurances and plans sector in Brazil  (National Regulatory Agency for Private Health Insurances and Plans, 2019a).

References:

National Regulatory Agency for Private Health Insurances and Plans. (2019a). Agência Nacional de Saúde Suplementar. https://www.gov.br/ans/pt-br

It seems not to have official estimates about the proportion of the population incurring out-of-pocket payments for health services. However, a study conducted by the Credit Protection Service Brazil (SPC Brasil) and by the National Confederation of Stores Owners (CNDL) with 1,500 people from large capitals showed that, from the 70% of people who did not have private health insurance, 25% made out of pocket payments for private services (CNDL, 2018).

References:

CNDL. (2018). Gastos dos Brasileiros com Saúde.

No (Brazilian Ministry of Health, 2019i).

References:

Brazilian Ministry of Health. (2019i). Repasses financeiros.

The following data were gathered from the professional bodies, but there is no information about whether these numbers refer to public or private sector. We assume that these numbers refer to both private and public sectors.

References:

Conselho Federal de Medicina. (2020). Demografia Médica no Brasil. https://www.fm.usp.br/fmusp/conteudo/DemografiaMedica2020_9DEZ.pdf

Conselho Federal de Enfermagem. (2019). Enfermagem em Números Conselho Federal de Enfermagem—Brasil. http://www.cofen.gov.br/enfermagem-em-numeros

There is a shortage of health professionals mainly in some parts of the countryside of Brazil. Areas with poor living conditions and restricted supply of goods, limited infrastructure or access to education tend to be less attractive to health professionals (including doctors) to live and work. This leads to a lack of health professionals willing to deliver healthcare to this population. In addition, on average, the number of trained health professionals is below the necessary to meet population’s demand. Brazil suffers with lower numbers and bad distribution of trained health professionals.

Many students migrate from small towns to big cities to pursue a university course in health-related areas. Once trained, many health professionals remain in large urban areas for their professional life. This leads to villages and towns suffering from a lack of health professionals to care for the population and high vacancy rates for medical doctors. As part of the strategies to reduce this problem, in 2013 the federal government instituted a program called “More Doctors” (Mais Médicos) which aimed to improve the primary care infrastructure, to increase availability of university courses for medicine, and to provide emergency supply of doctors to work in priority areas for the SUS (Giovanella et al., 2016; Girardi et al., 2016). The program More Doctors was substituted by the program “Doctors for Brazil” (Médicos pelo Brasil) in 2019. The new program “Doctors for Brazil” aims to supply remote areas of Brazil with doctors. There is an estimate that a total of 18,000 places will be created, with 4,000 located in the North and North-eastern areas of the country. Both Brazilian and foreign doctors are allowed to participate if their medical certificates are valid in Brazil. Other changes brought by the new program include doctors selection through admission tests and the establishment of work contracts in accordance with the Brazilian working laws (Confederação das Leis Trabalhistas – CLT) with two-year probationary period (Brazilian Ministry of Health, 2019e), as opposed to informal (hourly paid) jobs.

References:

Brazilian Ministry of Health. (2019e). Médicos pelo Brasil é aprovado pelo Congresso Nacional [Government]. http://saude.gov.br/noticias/agencia-saude/46092-medicos-pelo-brasil-e-aprovado-pelo-congresso-nacional

Giovanella, L., Mendonça, M. H. M. de, Fausto, M. C. R., Almeida, P. F. de, Bousquat, A., Lima, J. G., Seidl, H., Franco, C. M., Fusaro, E. R., & Almeida, S. Z. F. (2016). A provisão emergencial de médicos pelo Programa Mais Médicos e a qualidade da estrutura das unidades básicas de saúde. Ciência & Saúde Coletiva, 21(9), 2697–2708. https://doi.org/10.1590/1413-81232015219.16052016

Girardi, S. N., Stralen, A. C. de S. van, Cella, J. N., Wan Der Maas, L., Carvalho, C. L., & Faria, E. de O. (2016). Impacto do Programa Mais Médicos na redução da escassez de médicos em Atenção Primária à Saúde. Ciência & Saúde Coletiva, 21(9), 2675–2684. https://doi.org/10.1590/1413-81232015219.16032016

Yes. The Unified Social Assistance System (SUAS) provides some long-term care services to the population, such as long-term care institutions, day centres, palliative care, advance care directives, and others. The system’s coverage is means tested, provided to people without means to pay for their care or without family support (Brazilian Ministry of Citizenship, 2015). Poor people, without family support and with disabling health conditions may benefit from SUAS. Lack of information among the population regarding the existence of such services may be a potential barrier to access. The SUS may also provide some kind of LTC services through the Family Health Strategy (FHS). Although both SUAS and SUS may provide some LTC services, the provision is unsatisfactory and disintegrated.

References:

Brazilian Ministry of Citizenship, A. (2015). Unidades de acolhimento [Página]. MINISTÉRIO DA CIDADANIA Secretaria Especial do Desenvolvimento Social. http://mds.gov.br/assuntos/assistencia-social/unidades-de-atendimento/unidades-de-acolhimento/unidades-de-acolhimento

In the absence of a unified LTC system in Brazil, LTC services are provided through health and social care systems separately, and in a few instances, jointly. These are mostly delivered through the Family Health Strategy (FHS). For example, those who are bed bound may receive home visits from healthcare professionals and community health workers routinely. LTC may also be provided via high and medium complexity home care services through the program “It is better at Home” (Melhor em Casa). Those who are registered with this service have continuous support from the care home teams via routine appointments and via telephone if needed. Services offered to older people should follow the guidance stated in a document that establishes an integrated care pathway for older people in the SUS (Brazilian Ministry of Health, 2018e, 2019d, 2019h).

As part of SUS, people living with disabilities should receive integrated healthcare such as rehabilitation, basic and complex treatments, etc. (Brazilian Ministry of Health, 2019q). SUAS provides LTC within long-term institutions for people aged 60 years and over who are independent, or who have some degree of dependence, who do not have the means to live in a family environment, in their own home, or who have suffered abuse, violence, negligence, or abandonment. However, moving to those institutions are considered by the government a measure of last resort and the number of bed available are very limited (Brazilian Ministry of Citizenship, 2015).

The SUAS also provides the “Special Social Protection Service for Disadvantaged People, Older People, and their Families” (Serviço de Proteção Social Especial para Pessoas com Deficiência, Idosas e suas Famílias). This service aims to help older people with some degree of dependence, people living with disabilities, their carers, and those who have suffered violation of their rights (for example: lack of proper care from their carers, discrimination from family members, high level of stress from the carer etc.). The service aims to identify the needs of the older persons and their carers and make it feasible for them to access cash transference programmes, cultural and leisure activities, and public policy services. The service is offered by professionals and may be delivered in patients’ homes, day centres, Special Reference Centre for Social Assistance (CREAS) or Referenced Units. The service can be accessed following spontaneous demand or by referral from other social-assistance services (Brazilian Ministry of Citizenship, 2014). We could not identify data on the proportion of the population uses the public long-term care system. However, it is known that in 2014, 53,600 older people were living in long-stay institutions affiliated to SUAS (Alcantara et al., 2016).

In Brazil, very often family members are the main providers of care (unpaid care). However, private options such as paid carers, day care centres (getting quite popular in the last years) and long-stay institutions (the most traditional model of long-term care in Brazil, after the provision of care by family members) are available in the country (Alcantara et al., 2016). Data about the size of the private sector could not be found. However, according to data from the Institute for Applied Economic Research (IPEA), in 2017 there were 2,163 long-stay institutions in Brazil (33% were philanthropic, 64% were private and 0.03% were public/mixed) (Camarano, 2017). There are differences in the characteristics of people using public and private institutional long-term care. While some older people live in public long-stay institutions usually because of lack of financial and family support, older people with better financial resources are institutionalized in private institutions mainly when they present more severe health situation (Camarano, 2017).

References:

Alcantara, A. de O., Camarano, A. A., & Giacomin, K. C. (2016). Política Nacional do Idoso: Velhas e Novas Questões. http://repositorio.ipea.gov.br/bitstream/11058/9146/1/Institui%C3%A7%C3%B5es%20de%20longa%20perman%C3%AAncia.pdf

Brazilian Ministry of Health. (2018e). Orientações Técnicas para a Implementação de Linha de Cuidado para Atenção integral à Saúde da Pessoa Idosa no Sistema Único de Saúde—SUS. Ministério da Saúde do Brasil.

Brazilian Ministry of Health. (2019d). Estratégia Saúde da Família (ESF).

Brazilian Ministry of Health. (2019h). Programa Melhor em Casa.

Camarano, A. A. (2017). Cuidados para a população idosa: Demandas e perspectivas.

Although there has been an increase in the development of inter-sectoral policies that establish how and to whom health and social care services should be delivered/accessed in Brazil (e.g., integrated care for older people) (Brazilian Ministry of Health, 2018e), LTC is not a unified system in Brazil and the financing of such services is separate via health and social care ministries. As detailed in item VII: health-system financing, the three spheres of government in Brazil (federal, state, and municipal) are responsible for financing SUS, and a similar strategy is used within SUAS. Monetary resources allocated to each of these systems are directly transferred from the federal government to states, municipalities and the federal district, which results in decentralized and participatory management of public resources (laws 8742/93 and 8.080/90). Financing of such systems also occur via state and municipal taxation and each sphere of government manages their resources in line with some common shared responsibilities (Brasil, 1990, 1993).

In 2011, only six years after the implementation SUAS, the law 12.435/11 replaced the law 8.742/93 and established a system to regulate the organisation and provision of social assistance. This includes rules of social control, monitoring, evaluation, and management of SUAS, coordinated by the Ministry of Citizenship and in partnership with states, the Federal District and municipalities. This set of standards and rules introduced a new form of social assistance, breaking with a previous vision centred on charity and favour and establishing regular funding for social care (Brasil, 2011). In 2010, nearly R$11 billion was invested in assisting 1.62 million older people, which represented a growth percentage of 365% in the volume of funds invested and 177.7% in the total number of beneficiaries in relation to 2002 (Brasil, 2011).

References:

Brazilian Ministry of Health. (2018e). Orientações Técnicas para a Implementação de Linha de Cuidado para Atenção integral à Saúde da Pessoa Idosa no Sistema Único de Saúde—SUS. Ministério da Saúde do Brasil.

Brasil, no. 8080/90 (1990). http://www.planalto.gov.br/ccivil_03/leis/l8080.htm

Brasil, no. L8742 (1993). http://www.planalto.gov.br/ccivil_03/leis/l8742.htm

Brasil, no. L12435 (2011). http://www.planalto.gov.br/ccivil_03/_ato2011-2014/2011/lei/l12435.htm

The Ministry of Planning (“Ministério do Planejamento”, in Portuguese) (International Budget Partnership, 2018), in partnership with each relevant ministry (in this case, Ministry of Health and Ministry of Citizenship).

References:

International Budget Partnership. (2018). Defining and managing budget programs in the Health Sector: The Brazilian Experience.

There are several laws informing the planning of allocation and expenditure of public resources for the entire health (SUS) and social care (SUAS) systems which, together, finance the LTC services provided to older people in Brazil (Brasil, 2011). SUS has several participatory forums at federal, state, and municipality levels, which help inform the healthcare strategy nationally. These occur at different points in time along the year and are secured by different laws. As Brazil does not have a unified LTC system, and it is unclear which services are classified as being LTC, it is difficult to estimate how and how much of the total amount is allocated to LTC specifically every month/year. Further, for the financing of public/philanthropic LTC institutions, in addition to the budget coming from the public system financed mostly through taxation, the budget may come from the older person/family funds, older people’s pensions, philanthropy, donations, and others, all of which are varied (Freire et al., 2012; Watanabe, 2018). In the private LTC institutions, the main source of financing is through individual payment (e.g. pension, family funding) (Freire et al., 2012).

References:

Brasil, no. L12435 (2011). http://www.planalto.gov.br/ccivil_03/_ato2011-2014/2011/lei/l12435.htm

Freire, F. de S., Mendonça, L. H. de, & Costa, A. de J. B. (2012). Sustentabilidade econômica das instituições de longa permanência para idosos. Saúde em Debate, 36(95), 533–543. https://doi.org/10.1590/S0103-11042012000400005

Watanabe, H. (2018). Instituições de Longa Permanência conveniadas com o MDS.

The budget to be spent on social assistance, which includes LTC, follows a “transference system” and the priorities are set by the federal government, states, and municipalities in an independent way (Brazilian Ministry of Citizenship, n.d.). Decisions are based on strategic/economic/epidemiological figures and on active participation from the population in the decision-making processes (e.g., municipal and state health forums; local management collegiate; national older people’s council). The processes of planning and allocating resources are transparent, decentralized and regularly evaluated by CONASS, which ensures that the data are available for consultation online (Brasil, 2019).

References:

Brasil. (2019). Conselho Nacional de Secretários de Saúde – CONASS. https://www.conass.org.br/

Brazilian Ministry of Citizenship. (n.d.). Módulo II: o Financiamento do SUAS. Retrieved July 17, 2019, from http://aplicacoes.mds.gov.br/sagi/dicivip_datain/ckfinder/userfiles/pdf/aulas_or%C3%A7amento_mds_modulo_II.pdf

The National Fund for Social Assistance (Fundo Nacional de Assistência Social) transfers budget to states and municipalities according to the Pluriannual Plan, the Law of Budgetary Guidelines, and the Annual Budget Law. It is considered a decentralized system in which each level of government can manage how the money will be spent (Brazilian Ministry of Citizenship, n.d.). The social care budget allocated to assist older people has changed over the years (in R$ millions) within each of the country’s regions. This federal allocation considers the number of older people locally, the increase in the value of minimum salary/basic pension, poverty levels, among other variables (Brasil, 2011).

References:

Brazilian Ministry of Citizenship. (n.d.). Módulo II: o Financiamento do SUAS. Retrieved July 17, 2019, from http://aplicacoes.mds.gov.br/sagi/dicivip_datain/ckfinder/userfiles/pdf/aulas_or%C3%A7amento_mds_modulo_II.pdf

Brasil. (2011). Caderno SUAS: Financiamento da Assistência Social no Brasil. https://www.mds.gov.br/webarquivos/publicacao/assistencia_social/Cadernos/Suas_Financiamento_V.pdf

Using the budget allocated by the Federal government, states and municipalities then decide how to prioritise or to create program areas that require investment. We have no detailed information on the details of how this budget is spent locally.

Yes. SUS provides the health-related LTC, such as visits from community health teams, domiciliary care, and provision of treatment, which are all financed by the municipality budget of primary/secondary healthcare (Brazilian Ministry of Health, 2019l).

References:

Brazilian Ministry of Health. (2019l). Sobre a Assistência Farmacêutica.

Yes, there are private healthcare insurance companies that provide health-related LTC (ANS, 2016). In addition, private companies have started building residential villages for older people to live, to stay for a period of time or to spend a day. In these villages, older people receive social and healthcare assistance as required. However, such private services are expensive and only those who can afford it have access to it (an example of such a private programme can be seen here).

References:

ANS. (2016). ANS propõe novo modelo de assistência a idosos na saúde privada. Agência Brasil. https://agenciabrasil.ebc.com.br/geral/noticia/2016-05/ans-propoem-novo-modelo-na-assistencia-ao-idoso-na-saude-suplementar

Around 22% of the population aged 60 and over in Brazil have a private healthcare insurance  (ANS, 2013). However, we do not know how many of these individuals have access to LTC in this group. Data from the Institute for Applied Economic Research (IPEA) showed that 64% of the long-term care homes were private in Brazil, but we do not know how much of the costs are paid for by the individuals/families or health insurances (Camarano, 2017).

References:

ANS. (2013). Caderno de informação da saúde suplementar. Beneficiários, operadoras e planos. https://bvsms.saude.gov.br/bvs/periodicos/caderno_informacao_suplementar_dez2013.pdf

Camarano, A. A. (2017). Cuidados para a população idosa: Demandas e perspectivas. 

No.

No information was found about this.

The main source of LTC in Brazil is provided for by family/unpaid carers; however, the number of people who began providing care for older adults as ‘formal’ or ‘paid carers’ is increasing rapidly. There is no official statistic on the number of unpaid carers in Brazil. According to the Brazilian Annual Report of Social Information (Relação Anual de Informações Sociais), ‘informal care worker’ was the occupation with the largest growth rate between 2007 and 2017 (growing over 500% – from 5,263 to 34,051 registered informal carer workers) in Brazil (Brazilian Ministry of Economy, 2018). This number reflects a growing interest for the profession by Brazilians (mostly women); however, this may also mean a growing tendency of informal care workers being formally recognized as professionals.

Currently, informal care workers are hired as domestic employees and can be paid for hourly (not registered formally, without any pension or labour rights, and without a minimum payment that is set by the government), or by receiving the minimum wage or more (registered officially, with pension and labour rights as a domestic employee would). For domestic employees, everyone working more than three days a week for a family should be formally hired by law. These individuals are ‘hired’ by the family directly through their personal links, or through care agencies, and they provide from supervision through full time care, which is paid for according to the amount of care needs.

References:

Brazilian Ministry of Economy. (2018). RAIS 2018. http://www.rais.gov.br/sitio/index.jsf

According to the Brazilian Classification of Occupations (Classificação Brasileira de Ocupações, CBO) (CBO 5162-10 Cuidador de Idosos), the carer occupation can be performed by anyone. There are many private skill training courses being offered for people who want to get trained to work as carer, which are provided online or face-to-face, freely or paid for by the individual, the older person’s family, or by a care agency, or other health service. Here is an example of such courses.

‘Formal caregiving’ has been recognized as an occupation since 2002 by the Brazilian Classification of Occupations (Classificação Brasileira de Ocupações, CBO), but not as a profession (for that it would be necessary a law regulating its activities). Changing the status from occupation to profession had been approved by the Chamber of Deputies and the Senate House. However, the president of Brazil later denied this recognition justifying that the proposal had incurred conditions which restricted the free professional work. This project of law (PLC11/2016) stated that informal care workers should have completed basic education attainment (8 years or more), at least 160h of relevant training, to be aged 18 and above, to have no criminal records, and attested physical and mental capabilities. This would have been a landmark on improving the quality of the care provided for older people.

Due to the absence of a formalization of such profession, informal care workers do not have regulated set of training skills or basic professional rights. Even though the President has denied the recognition of the occupation as a profession, there is still a chance of this recognition to happen as deputies and senators plan to further discuss this in the near future (Conselho Federal de Enfermagem, 2019b). In addition, state and municipal laws have been proposed to try and systematise the care provided to older people locally, such as in Rio de Janeiro state (ALERJ, 2016). This state law states:

Art. 5º: The regular qualification, preparation, and qualification courses for Carers of Older People must have, at least, the duration of 160h (one hundred and sixty hours) of in-class training, with theoretical and practical content, being 25% (twenty-five percent) of the total number of hours dedicated to practical activities involving monitoring and supervision, and the course provider must involve professionals from professions related to the field of gerontology, such as: geriatricians, nurses, nutritionists, physiotherapists, psychologists, occupational therapists, and social workers.

Other professionals who are part of the Brazilian LTC workforce are regulated by their professional bodies, such as the Nursing Council for nurses and health assistants, Medical Council for physicians, and Physiotherapy Council for physiotherapists. However, none of these professionals need to be specialised in LTC beyond their generalist training in order to provide LTC for older people. It would depend on the employer to require such training.

References:

ALERJ. (2016). Lei Ordinária 7332.

Conselho Federal de Enfermagem. (2019b). Projeto de Lei do Cuidador é vetado Conselho Federal de Enfermagem—Brasil. http://www.cofen.gov.br/projeto-de-lei-do-cuidador-e-vetado_72314.html

Care homes in Brazil are recognised by the National Health Surveillance Agency (ANVISA) as ‘living settings’ (Brasil, 2005). They have strong links to social assistance policies and come less under the ‘health-systems radar’. The offer of health services often varies according to the legal nature of the institutions, meaning that care homes do not need to have health professionals as part of the staff team by the law. Even though every care home should inform the municipal health surveillance of its operation and licensing, many institutions work in informality and clandestinely, particularly small not-for-profit and private institutions. In addition, care home workers’ profession is not secured by law, meaning that anyone could work in care homes, regardless of their preparedness to carry out that role.

Each profession involved within the LTC workforce has its own regulatory body, except for the ‘informal care workers’, as explained in the previous item. Such professional councils regulate, inspect, and establish the necessary basic training, staff/user ration, quality monitoring, etc. for the overall role of each profession within any area of care. With regards to care for older people, in specific, there is the Brazilian Society of Geriatrics and Gerontology (https://sbgg.org.br/) and the National Academy for Palliative Care (https://paliativo.org.br/) which provide specialist knowledge, training, and accreditation for those working in LTC. However, there is no national council or guidelines which are specific for the LTC workforce. Though not recognized as a profession, there are formal dedicated spaces to try and formalize, inform, and support informal care workers, such as the Association for Carers of Older People of the Metropolitan Area of Sao Paulo (ACIRMESP – https://www.acirmesp.org.br/).

The National Surveillance Agency – ANVISA regulates the minimum staff and infrastructure within care homes in Brazil, as described in the law RDC nº 283 published on 26 September 2005 (Brasil, 2005). For care workers, for example, this document states the staff/user ratio according to the older people’s level of care dependence:

Level I (low dependence): one care worker for 20 older adults per 8h/day.

Level II (medium dependence): one care worker for every10 older adults per shift.

Level III (high dependence): one care worker for every 6 older adults per shift.

This ANVISA document also details key quality monitoring and compliance variables (page 11), which can be used to fine or close down an institution for poor standards, for example (e.g., mortality rates, prevalence of dehydration and undernutrition, infection, pressure injuries, etc.) (Brasil, 2005). A single annual report detailing such variables are sent to ANVISA by the care home managers. ANVISA can make unannounced visits for inspection voluntarily or in case there is a formal complaint from anyone. However, ANVISA does not monitor the quality of the day-to-day care and interactions with older people (e.g., outside visits, person-centred care, eye contact, etc.). 

References:

Brasil. (2005). Legislação—Anvisa. http://antigo.anvisa.gov.br/legislacao/?inheritRedirect=true#/visualizar/27647

No data about this have been found. However, there was a huge increase in the rate of people working as carers for older people between 2007 and 2017 (growth of more than 500% – from 5,263 to 34,051 registered informal care workers) (Brazilian Ministry of Economy, 2018). Qualitative research shows that people working in care homes are generally undervalued and underpaid (Salcher et al., 2015). However, there is a general lack of national and representative data on this topic in Brazil.

References:

Brazilian Ministry of Economy. (2018). RAIS 2018. http://www.rais.gov.br/sitio/index.jsf

Salcher, E. B. G., Portella, M. R., & Scortegagna, H. de M. (2015). Cenários de instituições de longa permanência para idosos: Retratos da realidade vivenciada por equipe multiprofissional. Revista Brasileira de Geriatria e Gerontologia, 18, 259–272. https://doi.org/10.1590/1809-9823.2015.14073

It is not common for people to leave Brazil to work as informal care workers in other countries, and it is also rare for foreigners to come and work as informal care workers in Brazil. However, experts have indicated that, during the economic downturn, an increasing number of Brazilians (mainly women and mostly illegally) emigrated to work as professional carers in other countries (IEA USP, 2017). When the terms ‘imigração’ (immigration) and ‘cuidador de idosos’ (carers of older people) are added to the Google search engine, a plethora of agencies that help mediate the migration of Brazilians to work as informal care workers in other countries come up, specially Canada, United States and Europe. However, we could not find any official source of information detailing the number, destination, and characteristics of these individuals.

Among Brazilian people moving from one state to another within Brazil to work as informal care workers, a study suggests that this movement is generally observed from the North-eastern region, and also from the states of Minas Gerais, Parana and Santa Catarina, towards Sao Paulo and Rio de Janeiro states (Guimarães et al., 2011). No further information could be found about how many and who are these individuals. In general, the main reason for migration within Brazil is economical or ecological disasters. A study conducted by Oliveira and Jannuzzi (2005) on the distribution of migrants per sex and reasons for displacement/migration based on data from PNAD 2001 (a national demographic census conducted by the government) shows that most people migrate to other country regions to live with the family who had moved or due to the person’s job. This study also shows that within-country migration mostly occurs in the group of people aged 20-54 (Oliveira and Jannuzzi, 2005).

References:

Guimarães, N. A., Hirata, H. S., Sugita, K., Guimarães, N. A., Hirata, H. S., & Sugita, K. (2011). CUIDADO E CUIDADORAS: O TRABALHO DE CARE NO BRASIL, FRANÇA E JAPÃO. Sociologia & Antropologia, 1(1), 151–180. https://doi.org/10.1590/2238-38752011v117

IEA USP. (2017). Fenômeno da migração também tem relação com idosos—IEA USP. http://www.iea.usp.br/noticias/fenomeno-da-migracao-tambem-tem-relacao-com-idosos

Oliveira, K. F. de, & Jannuzzi, P. de M. (2005). Motivos para migração no Brasil e retorno ao nordeste: Padrões etários, por sexo e origem/destino. São Paulo em Perspectiva, 19(4), 134–143. https://doi.org/10.1590/S0102-88392005000400009

The work is performed in households or in care institutions. The LTC workers may be hired as either self-employed or salaried workers and their working hours vary between full time, upon demand (hourly paid), or part time (Brazilian Ministry of Economy, 2019). When individuals are self-employed, there are no employer-employee formal guarantees (e.g., pension, benefits), although they are still required to pay taxes. Formal employment is normally established through the Workers Law Consolidation (Consolidação das Leis do Trabalho – CLT), which is a formal/registered employment scheme. Care workers (informal care workers) are often hired as domestic employees as they are included under this category of occupation as described in the laws N.5.859/72, N. 7.418/85, N. 11.354/06 and Article 7 of the Federal Constitution. Formal employment under Workers Law Consolidation or as a domestic employee guarantees workers’ rights, such as: a minimum salary (which is established for overall workers and pension), holidays, maternity, and paternity leaves, etc. There are no official data about how many carers are working under informal circumstances. As mentioned previously, the number of formally hired carers have increased dramatically in the past years (from 5,263 in 2007 to 34,051 in 2017) (Brazilian Ministry of Economy, 2018).

References:

Brazilian Ministry of Economy. (2018). RAIS 2018. http://www.rais.gov.br/sitio/index.jsf

Brazilian Ministry of Economy. (2019). Classificação Brasileira de Ocupações—Relatório da Familia—4.0.15. http://www.mtecbo.gov.br/cbosite/pages/relatorio/relatorioTemplateWordFamilia.jsf

People may volunteer in some care homes, such as through providing pastoral care, musicotherapy, arts therapy, writing/reading lessons, etc. An example of such initiative can be found here. There are non-profit associations and blogs where volunteer carers may subscribe themselves and can become part of a community which provides care for others (e.g. “portal da terceira idade” and “velho amigo”). Usually, volunteering schemes are set up by each institution and there are no official data about how many volunteers exist in Brazil, how these are enrolled, and what requisites they have. There are also healthcare students who practice their care and research skills in care homes which are linked through the Universities. There are also donation schemes in which churches, individuals, and large institutions donate food, clothes, and other items.

People may volunteer in some care homes, such as through providing pastoral care, musicotherapy, arts therapy, writing/reading lessons, etc. An example of such initiative can be found here. There are non-profit associations and blogs where volunteer carers may subscribe themselves and can become part of a community which provides care for others (e.g., “portal da terceira idade” and “velho amigo”). Usually, volunteering schemes are set up by each institution and there are no official data about how many volunteers exist in Brazil, how these are enrolled, and what requisites they have. There are also healthcare students who practice their care and research skills in care homes which are linked through the Universities. There are also donation schemes in which churches, individuals and large institutions donate food, clothes, and other items.

Yes. Dementia is included in the portfolio of the Brazilian Ministry of Health, as part of healthcare policies for older people. Some examples are the National Healthcare Policy for Older People, the Alzheimer’s disease Clinical Therapeutic Protocol, and the Older People’s Statute (Brazilian Ministry of Health, 2006a, 2017c; Presidency of Republic of Brazil, 2003).

References:

Brazilian Ministry of Health. (2006a). Política Nacional de Saúde da Pessoa Idosa. http://bvsms.saude.gov.br/bvs/saudelegis/gm/2006/prt2528_19_10_2006.html

Brazilian Ministry of Health. (2017c). PCDT Alzheimer. Brazilian Ministry of Health.

Presidency of Republic of Brazil. (2003). Estatuto do Idoso. Presidency of Republic of Brazil; National Congress of Brazil’s Information System. http://www.planalto.gov.br/ccivil_03/leis/2003/l10.741.htm

The Ministry of Health. In Brazil dementia is considered a health issue, therefore it is part of the responsibilities of the Ministry of Health (Brazilian Ministry of Health, 2006b).

References:

Brazilian Ministry of Health. (2006b). Política Nacional de Saúde da Pessoa Idosa. Brazilian Ministry of Health.

Ageing and Mental health.

No. Although dementia is a topic discussed by the Division for Older People Healthcare (in the Ministry of Health) there is no dementia-specific representative in the government.

Yes. There is the Law project number 4364/2020 (PL 4364/2020), which institutes the “National Policy for Integrated Care for People Living with Alzheimer’s Disease and other Dementias”. This law project has been approved by the Brazilian Federal Senate and waits for approval from the Chamber of Deputies to be implemented (Brazilian Federal Senate, 2021). Members of STRiDE-Brasil have been advocating for a more comprehensive and person-centred care approach in this law. Some achievements have already happened; however, more changes can be done to improve the law. Therefore, the STRiDE-Brasil team continues to advocate for improving the law.

Apart from that, some municipalities have developed regional plans for dementia. For instance, the Federal District approved in 2021 the law 6.926 regarding the policy for prevention, treatment, and support for people living with Alzheimer’s disease and other dementias and their family carers (Federal District Government, 2021). In the same trend, the city of São Paulo approved also in 2021 the PL 769/2019 (São Paulo Chamber of Deputies, 2019) in the state of Rio Grande do Sul there is the PL 131/2018 (Projeto de Lei n 131/2018, 2018) and in the city of Novo Hamburgo there is the PL 12/2020 (Novo Hamburgo Municipal Chamber, 2020). All of them aim to support people living with dementia and their carers. Besides, some politicians have shown a growing interest in dementia and discussions have been taking place in the Brazilian government. For example, the Professor Ricardo Nitrini (member of the STRiDE-Brasil steering committee) was invited to a meeting in the Chamber of Deputies in 2019 to discuss the creation of a possible dementia plan in Brazil, at that time. In addition, Professor Cleusa Ferri was invited to a meeting in 2020 in the Ministry of Health to discuss strategies for dementia care.

References:

Brazilian Federal Senate. (2021). Aprovado projeto que institui política de enfrentamento ao Alzheimer. https://www12.senado.leg.br/noticias/materias/2021/11/16/aprovado-projeto-que-institui-politica-de-enfrentamento-ao-alzheimer

Federal District Government. (2021). LEI N^o 6.926—Política distrital para prevenção, tratamento e apoio às pessoas com doença de Alzheimer e outras demências. https://www.tjdft.jus.br/institucional/relacoes-institucionais/arquivos/lei-no-6-926-de-02-de-agosto-de-2021.pdf

Novo Hamburgo Municipal Chamber. (2020). Projeto de Lei Municipal 12/2020—Novo Hamburgo. Camara Municipal. https://portal.camaranh.rs.gov.br/pm3/informacao_e_conhecimento/noticias/novo-hamburgo-podera-ter-politica-de-enfrentamento-ao-alzheimer

São Paulo Chamber of Deputies. (2019). Projeto de Lei da Câmara Municipal de São Paulo, n 769, de 2019. https://splegisconsulta.camara.sp.gov.br/Pesquisa/DetailsDetalhado?COD_MTRA_LEGL=1&COD_PCSS_CMSP=769&ANO_PCSS_CMSP=2019

The last updated version of “The National Policy for Integrated Care for People Living with Alzheimer’s Disease and other Dementias” was in 12 November 2021.

No such information has been found.

No.

Key goals of “The National Policy for Integrated Care for People Living with Alzheimer’s Disease and other Dementias” are: to offer support for people living with dementia to live as independently as possible, to offer a healthcare system that support the family carers to cope with dementia challenges, to support health professionals training in dementia, to prioritize scientific research on dementia.

Policies for older people and the law projects described above try to address some needs of people living with dementia. Regarding the participation of families/carers in the development of policies, it still does not seem to be a reality in Brazil. However, generally speaking, at times, documents under discussion are being made available for public consultation over a period of time. For example, families, carers, and patients were able to make a contribution through public consultation when the Alzheimer’s Disease Clinical Therapeutic Protocol was developed (Brazilian Ministry of Health, 2017c).

References:

Brazilian Ministry of Health. (2017c). PCDT Alzheimer. Brazilian Ministry of Health.

No information was found about that.

Yes. In cases where policies are not implemented, a person or organization that feel themselves in disadvantage for not having their rights protected may file a lawsuit against the organization or a writ of mandamus, depending on the case. The legal consequences will vary based on each situation, but these consequences may be payments of fines or for moral damages, the obligation of following what is stated in the policy etc. (Presidency of Republic of Brazil, 1988, 2009).

References:

Presidency of Republic of Brazil. (1988). Federal Constitution of Brazil. http://www.planalto.gov.br/ccivil_03/constituicao/constituicao.htm

Presidency of Republic of Brazil. (2009). Lei 12016. http://www.planalto.gov.br/ccivil_03/_ato2007-2010/2009/lei/l12016.htm

Yes. There are many policies for older people in Brazil in which dementia is indirectly and sometimes directly integrated into. Examples are:

– The “National Healthcare Policy for Older People” (Política Nacional de Saúde da Pessoa Idosa) that aims to recover, maintain, and promote autonomy and independence of older people (any Brazilian citizen aged 60 years and over) through collective and individual healthcare measures in line with SUS (Brazilian Ministry of Health, 2006b).

– The “National Policy for Primary Care” (Política de Nacional de Atenção Básica) considers changes and updates in the primary care system. The policy emphasizes the importance of the primary care as the main gateway to access the entire public healthcare system (Brazilian Ministry of Health, 2012).

– The “Family Healthcare Strategy” (Estratégia de Saúde da Família) aims to promote quality of life for the Brazilian population and intervene in factors that put health at risk, such as lack of physical activity, tobacco smoking, poor diet, etc. Healthcare teams work closely with people, allowing the professionals to know the person, their family, and the neighbourhood (Brazilian Ministry of Health, 2019c).

– The “It is Better at Home Program” (Programa Melhor em Casa) is a service indicated for people who have temporary or definitive difficulties to leave home and reach a healthcare unit or for people who depend on home-care services. The program aims to provide the patient with care closer to the family’s routine, avoiding unnecessary hospitalizations and reducing the risk of infections (Brazilian Ministry of Health, 2019h). 

– The “Technical Guidelines for Implementing a Healthcare Pathway for Integral Health for Older People” (Orientações Técnicas para Implementação da Linha de Cuidado para Atenção Integral à Saúde da Pessoa Idosa) was a document developed to orientate Brazilian states, municipalities, and the Federal District regarding how to provide integral healthcare for older people. The guidelines take in consideration both the identification of older people’s healthcare needs and their functional capacity (Brazilian Ministry of Health, 2018e).

– The “Training Notebook of Primary Healthcare Professionals for Older People’s Health”  (Caderno de Formação – Ação: Capacitação dos Profissionais da Atenção Básica sobre a Saúde da Pessoa Idosa) is used in trainings of primary healthcare professionals and brings educational information about the general health of older people (including information on dementia) (Brazilian Ministry of Health, 2017a).

References:

Brazilian Ministry of Health. (2006b). Política Nacional de Saúde da Pessoa Idosa. Brazilian Ministry of Health.

Brazilian Ministry of Health. (2012). Política Nacional de Atenção Básica. http://189.28.128.100/dab/docs/publicacoes/geral/pnab.pdf

Brazilian Ministry of Health. (2017a). Caderno de Formação – Ação: Capacitação dos Profissionais da Atenção Básica sobre a Saúde da Pessoa Idosa.

Brazilian Ministry of Health. (2018e). Orientações Técnicas para a Implementação de Linha de Cuidado para Atenção integral à Saúde da Pessoa Idosa no Sistema Único de Saúde—SUS. Ministério da Saúde do Brasil.

Brazilian Ministry of Health. (2019c). Estratégia Saúde da Família.

Brazilian Ministry of Health. (2019h). Programa Melhor em Casa.

The above mentioned national policies indirectly cover dementia in these areas: risk factors prevention, diagnosis, and treatment (Brazilian Ministry of Health, 2018e).

References:

Brazilian Ministry of Health. (2018e). Orientações Técnicas para a Implementação de Linha de Cuidado para Atenção integral à Saúde da Pessoa Idosa no Sistema Único de Saúde—SUS. Ministério da Saúde do Brasil.

Yes, there some dementia-specific documents at subnational levels. We could identify four of them. They are the law 6.926 in the Federal District (Federal District Government, 2021), the PL 131/2018 in the state of Rio Grande do Sul (Projecto de Lei n131/2018, 2018), the PL 769/2019 in the municipality of São Paulo (São Paulo Chamber of Deputies, 2019), and the PL 12/2020 in the city of Novo Hamburgo (Novo Hamburgo Municipal Chamber, 2020). They relate to policy for prevention, treatment, and support for people living with Alzheimer’s disease and other dementias and their family carers.

Besides, there are some policy documents that include strategies to improve the quality of care and accessibility to mental health services for older people in general, with dementia being explicitly cited as one of the conditions included. These documents are the State of Paraná Plan for Older People (Paraná Government, 2014), the State of Pará Plan for Older People (Pará Government, 2017) and the Municipality of São Paulo Healthcare Plan (São Paulo City Hall, 2015). Even though no documents exist for dementia specifically, the municipality of São José dos Campos, for example, offers dementia training for doctors, nurses, and dentists. This training is based on discussions of dementia-related clinical cases with a multidisciplinary team. Furthermore, there is an “Ageing Workshop” for training health community agents and nursing assistants in an array of topics relating to ageing, including dementia also in São José dos Campos. In Brazil there are 5,570 municipalities which are decentralised from the federal government; thus, it is possible that other unknown local initiatives exist.

References:

Federal District Government. (2021). LEI N^o 6.926—Política distrital para prevenção, tratamento e apoio às pessoas com doença de Alzheimer e outras demências. https://www.tjdft.jus.br/institucional/relacoes-institucionais/arquivos/lei-no-6-926-de-02-de-agosto-de-2021.pdf

Novo Hamburgo Municipal Chamber. (2020). Projeto de Lei Municipal 12/2020—Novo Hamburgo. Camara Municipal. https://portal.camaranh.rs.gov.br/pm3/informacao_e_conhecimento/noticias/novo-hamburgo-podera-ter-politica-de-enfrentamento-ao-alzheimer

Paraná Government. (2014). Plano Estadual dos Direitos da Pessoa Idosa do Paraná: 2015 a 2018. http://www.cedi.pr.gov.br/arquivos/File/2015/publicacoes/Plano_Estadual_Idoso_publicado.pdf

Paraná Government. (2017). Plano Estudual de Atendimento à Pessoa Idosa: 2016-2019.

São Paulo Chamber of Deputies. (2019). Projeto de Lei da Câmara Municipal de São Paulo, n 769, de 2019. https://splegisconsulta.camara.sp.gov.br/Pesquisa/DetailsDetalhado?COD_MTRA_LEGL=1&COD_PCSS_CMSP=769&ANO_PCSS_CMSP=2019

São Paulo City Hall. (2015). Plano Municipal de Saúde de São Paulo 2014-2017. City Hall of Sao Paulo.

Dementia is framed as a serious condition that may lead to a physically and psychologically dependent-life, with high impact in the quality of life of family carers (Brazilian Ministry of Health, 2018e).

References:

Brazilian Ministry of Health. (2018e). Orientações Técnicas para a Implementação de Linha de Cuidado para Atenção integral à Saúde da Pessoa Idosa no Sistema Único de Saúde—SUS. Ministério da Saúde do Brasil.

Yes.

Yes.

Yes.

Yes.

Yes.

It is also important to say that the health policies on ageing in Brazil so far have prioritized a longitudinal approach, not focusing on specific diseases but on people’s functionality.

The documents focus on keeping people as independent as possible, on implementing strategies to prevent diseases, and on adopting a person-centred care to promote quality of life and well-being (Brazilian Ministry of Health, 2018e; United Nations, 2018).

References:

Brazilian Ministry of Health. (2018e). Orientações Técnicas para a Implementação de Linha de Cuidado para Atenção integral à Saúde da Pessoa Idosa no Sistema Único de Saúde—SUS. Ministério da Saúde do Brasil.

United Nations. (2018). Transforming Our World: The 2030 Agenda for Sustainable Development. In A New Era in Global Health. https://doi.org/10.1891/9780826190123.ap02

The Law Project number 4364/2020 entitled “The National Policy for Integrated Care for People Living with Alzheimer’s Disease and other Dementias” recognizes people living with dementia and their carers and tries to provide psychological, social, and clinical support for these persons. In the “Technical Guidelines for Implementing a Healthcare Pathway for Integral Health for Older People” (Brazilian Ministry of Health, 2018e) dementia is recognised as a threat to independent life, strongly impacting on people, family, and carer’s quality of life.

References:

Brazilian Ministry of Health. (2018e). Orientações Técnicas para a Implementação de Linha de Cuidado para Atenção integral à Saúde da Pessoa Idosa no Sistema Único de Saúde—SUS. Ministério da Saúde do Brasil.

It is stated in the Older People’s Statute that mistreatment and abuse towards any older person (with and without dementia) is not acceptable and will be treated under the penalty of law (Presidency of Republic of Brazil, 2003).

References:

Presidency of Republic of Brazil. (2003). Estatuto do Idoso. Presidency of Republic of Brazil; National Congress of Brazil’s Information System. http://www.planalto.gov.br/ccivil_03/leis/2003/l10.741.htm

Yes. Nowadays, the care pathway in Brazil focuses on older people’s multidimensional assessment in the context of healthy ageing. Healthcare is not only centred on the absence of disease, but is focused on the maintenance of independence, avoidance of functional capacity loss, and promotion of good quality of life (Brazilian Ministry of Health, 2018e).

References:

Brazilian Ministry of Health. (2018e). Orientações Técnicas para a Implementação de Linha de Cuidado para Atenção integral à Saúde da Pessoa Idosa no Sistema Único de Saúde—SUS. Ministério da Saúde do Brasil.

At policy level, yes. Community healthcare agents and primary healthcare staff should conduct a multidimensional assessment and, from that, identify what the person is able to do independently and what help is needed. This is part of the integral care for older people, that considers clinical, psychosocial, and functional aspects of a person’s life. As one of the aims of the multidimensional assessment is to keep people’s independence, it is expected that support regarding the maintenance of an active role in the community is provided. It is important to state that all older persons can receive education regarding the maintenance of an active role in the community, regardless of having dementia (Brazilian Ministry of Health, 2018e).

References:

Brazilian Ministry of Health. (2018e). Orientações Técnicas para a Implementação de Linha de Cuidado para Atenção integral à Saúde da Pessoa Idosa no Sistema Único de Saúde—SUS. Ministério da Saúde do Brasil.

Probably yes (policy level), but there is no evidence that this occurs in practice. Not only people living with dementia, but older people in general as part of the multidimensional assessment which aims to keep people clinically, psychosocially, and functionally independent (Brazilian Ministry of Health, 2018e).

References:

Brazilian Ministry of Health. (2018e). Orientações Técnicas para a Implementação de Linha de Cuidado para Atenção integral à Saúde da Pessoa Idosa no Sistema Único de Saúde—SUS. Ministério da Saúde do Brasil.

This should happen (stated in policy), but there is no evidence that this occurs in practice. Not only people living with dementia, but all older people, as part of the integral healthcare orientation document and the multidimensional assessment for older people (Brazilian Ministry of Health, 2018e). However, we could not find information about how many older adults on average have this assessment completed routinely throughout the country, nor there is information about how this is managed when the person with dementia can no longer express his/her wishes. There is not a clear guidance about how this should be done, so it depends on the willingness of the clinician involved in the care provided.

References:

Brazilian Ministry of Health. (2018e). Orientações Técnicas para a Implementação de Linha de Cuidado para Atenção integral à Saúde da Pessoa Idosa no Sistema Único de Saúde—SUS. Ministério da Saúde do Brasil.

The National Policy for Older People’s Health (Brazilian Ministry of Health, 2006b) recognises the need for a high quality workforce with sufficient knowledge to take care of older people. The government, through its Federal, State, and Municipal levels provide training to professionals working at primary care level so that they can recognise people with cognitive impairment and refer them to adequate, more specialised, and integrated care units (Informal Source, 2019). Indicators of quality assurance include e.g., how many older adults have had a routine geriatric assessment completed and how many people living with dementia have been diagnosed, etc. However, this information is not available, or is not open for consultation.

References:

Brazilian Ministry of Health. (2006b). Política Nacional de Saúde da Pessoa Idosa. Brazilian Ministry of Health. http://bvsms.saude.gov.br/bvs/saudelegis/gm/2006/prt2528_19_10_2006.html

Yes. The need for multidisciplinary healthcare teams with sufficient knowledge about older people is mentioned as a challenge to be overcome in the National Policy for Older People’s Health and in the Law Project 4364/2020 (Brazilian Federal Congress, 2020; Brazilian Ministry of Health, 2006). However, the long-term care workforce is not specifically mentioned.

References:

Brazilian Federal Congress. (2020). Projeto de Lei do Senado 4364, de 2020. https://www25.senado.leg.br/web/atividade/materias/-/materia/144381

Brazilian Ministry of Health. (2006). Política Nacional de Saúde da Pessoa Idosa. http://bvsms.saude.gov.br/bvs/saudelegis/gm/2006/prt2528_19_10_2006.html

The documents do not specify key actors. Based on the policies outlined above, we assume that the Ministry of Health is a key actor.

Yes. The “Technical Guidelines for Implementing a Healthcare Pathway for Integral Health for Older People” is a document that supports integrated care in the Brazilian Unified Health System – SUS. This document explains that the government provides a “healthcare notebook” for older people, in which each older person should have her health information recorded. Based on this information, the person then becomes subject to a multidimensional assessment which considers physical, psychological, and emotional aspects of a person’s life in order to offer quality healthcare to each individual person. Based on these two tools, a “Person-Centered Therapeutic Plan” (Programa Terapeutico Singular – PTS) is tailored according to the needs and personal situation of each patient aiming at delivering integrated care, education, and better quality of life (Brazilian Ministry of Health, 2018e).

References:

Brazilian Ministry of Health. (2018e). Orientações Técnicas para a Implementação de Linha de Cuidado para Atenção integral à Saúde da Pessoa Idosa no Sistema Único de Saúde—SUS. Ministério da Saúde do Brasil.

As the existing policies were developed to meet the needs of older people in Brazil (regardless of having dementia) they are broad in scope and incorporate other aspects of care, such as general healthcare (Brazilian Ministry of Health, 2006b). Mental health care is available through the National Policy for Primary Care (Política de Nacional de Atenção Básica) for all people of all ages. People who have been identified to be in need of mental health support may be sent to the Centres of Psychosocial Attention (Centro de Atenção Psicosocial – CASP) where they receive specialised care (Brazilian Ministry of Health, 2012, 2018e). People living with dementia might follow this route; however, these individuals are most often involved in the health system through the primary healthcare units, rather than through the mental health services.

References:

Brazilian Ministry of Health. (2006b). Política Nacional de Saúde da Pessoa Idosa. Brazilian Ministry of Health. http://bvsms.saude.gov.br/bvs/saudelegis/gm/2006/prt2528_19_10_2006.html

Brazilian Ministry of Health. (2012). Política Nacional de Atenção Básica. http://189.28.128.100/dab/docs/publicacoes/geral/pnab.pdf

Brazilian Ministry of Health. (2018e). Orientações Técnicas para a Implementação de Linha de Cuidado para Atenção integral à Saúde da Pessoa Idosa no Sistema Único de Saúde—SUS. Ministério da Saúde do Brasil.

It attempts to recognise common barriers to access. The National Policy for Primary Care document recognises that in some geographical areas of Brazil services are difficult to access. Therefore, some healthcare teams provide care for people living in regions with difficult access to services, such as rural, riverside, and Amazon rainforest (Brazilian Ministry of Health, 2012). Despite its challenges, in theory, such teams should have access to transportation (by car or by boat) so that such communities could be visited by healthcare providers. Older people’s policies mention the integration and coordination with other areas (intersectoral approach) to overcome some of these challenges. As healthcare is a right of every person in Brazil, it is implied that the government must actively identify strategies to overcome eventual barriers of access.

References:

Brazilian Ministry of Health. (2012). Política Nacional de Atenção Básica. http://189.28.128.100/dab/docs/publicacoes/geral/pnab.pdf

In Brazil, there is the Unified Health System (SUS), and the concept of equity is already incorporated in the government healthcare policies, being one of the three main principles of SUS. The National Healthcare Policy for Older People incorporates equity and universality in the sense that healthcare is offered to all persons aged 60 years and over regardless of whether they have dementia (Brazilian Ministry of Health, 2006b). However, although all people in Brazil are offered the same right of accessing care through the SUS (funded by public sector), people who are better off tend to use healthcare services provided by the private sector through out-of-pocket payments or healthcare insurances. So, there is a selection bias among people who use SUS. But even those using the public services, face different realities depending on where they live because the quality of and access to health services may vary according to neighbourhoods and cities. The SUS principles include universality and equity, but this is different in the different parts of the country.

References:

Brazilian Ministry of Health. (2006b). Política Nacional de Saúde da Pessoa Idosa. Brazilian Ministry of Health. http://bvsms.saude.gov.br/bvs/saudelegis/gm/2006/prt2528_19_10_2006.html

The National Healthcare Policy for Older People outlines the importance of immunization campaigns, prevention programs for chronic non-communicable diseases, and educational programs on healthy lifestyle (Brazilian Ministry of Health, 2006b). According to the National Policy of Primary Care healthcare-community agents are responsible for visiting people from their community on a regular basis. These visits aim, among other objectives, to assess the health of people and to guide them towards disease prevention and risk reduction (Brazilian Ministry of Health, 2012). It is relevant to note that this policy includes people of all ages, not only older people.

References:

Brazilian Ministry of Health. (2006b). Política Nacional de Saúde da Pessoa Idosa. Brazilian Ministry of Health. http://bvsms.saude.gov.br/bvs/saudelegis/gm/2006/prt2528_19_10_2006.html

Brazilian Ministry of Health. (2012). Política Nacional de Atenção Básica. http://189.28.128.100/dab/docs/publicacoes/geral/pnab.pdf

No. Sustainability is not addressed explicitly.

The National Dementia Policy was created by a group that comprised a doctor, politicians, and others. The law created in the municipality of São Paulo was developed by a group composed of healthcare professionals, communication professionals, politicians etc. These professionals generally give expert inputs, the politicians write the law and are responsible for legislative procedures. The creation or development of some policies may be discussed in commissions composed of parliamentarians and civil society representatives.

There are no monitoring targets specified in the policy documents. In terms of monitoring, there are health and social indicators available in the Brazilian Information Systems that may be used to support the monitoring of policies (such as mortality rate, number of live births, number of hospitalizations, many data stratified by sex, age etc.). For instance, some academic publications make use of these indicators to show advances or setbacks in the healthcare system. Another example is an article that shows positive impact of the Family Health Strategy program on mortality from heart and cerebrovascular diseases (Rasella et al., 2014).

References:

Rasella, D., Harhay, M. O., Pamponet, M. L., Aquino, R., & Barreto, M. L. (2014). Impact of primary health care on mortality from heart and cerebrovascular diseases in Brazil: A nationwide analysis of longitudinal data. BMJ, 349. https://doi.org/10.1136/bmj.g4014

The National Policy for Older People’s Health stated in 2006 that some local, state, and municipal managers’ experiences were important for the establishment of the policy. However, no details about specific experiences and names of these managers were mentioned in the document (Fernandes & Soares, 2012).

References:

Fernandes, M. T. de O., & Soares, S. M. (2012). O desenvolvimento de políticas públicas de atenção ao idoso no Brasil. Revista Da Escola de Enfermagem Da USP, 46(6), 1494–1502. https://doi.org/10.1590/S0080-62342012000600029

Their expectations were to better organise healthcare services for older people (Fernandes & Soares, 2012).

References:

Fernandes, M. T. de O., & Soares, S. M. (2012). O desenvolvimento de políticas públicas de atenção ao idoso no Brasil. Revista Da Escola de Enfermagem Da USP, 46(6), 1494–1502. https://doi.org/10.1590/S0080-62342012000600029

The Ministry of Health tries to conduct dementia awareness campaigns in the whole country, every year in September. Actions carried out by dementia associations also greatly contribute to increase dementia awareness, stigma reduction, and the development of dementia-friendly communities. These types of action are supported by the Older People’s Statute as they contribute to increase attention and protection of older people (Presidency of Republic of Brazil, 2003).

References:

Presidency of Republic of Brazil. (2003). Estatuto do Idoso. Presidency of Republic of Brazil; National Congress of Brazil’s Information System. http://www.planalto.gov.br/ccivil_03/leis/2003/l10.741.htm

The “Technical Guidelines for Implementing a Healthcare Pathway for Integral Health for Older People” mentions about potentially modifiable risk factors such as physical inactivity, smoking, low cognitive activity etc. (Brazilian Ministry of Health, 2018e). In addition, primary healthcare policies, such as the Family Health Strategy, carry an important role in the reduction of risk factors for dementia, even though this policy has not been developed specifically for dementia, but for cardiovascular disease and diabetes mainly. The primary healthcare policies, among other things, promote preventive actions towards hypertension, diabetes, promotion of healthier lifestyles etc. which may contribute to the risk reduction of dementia.

References:

Brazilian Ministry of Health. (2018e). Orientações Técnicas para a Implementação de Linha de Cuidado para Atenção integral à Saúde da Pessoa Idosa no Sistema Único de Saúde—SUS. Ministério da Saúde do Brasil.

The “National Policy for Primary Care” is responsible for the first contact with the population and for referring people to more specialised services in order to receive proper diagnosis (Brazilian Ministry of Health, 2012). We had previously estimated that dementia is underdiagnosed, and we believe that those diagnosed are in general at more advanced stages of the disease. In practice, patients suspected to have dementia by primary care professionals should be referred to a specialist (usually a geriatrician, psychiatrist, or a neurologist), who will follow through each case and will prescribe anti-cholinesterase drugs or other medication routinely. The post-diagnostic support is generally provided through primary care services in which people living with dementia would receive a similar type of support like other older people with chronic conditions. The care itself is not provided by public services and there are no dementia-specific mainstream post-diagnostic services for people living with dementia and their carers. A few initiatives can be found locally through University hospitals where support groups are provided, or through private services.

References:

Brazilian Ministry of Health. (2012). Política Nacional de Atenção Básica. http://189.28.128.100/dab/docs/publicacoes/geral/pnab.pdf

The government has been investing in training their workforce so they can recognize signs of cognitive impairment (informal source, 2019). In São José dos Campos (state of São Paulo) there is a dementia training for doctors, nurses, and dentists. This programme is based on discussions of dementia clinical cases together with a multidisciplinary team (informal source, 2019). As stated above, Brazil comprises 5,570 municipalities, thus other unknown strategies might exist. The Law Project 4364/2020 supports the health professionals training in dementia.

The Law Project 4364/2020, states support for family carers. However, there is no detailed information on how this would be done. Currently, there are no areas for action in this category. This is left to the families themselves and to the primary care units.

The Law Project 4364/2020 (if approved) currently states that all people with dementia should be confidentially registered in an information system from SUS.

The Law Project 4364/2020 (if approved) will prioritise dementia research in Brazil. So far, the Brazilian research institutions have been investing in research on dementia. Between 2002 and April 2019, a total of US$5,397,116.92 were invested in 66 research projects on dementia by the Department of Science and Technology through the Ministry of Health (Brazilian Ministry of Health, 2019g). At local level, agencies have been financing a number of studies. For example, the agency FAPESP (São Paulo Research Foundation) has allocated 421 scholarships and research funds for dementia research, and when it comes to Alzheimer’s disease, this number rises to 884 (however, we cannot distinguish whether these 884 research funds focus on Alzheimer’s disease only or cover Alzheimer’s and other types of dementia) (FAPESP, 2019).

References:

Brazilian Ministry of Health. (2019g). Pesquisa Saúde. https://pesquisasaude.saude.gov.br/

FAPESP. (2019). FAPESP :: Fundação de Amparo à Pesquisa do Estado de São Paulo. http://www.fapesp.br/

Yes, the national laws are described as follows:

• National Law No. 11.736 establishes the 21 September as the national day of the Alzheimer’s disease, which aims to increase people’s awareness of the condition (Presidency of Republic of Brazil, 2008).
• National Law No. 5.233 states that people with cognitive impairment, such as Parkinson’s disease, are eligible for keeping their entire salaries as retirement pensions.
• There is the Ordinance No. 703 that establishes a “Program for Supporting People with Alzheimer’s Disease” (Programa de Assistência aos Portadores da Doença de Alzheimer, Portaria número 703) in the Brazilian Unified Healthcare System (SUS). According to this programme, the Reference Centres for Older People’s Healthcare (belonging to SUS) are responsible for diagnosing, treating, and accompanying people with Alzheimer’s Disease as well as supporting their families and carers (Presidency of Republic of Brazil, 1967). These Reference Centres are hospitals with physical infrastructure, equipment, and human resources adequate to provide healthcare to older people in an integrated way. Besides that, these centres should have, an outpatient clinic specialized in older people, geriatric day hospital (it is a kind of hospital that offers healthcare services to older people who are able to return home at the end of the day), and should provide homecare services of medium complexity for older people. A total of 74 Reference Centres are distributed among the 26 Brazilian federal states and the federal district (Brazilian Ministry of Health, 2002).

In addition, there are many “Law Projects” (Projeto de Lei no Senado or Projeto de Lei, in Portuguese) that are submitted to the federal congress for assessment and vote before becoming legally binding. This process may last years until completion. Some of the law projects are related to dementia. These are:

• PLS No. 4364 (2020): aims to create The National Policy for Integrated Care for People Living with Alzheimer’s Disease and other Dementias (Brazilian Federal Congress, 2020).
• PLS No. 30 (2018): aims to allow people living with dementia to manage a Brazilian financial fund (FGTS) at any time, which they would otherwise only be allowed to manage after retirement or under specific circumstances (Brazilian Federal Congress, 2018).
• PLS No. 61 (2017): people with Alzheimer’s disease to receive income tax payment waiver (Brazilian Federal Congress, 2017).
• PLS No. 523 (2011): provides subsidised medicine for people with Alzheimer’s disease, Parkinson’s disease, depression, diabetes etc. (Brazilian Federal Congress, 2011b).
• PLS No. 412 (2011): supports campaigns advising prevention and timely diagnosis of Alzheimer’s disease (Brazilian Federal Congress, 2011a, p. 412).

References:

Brazilian Federal Congress. (2011a). Projeto de Lei do Senado n° 412, de 2011—Pesquisas—Senado Federal. https://www25.senado.leg.br/web/atividade/materias/-/materia/101226

Brazilian Federal Congress. (2011b). Projeto de Lei do Senado n° 523, de 2011—Pesquisas—Senado Federal. https://www25.senado.leg.br/web/atividade/materias/-/materia/101821

Brazilian Federal Congress. (2017). Projeto de Lei do Senado n° 61, de 2017—Pesquisas—Senado Federal. https://www25.senado.leg.br/web/atividade/materias/-/materia/128350

Brazilian Federal Congress. (2018). Projeto de Lei do Senado n° 30, de 2018—Pesquisas—Senado Federal. https://www25.senado.leg.br/web/atividade/materias/-/materia/132157

Brazilian Federal Congress. (2020). Projeto de Lei do Senado 4364, de 2020. https://www25.senado.leg.br/web/atividade/materias/-/materia/144381

Brazilian Ministry of Health (Ed.). (2002). Redes estaduais de atenção à saúde do idoso: Guia operacional e portarias relacionadas. Editora MS. http://bvsms.saude.gov.br/bvs/publicacoes/redes_estaduais.pdf

Presidency of Republic of Brazil. (1967). Lei 5233. http://www.planalto.gov.br/ccivil_03/LEIS/1950-1969/L5233.htm

Presidency of Republic of Brazil. (2008). Lei 11736. http://www.planalto.gov.br/ccivil_03/_ato2007-2010/2008/lei/L11736.htm

Yes. There is Law No. 10.741 established in 2003 (“Older People’s Statute”), which guarantees the rights of all Brazilians aged 60 years and over. Older people (those aged 60 years and over) with dementia are included in this law and, in theory, should be given access to social protection, access to healthcare, housing, dignity, food, education, culture, sports, leisure, work, and transport. There is Normative No. 41 (2018) from the Ministry of Health that outlines palliative care and advance care directives in the context of SUS. The aim of this Normative is to provide quality of life for people with life-threatening diseases from the diagnosis to the end of life. The actions carried out include, among others, the provision of medicines to alleviate pain and the offer of psychological support for both the patients and their families (Brazilian Ministry of Health, 2018g, 2019b). The Law number 10.216 (2001) outlines about rights and protection of people living with mental disorders (Presidency of Republic of Brazil, 2001, p. 216). These laws comply with international human rights standards.

References:

Brazilian Ministry of Health. (2018g). RESOLUÇÃO N^o 41, DE 31 DE OUTUBRO DE 2018—Imprensa Nacional. http://www.in.gov.br/materia

Brazilian Ministry of Health. (2019b). Cuidados Paliativos no SUS. Ministério Da Saúde.

Presidency of Republic of Brazil. (2001). Lei 10.216. http://www.planalto.gov.br/ccivil_03/leis/leis_2001/l10216.htm

Yes.

Yes.

Yes.

Yes.

Yes and no.

There is guidance, for example, from the Brazilian Society of Geriatrics and Gerontology, in partnership with ‘Choosing Wisely’, which states that people should not be mechanically contained/restrained (SBGG, 2018). However, this is not prohibitive and still is common practice in Brazil. Mostly, the guidance available says restrains (chemical/physical/environmental) should be avoided and should be done only as a last resource to a) protect the person, b) protect others, c) guarantee effective treatment. This decision should be discussed among the multidisciplinary team and with the family, and the reasons for that should be documented.

References:

SBGG. (2018, June 7). CBGG 2018: SBGG divulga recomendações sobre escolhas sensatas em saúde em parceria com Choosing Wisely Brasil. SBGG. https://sbgg.org.br/cbgg-2018-sbgg-divulga-recomendacoes-sobre-escolhas-sensatas-em-saude-em-parceria-com-choosing-wisely-brasil/

Yes. Although there is no law specifically outlining advance care directives, the Brazilian Ministry of Health has regulated palliative care in SUS through Normative No. 41 (2018). In this regulation, advance care directives are considered for all people with any life threatening disease, including dementia (Brazilian Ministry of Health, 2019b).

References:

Brazilian Ministry of Health. (2019b). Cuidados Paliativos no SUS. Ministério Da Saúde.

The Brazilian Association of Psychiatry runs a campaign for ending discrimination to people with mental health disorders, not only to people living with dementia (ABP | Campanha Psicofobia, n.d.). In addition, there is “Law Project” No 74 (2014) which was created to criminalise discrimination against people with mental health disorders. However, this law project seems to be ended without any conclusion in the Senate House Website (Projeto de Lei Do Senado N° 74, de 2014, 2014).

References:

ABP | Campanha Psicofobia. (n.d.). Psicofobia. Retrieved October 30, 2019, from https://www.psicofobia.com.br

Projeto de Lei do Senado n° 74, de 2014. (2014). https://www25.senado.leg.br/web/atividade/materias/-/materia/116394

No provisions were found.

No.

Yes. The Brazilian Federal Constitution (1988) in article number 229 states that off-spring must support their older parents. Moreover, the Older People’s Statute and the National Healthcare Policy for Older People advocates that older people have the right to be supported by their family members (or at least by the society). Yet in Brazil, it is commonly expected by society that older people receive support from their children (Presidency of Republic of Brazil, 1988).

References:

Presidency of Republic of Brazil. (1988). Federal Constitution of Brazil. http://www.planalto.gov.br/ccivil_03/constituicao/constituicao.htm

It is obtained through Court proceedings. The curators may be spouses, parents, children, in cases where the people mentioned are missing, the judge may choose another person as a curator or the representative of the institutions where the older person lives. The curatorship may be awarded on a temporary basis (Jusbrasil, 2018).

References:

Jusbrasil. (2018). Saiba o que é e como ocorre a Interdição de Idoso. Jusbrasil. https://beatriceekarlalopes.jusbrasil.com.br/artigos/573034226/saiba-o-que-e-e-como-ocorre-a-interdicao-de-idoso

Yes. There is a “Clinical Protocol of Therapeutic Guidelines” (Protocolo Clínico de Diretrizes Terapêuticas – PCDT) about Alzheimer’s Disease”. It guides health professionals and the population on the diagnosis and treatment of Alzheimer’s Disease (Brazilian Ministry of Health, 2017c). There is also a “Technical-Scientific Opinion” (Parecer Técnico-Científico) about the prevention of Alzheimer’s Disease (Valle, 2013), the “recommendations for diagnosing Alzheimer’s disease in Brazil” (Nitrini et al., 2005), and “recommendations in Alzheimer” (Brucki & Schultz, 2011).

References:

Brazilian Ministry of Health. (2017c). PCDT Alzheimer. Brazilian Ministry of Health.

Brucki, S. M. D., & Schultz, R. (2011). Manual de recomendações da ABN em Alzheimer-2011. 5. https://neurologiahu.ufsc.br/files/2012/08/Manual-de-recomendações-da-ABN-em-Alzheimer-2011.pdf

Nitrini, R., Caramelli, P., Damasceno, B. P., Brucki, S. M. D., & Anghinah, R. (2005). Diagnóstico de Doença de Alzheimer no Brasil. Avaliação cognitiva e funcional. Arq Neuropsiquiatr, 8.

Valle, E. A. (2013). Parecer Técnico-Científico: Prevenção da demência.

The existing one is national.

The Clinical Protocol of Therapeutic Guidelines was approved by the government, it was developed by the Ministry of Health.

The “Clinical Protocol of Therapeutic Guidelines about Alzheimer’s Disease” was developed in 2017 by the Ministry of Health (Brazilian Ministry of Health, 2017c).

Prior to this, the Brazilian Academy of Neurology published consensus papers regarding the diagnosis and treatment of Alzheimer’s disease, such as the “recommendations for diagnosing Alzheimer’s disease in Brazil”, developed in 2005, and the “recommendations in Alzheimer” developed in 2011.

References:

Brazilian Ministry of Health. (2017c). PCDT Alzheimer. Brazilian Ministry of Health.

These guidelines are evidence-based and mainly developed by healthcare professionals (clinicians and managers). Although specialists and members of public may contribute for their development, once finalised, these documents are not widely available to the public. Thus, many people, including doctors (especially those working in the private sector) do not know about the existence of these guidelines.

Yes, but mainly in rural and remote areas.

Natural medicines are used by the population, although there is no evidence of their effect. Some of them are:  ginkgo biloba, selegiline, vitamin E, and omega 3 (Brazilian Alzheimer’s Association, 2019). Faith healers are not widely used in Brazil for treating and managing dementia, in some cases, sporadic prayer groups may exist for that aim.

References:

Brazilian Alzheimer’s Association. (2019). ABRAZ. ABRAZ. https://abraz.org.br/2020/

Natural medicines are communicated by “word of mouth” and can be purchased in pharmacies or natural products stores without prescription. Traditional/Faith healers are not common in Brazil, but there are the so called ‘benzedeiras’ (blessers), who were common in the past, and generally prescribe teas or pray for someone who is ill.

There is no mechanism in government to coordinate care specifically for people living with dementia. However, there is the National Policy for Primary Care (Política Nacional de Atenção Básica) that includes the Family Healthcare Strategy (a multidisciplinary team of health professionals that provides regular care to the community). These groups are the first point of contact between people in the community and the provision of public healthcare (Brazilian Ministry of Health, 2012). Based on a multidimensional assessment, people are referred to more specialized care where they can access diagnoses and treatments when needed. There is also a programme/service called “Matriciamento em Saúde Mental” which is a model of delivering healthcare where two or more professional teams create a proposal of a pedagogical-therapeutic intervention. In Brazil, this model is developed between the Family Health Strategy (reference team) and a supportive mental health team (in the case of dementia). The aim is to make the system less hierarchical by providing a specialized technical support to an interprofessional team so as to broaden their field of action and to qualify their actions (Brazilian Ministry of Health, 2011b).

References:

Brazilian Ministry of Health. (2011b). Guia prático de matriciamento em saúde mental. http://bvsms.saude.gov.br/bvs/publicacoes/guia_pratico_matriciamento_saudemental.pdf

Brazilian Ministry of Health. (2012). Política Nacional de Atenção Básica. http://189.28.128.100/dab/docs/publicacoes/geral/pnab.pdf

There is no coordinated planning nor resourcing of care specifically for people living with dementia in Brazil. What we have that may be closer to a coordinated care is the “Matriciamento em Saúde Mental” (cited above), that could include health and educational sectors from below.

Considering the “Matriciamento em Saúde Mental”, it is at national level.

We could not find an answer for this. It seems that the topic has gained some attention among intersectoral working groups as the law for the dementia plan has been approved by the Senate. It is likely that, at some point, formal agreements and joint plans have been established for the implementation of the policy. Besides, it is possible to observe communication across sectors regarding policies to older people in general.

Yes, if we consider the “Matriciamento em Saúde Mental” care coordination occurs at all levels, but it is coordinated by the primary level of care.

There is no specific care coordination for people living with dementia. In the cases of the “Matriciamento em Saúde Mental”, there is neither supervision nor referral, it is a system that works horizontally, so when the family health team needs support regarding education, group intervention related to mental health etc., the “matriciamento” team is requested (Brazilian Ministry of Health, 2011b). The process through which different health and social care services which are relevant for people living with dementia should be coordinated/integrated is detailed in policies led by the Ministry of Health (Brazilian Ministry of Health, 2002, 2018e).

References:

Brazilian Ministry of Health. (2002). Redes estaduais de atenção à saúde do idoso: Guia operacional e portarias relacionadas. Editora MS. http://bvsms.saude.gov.br/bvs/publicacoes/redes_estaduais.pdf

Brazilian Ministry of Health. (2011b). Guia prático de matriciamento em saúde mental. http://bvsms.saude.gov.br/bvs/publicacoes/guia_pratico_matriciamento_saudemental.pdf

Brazilian Ministry of Health. (2018e). Orientações Técnicas para a Implementação de Linha de Cuidado para Atenção integral à Saúde da Pessoa Idosa no Sistema Único de Saúde—SUS. Ministério da Saúde do Brasil.

Brazil’s last presidential election was in October 2018 and the new government started its activities in January 2019. As many changes are still taking place in this new government, it is difficult to predict potential dementia policy changes over the next years. We are aware that a new department was created this year in the Ministry of Health (Secretaria de Atenção Primária) and dementia is one of their priorities. Prof. Cleusa Ferri has been invited to go to Brasilia to talk to the Secretary of that Secretariat.

The priority mentioned above can be an indicator of more attention given to dementia. Another evidence was the approval of the dementia plan by the Senate House, although it still needs to be approved by the Chamber of Deputies and, later on, to be implemented.

According to a member of the Secretariat of Primary Attention from the health ministry, currently there are two big gaps in services provision which motivate priority actions. These gaps are the neurodevelopment (early childhood) and the neurodegeneration (older people living with dementia).

Yes. The first National Dementia Plan is likely to be totally approved as it has been already approved by the Senate House, but it still needs approval from the Chamber of Deputies and sanction from the president of the Republic. The STRiDE Brazil team is in direct contact with government and STRiDE-Brasil may be key in these policy changes. Professor Cleusa Ferri has contact with the Ministry of Health through her work in the Health Technology Assessment and has been invited to some events to raise awareness and push dementia to the NCD agenda. Professor Nitrini from the STRiDE-Brazil Steering Committee was also invited to go to a meeting at the Chamber of Deputies with several politicians. From that meeting it was agreed that a commission would be created including civil society and politicians to take the further steps to prioritize dementia on the public health and social agenda. It seems that this, together with STRiDE Brazil activities, may accelerate the development of a national strategy in the next few years. Besides, professor Cleusa Ferri has been awarded with a grant from the Ministry of Health to develop the First Dementia National Report which will inform about various topics in dementia such as epidemiology, situation of care, costs etc.

There is no evidence about this question.

We are living a complex political time. It is hard to say what is going to happen in the near future. The 2019 pension reform is estimated to save R$800 billion over the next ten years. However, the socioeconomic consequences and the impact on welfare through this reform are yet to be understood. Besides, the Covid-19 pandemic has raised different priorities in terms of healthcare systems in Brazil and the consequences on the population are still difficult to estimate, as the pandemic is still in place.

No, there is nothing officially agreed about that. However, Professor Cleusa Ferri will try to review the guidelines developed in 2017 (Brazilian Ministry of Health, 2017c) through her work in the Health Technology Assessment Unit. The revision may lead to a new version that could be expected by 2022 or 2023.

References:

Brazilian Ministry of Health. (2017c). PCDT Alzheimer. Brazilian Ministry of Health.

The Brazilian Ministry of Health, the Brazilian Ministry of Citizenship, dementia associations, the STRiDE team, and national steering group, politicians.

Yes, through FEBRAZ (Brazilian Federation of Alzheimer’s Associations) and focal/local initiatives in health and universities/schools (FEBRAZ, 2019). For example, the World Alzheimer’s Day, celebrated on the 21^st September.

References:

FEBRAZ. (2019). Instituto Não Me Esqueças. http://www.naomeesquecas.com.br/conteudo/

Most campaigns are carried out during World Alzheimer’s Month by Alzheimer’s Associations at subnational levels. Up to 2018, the NGOs would each organise awareness, advocacy, and information provision events, including lighting buildings in purple, holding local seminars on dementia, scheduling public hearings with the local City Council members, offering speakers to give a presentation about dementia to local school teachers, having key-speakers to deliver presentations to the caregivers and the public in general, organizing cognitive activities for the impaired older people, setting up dementia movie sessions at the Older People’s Centres, providing technical and practical training to primary healthcare assistants. Some of these campaigns were named: Because I Care (Porque eu me importo); Purple September (Setembro lilás), Tribute Gallery Page (Galeria de tributos), Be the Wire that Supports our Memories (Seja o fio que sustenta nossas lembranças) and Every Three Seconds (A cada 3 segundos). The main delivery channels are through TV and radio coverage, and also through social media and advertisement. In 2019, the Ministry of Health was more involved with the campaign related to World Alzheimer’s Day and promoted a talk with specialists about dementia with live online transmission. In addition, in September 2019, the PAHO/WHO developed an anti-stigma campaign called “Let’s Talk About Dementia” in the Americas (Reyes, 2019).

References:

Reyes, O. (2019, September 1). PAHO/WHO | Anti-stigma campaign ‘Let’s Talk About Dementia’ marks beginning of World Alzheimer’s Month in the Americas. Pan American Health Organization / World Health Organization. https://www.paho.org/hq/index.php?option=com_content&view=article&id=15390:anti-stigma-campaign-let-s-talk-about-dementia-marks-beginning-of-world-alzheimer-s-month-in-the-americas&Itemid=1926&lang=en

The training and education in dementia received by these population groups are not systematic and not nationally spread. These are local and few initiatives.

There are few recent studies and official documentations exploring this topic in Brazil. According to a study conducted in São Paulo, 14.8% of the population showed some type of stigma regarding the Alzheimer’s disease (for example: stereotypes, prejudice, and discrimination) (Blay & Peluso, 2010).  Another study also carried out in São Paulo showed that Alzheimer’s disease was identified as memory loss by 46.4% of interviewed people, it was believed to be a mental illness by 39.4% and the majority of people attributed isolation and drug use as the main causes of the disease (Blay & de Toledo Piza Peluso, 2008). It is important to note that these studies were conducted around ten years ago in São Paulo. In a not yet published study, a master student of Prof. Cleusa Ferri, showed that 69.7% of 87 older people attending primary care recognized a case vignette as dementia, and 25% knew it by the name of Alzheimer’s disease (Opaleye et al., 2018). According to a survey published in the World Alzheimer Report: Attitudes to Dementia (2019), from all the Brazilian respondents, 19.5% of the general public and 26.4% of the healthcare practitioners said they would make an effort to keep their dementia a secret when meeting people; 69.6% of the general public revealed they perceive people living with dementia as unpredictable and impulsive. In this same survey, when asked whether people living with dementia were perceived as dangerous persons, 18% of the general public and 15% of the healthcare professionals agreed with this statement (Alzheimer’s Disease International, 2019).

References:

Alzheimer’s Disease International. (2019). World Alzheimer Report: Attitudes to Dementia. https://www.alz.co.uk/research/WorldAlzheimerReport2019.pdf

Blay, S. L., & de Toledo Piza Peluso, E. (2008). The public’s ability to recognize Alzheimer disease and their beliefs about its causes. Alzheimer Disease and Associated Disorders, 22(1), 79–85. https://doi.org/10.1097/WAD.0b013e31815ccd47

Blay, S. L., & Peluso, E. T. P. (2010). Public stigma: The community’s tolerance of Alzheimer disease. The American Journal of Geriatric Psychiatry, 18(2), 163–171. https://doi.org/10.1097/JGP.0b013e3181bea900

Opaleye, D., Machado, D. de A., Campos, T. P., Laks, J., & Ferri, C. P. (2018). Dementia in Brazil: Preferences on diagnosis disclosure in primary care. AAIC 2018, Chicago.

Yes. At the end of June 2019, there was a session in the Chamber of Deputies to discuss public policies for treating and preventing dementia in Brazil. This might be considered progress towards perceiving and supporting people living with dementia and their carers. In this session in the Chamber of Deputies, many topics, such as stigma reduction, prevention, support for carers, day care and long-term care institutions, were discussed. At the end of the session, it was agreed that a Dementia Committee should be created including members of Parliament and the general public in order to create a National Dementia Plan. A member of the STRiDE-Brazil Steering Committee gave a talk about dementia in this session and presented the STRiDE project. The dissemination of the STRiDE project may also work changing perceptions of dementia among the population. According to the study cited in the question above (from Cleusa’s Master student), out of 87 interviewed older people, 84.7% of them would like to know the diagnosis of dementia and should then be diagnosed, and 82.1% would like to share the diagnosis with a caregiver (Opaleye et al., 2018). In addition, some Brazilian soap operas have been showing characters living with Alzheimer’s, for example “Senhora do Destino, in 2004”, “I love Paraisopolis, in 2015”, “Deus Salve o Rei, in 2018” and “Salve-se quem Puder in 2020”. Soap operas are a popular form of mass entertainment in Brazil and may reflect the growing attention given to the cause of dementia. The first approval of the National Dementia Policy by the Senate House seems to be an indicator of the process of changing perceptions in the country.

References:

Opaleye, D., Machado, D. de A., Campos, T. P., Laks, J., & Ferri, C. P. (2018). Dementia in Brazil: Preferences on diagnosis disclosure in primary care. AAIC 2018, Chicago.

We could not find any specific evidence on that. However, we would assume that some of these factors are: stigma, lack of knowledge on dementia among society and even among healthcare professionals, the belief that living with dementia is natural as a person gets older, and “devaluation” of persons living with dementia. According to Blay and Peluso (2010), fewer years of education are associated with higher probability of stigmatizing people with Alzheimer (Blay & Peluso, 2010). In addition, Blay and Peluso (2008), showed that marital and economic status (besides level of education) influence responses about causes of Alzheimer’s Disease (AD). Married or previously married people showed a tendency to attribute AD to psychosocial causes, while people with unfavourable economic status tended to attribute AD to more biological origins, and people with 0 to 7 years of education attributed AD to spiritual/moral causes (Blay & de Toledo Piza Peluso, 2008).

References:

Blay, S. L., & de Toledo Piza Peluso, E. (2008). The public’s ability to recognize Alzheimer disease and their beliefs about its causes. Alzheimer Disease and Associated Disorders, 22(1), 79–85. https://doi.org/10.1097/WAD.0b013e31815ccd47

Blay, S. L., & Peluso, E. T. P. (2010). Public stigma: The community’s tolerance of Alzheimer disease. The American Journal of Geriatric Psychiatry, 18(2), 163–171. https://doi.org/10.1097/JGP.0b013e3181bea900

The general public is educated on issues related to physical and biological aspects of dementia, as well as legal rights and decision-making capacity. There is also awareness raising and information regarding pharmacological and non-pharmacological options, risk factors reduction, and stigma reduction. Trainings also cover signs and stages of dementia, cognitive and behavioural changes, strategies to interact, and to live with people living with dementia and even some aspects of palliative care. The focus is on how to be empathetic, sensitive, and supportive (Informal Source, 2019). It is important to say, however, that these trainings happen in small proportions only.

No. Only in terms of how much the topic “Alzheimer’s Disease” is accessed on Google during the campaigns in September.

Some actions were taken to make public spaces and buildings more accessible; such as parks with parking lots reserved for older people, ramps for entering public buildings, wider sidewalks to reduce older people’s risk of falling. However, these improvements are not evenly adopted across the country. Many cities and neighbourhoods do not have any of these accessibility spaces, especially those located in the poorer regions of Brazil. Some cities in the country have developed a program called the “City Gym” (Academia da Cidade, in Portuguese). This program aims to revitalize public spaces by making them more accessible and transforming them into public gyms where people of all ages can participate in physical activities and enjoy a leisure environment (Recife City Hall, 2019). Based on this programme, originally developed by some municipalities, the Brazilian Ministry of Health created the “Health Gym” (Academia da Saúde, in Portuguese) Programme, which aims to promote physical activity, healthy diet, education in health, and healthy and sustainable lifestyle at national level (Brazilian Ministry of Health, 2011a).

References:

Brazilian Ministry of Health. (2011a). Academia da Saúde.

Recife City Hall. (2019). Academia da Cidade | Prefeitura do Recife. http://www2.recife.pe.gov.br/servico/academia-da-cidade

Free public transport is available for people over 65 years of age using urban public transportation, as secured by the ‘older people’s statute’ (Presidency of Republic of Brazil, 2003). For more details on this, please refer to part 9. The public transport is mostly made up of buses and, although they have priority seats for older people, they are not well adapted in terms of accessibility for older people to use them. For example, the buses’ steps are very steep, making it difficult for many older people to enter. In addition, the bus floors may not be adequate or spacious enough for older people to walk on. A selection of the buses available are adapted for disabled people, in which wheelchairs can be allocated. People living with disability should also have access to free transportation under the ‘disabled people’s statute’. The Federal and District Attorney services are responsible for ensuring that these laws are realised in practice at municipal level.

References:

Presidency of Republic of Brazil. (2003). Estatuto do Idoso. Presidency of Republic of Brazil; National Congress of Brazil’s Information System. http://www.planalto.gov.br/ccivil_03/leis/2003/l10.741.htm

The Brazilian Ministry of Health produced guidance on home safety for older people, which is available on its Virtual Library Webpage (Brazilian Ministry of Health, 2018b). The state of São Paulo has adopted a “Universal Design” for guiding the construction of affordable homes and villas in the state. As part of it, there is a public document with guidance towards home adaptation aiming at including all citizens with special needs over the life-course (Government of the State of São Paulo, n.d.). Some manuals for carers also include guidance on home modification, for example, the Alzheimer’s Carer Manual (d’Alencar et al., 2010). Health professionals frequently provide guidance to patients regarding home safety. However, we could not find any document (widely-known by the population) with guidance towards home modification.

References:

Brazilian Ministry of Health. (2018b). Casa segura para o idoso. http://bvsms.saude.gov.br/dicas-em-saude/2920-casa-segura-para-o-idoso

d’Alencar, R. S., Pedreira dos Santos, E. M., and Tebaldi Pinto, J. B. (2010). http://www.uesc.br/editora/livrosdigitais2015/alzheimer_manual_cuidador.pdf

Government of the State of São Paulo. (n.d.). Desenho Universal: Habitação de interesse social. Retrieved November 18, 2019, from http://www.mpsp.mp.br/portal/page/portal/Cartilhas/manual-desenho-universal.pdf

The SUS provides assistive technology such as wheelchairs, walking sticks, orthoses, protheses etc. (Brazilian Ministry of Health, 2016a). More details on this matter can be seen in Part 7.

References:

Brazilian Ministry of Health. (2016a). Conheça a assistência oferecida pelo SUS às pessoas com deficiências.

There are initiatives to improve community places in Brazil. Some municipalities have created age-friendly neighbourhoods and the International Longevity Centre – Brazil (ILC-Brazil), which is a think tank advocating longevity and active ageing, and has supported and supervised “age-friendly city” projects in Brazil (ILC Brazil, 2019). However, these initiatives are isolated and not generalised throughout Brazil. For example, in the city of São José dos Campos, in the state of São Paulo, there are age-friendly houses where older persons go to meet each other, exercise, dance and socialize together. This is a municipality initiative that is run by the department of social development, and not within the health department. In the state of São Paulo, there are social centres (social meeting spaces) for people aged 60 years and over to meet, socialize, and participate in activities (Secretaria Estadual de Assistência e Desenvolvimento Social, n.d.).

References:

ILC Brazil. (2019). ILC BRAZIL. http://ilcbrazil.org/

Secretaria Estadual de Assistência e Desenvolvimento Social. (n.d.). SP Amigo do Idoso. Retrieved November 10, 2019, from http://www.desenvolvimentosocial.sp.gov.br/portal.php/programas_spamigodoidoso

In Brazil, the FEBRAz associations organise social events for people living with dementia during the month of September. Throughout the rest of the year, the supporting events are targeted at carers of people living with dementia (FEBRAZ, 2019). Moreover, municipalities develop initiatives and places where older people can participate in social activities.

References:

FEBRAZ. (2019). Instituto Não Me Esqueças. Http://Www.Naomeesquecas.Com.Br/. http://www.naomeesquecas.com.br/conteudo/

The number of people living with dementia is not routinely monitored in Brazil. However, there is monitoring of causes of death based on death certificates. Alzheimer’s disease can be recorded on these. Data collection is carried out through Datasus (an online public database from the Ministry of Health) (Datasus, 2019).

References:

Datasus. (2019). DATASUS. http://www2.datasus.gov.br/DATASUS/index.php?area=0205&id=6937&VObj=http://tabnet.datasus.gov.br/cgi/deftohtm.exe?sim/cnv/obt10

No.

No.

No.

The Datasus platform has a Mortality Information System that provides online data about mortality from Alzheimer’s disease. The number of deaths are available from 1996 to 2017 by: location, sex, age, education, ethnicity, and marital status.

For the mortality data, the death certificate is used.

Yes, through the DATASUS platform.

Yes, mortality data on Alzheimer’s disease can be disaggregated by gender and geographical area. Information on other types of dementia is not available.

According to the Global Burden of Disease Study 2016, the estimated prevalence of dementia in Brazil was approximately 16.9% in 2016 (GBD 2016, 2019). A systematic review conducted between 1990 and 2010 with older people aged 60 years and over found that, among high quality studies, all conducted in urban areas of São Paulo state, the prevalence of dementia ranged from 5.1% to 19.0% (Fagundes et al., 2011). Another study projected the prevalence of dementia among people 65 years and older in Brazil based on Census data (2010). The authors estimated that prevalence in the national territory would be 7.9% in 2020 (Burlá et al., 2013). There are several articles reporting prevalence measures in the literature; all of these were conducted in the south or southeast of Brazil. Therefore, there is lack of updated studies representative of the Brazilian population. The incidence rate of dementia was 13.8 per 1,000 person-years according to a study carried out in the city of Catanduva, São Paulo, with individuals aged 65 years and over (Nitrini et al., 2004). A study conducted in the city of Porto Alegre found the incidence rate of Alzheimer’s disease as 14.8 per 1,000 person-years (Chaves et al., 2009).

References:

Burlá, C., Camarano, A. A., Kanso, S., Fernandes, D., & Nunes, R. (2013). Panorama prospectivo das demências no Brasil: Um enfoque demográfico. Ciência & Saúde Coletiva, 18(10), 2949–2956. https://doi.org/10.1590/S1413-81232013001000019

Chaves, M. L., Camozzato, A. L., Godinho, C., Piazenski, I., & Kaye, J. (2009). Incidence of Mild Cognitive Impairment and Alzheimer Disease in Southern Brazil. Journal of Geriatric Psychiatry and Neurology, 22(3), 181–187. https://doi.org/10.1177/0891988709332942

Fagundes, S. D., Silva, M. T., Thees, M. F. R. S., & Pereira, M. G. (2011). Prevalence of dementia among elderly Brazilians: A systematic review. Sao Paulo Medical Journal, 129(1), 46–50. https://doi.org/10.1590/S1516-31802011000100009

GBD 2016. (2019). Global, regional, and national burden of Alzheimer’s disease and other dementias, 1990–2016: A systematic analysis for the Global Burden of Disease Study 2016. The Lancet Neurology, 18, 88–106. http://dx.doi.org/10.1016/S1474-4422(18)30403-4

Nitrini, R., Caramelli, P., Herrera, E., Bahia, V. S., Caixeta, L. F., Radanovic, M., Anghinah, R., Charchat-Fichman, H., Porto, C. S., Carthery, M. T., Hartmann, A. P. J., Huang, N., Smid, J., Lima, E. P., Takada, L. T., & Takahashi, D. Y. (2004). Incidence of dementia in a community-dwelling Brazilian population. Alzheimer Disease and Associated Disorders, 18(4), 241–246.

According to a study published in 2019 that systematically analysed data from the Global Burden of Disease Study 2016, there were 80,600 deaths (69,174 to 94,940; 95% confidence interval) due to dementia in Brazil in 2016 (GBD 2016, 2019). We could not find specific data for YLL. However, a subnational analysis of the Global Burden of Disease carried out for Brazil (from 1990 to 2016) described a small and non-significant increase in the age-standardised YLL rate of 2.7% (-1.3% to 7.0%) for Alzheimer’s disease over the observed period (GBD 2016, 2018).

References:

GBD 2016. (2018). Burden of disease in Brazil, 1990-2016: A systematic subnational analysis for the Global Burden of Disease Study 2016. The Lancet Neurology, 392. http://dx.doi.org/10.1016/S0140-6736(18)31221-2

GBD 2016. (2019). Global, regional, and national burden of Alzheimer’s disease and other dementias, 1990–2016: A systematic analysis for the Global Burden of Disease Study 2016. The Lancet Neurology, 18, 88–106. http://dx.doi.org/10.1016/S1474-4422(18)30403-4

We could not find specific data for YLD due to dementia. However, a subnational analysis of the Global Burden of Disease project carried out for Brazil between 1990 and 2016 (GBD 2016, 2018) described an increase in the age-standardised YLD rate of 4.9% (2.3% to 7.7%) for Alzheimer’s disease over the years analysed.

References:

GBD 2016. (2018). Burden of disease in Brazil, 1990-2016: A systematic subnational analysis for the Global Burden of Disease Study 2016. The Lancet Neurology, 392. http://dx.doi.org/10.1016/S0140-6736(18)31221-2

All studies on prevalence were conducted in the South and South-Eastern regions of Brazil, so we do not have data from other regions to compare. Even within the same region there is, however, an important variation on prevalence, but this is more likely due to differences in the methodology used in the different studies.

No information was found on this.

No information was found on this.

Yes. According to a systematic review conducted in 2011 (Fagundes et al., 2011), the prevalence of dementia was higher among women in all studies selected. The authors of this systematic review acknowledge that the age distribution of the sample populations was not uniform, which may explain the variation in the prevalence of dementia that was detected, as women tend to live eight years longer than men on average in Brazil, and, therefore, would contribute more to the prevalence rates of dementia. The review also showed that the prevalence of dementia increased with age and was inversely related to the socioeconomic status and number of years of education.

References:

Fagundes, S. D., Silva, M. T., Thees, M. F. R. S., & Pereira, M. G. (2011). Prevalence of dementia among elderly Brazilians: A systematic review. Sao Paulo Medical Journal, 129(1), 46–50. https://doi.org/10.1590/S1516-31802011000100009

No information was found specifically regarding dementia in this question. However, a longitudinal study conducted in São Paulo on Life Expectancy with Cognitive Impairment (LEWCI) showed that at the age of 60 years LEWCI was 1.9 years among men but varied between 3.4 years for men with no schooling and 0.6 years for men with 8 years of schooling. For women, the LEWCI was 3.1 years, varying from 4.5 years among women with no schooling to 1.0 years among those with 8 years of schooling (Andrade et al., 2019).

References:

Andrade, F. C. D., Corona, L. P., & de Oliveira Duarte, Y. A. (2019). Educational Differences in Cognitive Life Expectancy Among Older Adults in Brazil. Journal of the American Geriatrics Society, 67(6), 1218–1225. https://doi.org/10.1111/jgs.15811

No information was found on this topic.

Yes. Results from São Paulo Ageing and Health Study, published in 2008, showed that non-skilled occupation and unfavourable personal income increased the risk of dementia. Illiteracy and a cumulative effect of socioeconomic adversities across the life-course were also associated with higher prevalence of dementia in São Paulo (Scazufca et al., 2010).

References:

Scazufca, M., Almeida, O. P., & Menezes, P. R. (2010). The role of literacy, occupation and income in dementia prevention: The São Paulo Ageing & Health Study (SPAH). International Psychogeriatrics, 22(8), 1209–1215. https://doi.org/10.1017/S1041610210001213

There has been no specific campaign for dementia risk reduction in Brazil. However, there are strong efforts by primary and secondary care services, as well as federal state and municipal programs to prevent and reduce the burden of established risk factors for other chronic conditions, which are risk factors for dementia too. These include smoking, high blood pressure, and diabetes. Campaigns are communicated through television programmes, paper adverts, and education groups in the community (school, parks, etc.). Prevention program such as HIPERDIA (for diabetes and hypertension) are conducted in the PCU (Primary Care Units).

Longitudinal studies on dementia identified the following as risk factors: advanced age (Nitrini et al., 2004) and years of education (Chaves et al., 2009).

References:

Chaves, M. L., Camozzato, A. L., Godinho, C., Piazenski, I., & Kaye, J. (2009). Incidence of Mild Cognitive Impairment and Alzheimer Disease in Southern Brazil. Journal of Geriatric Psychiatry and Neurology, 22(3), 181–187. https://doi.org/10.1177/0891988709332942

Nitrini, R., Caramelli, P., Herrera, E., Bahia, V. S., Caixeta, L. F., Radanovic, M., Anghinah, R., Charchat-Fichman, H., Porto, C. S., Carthery, M. T., Hartmann, A. P. J., Huang, N., Smid, J., Lima, E. P., Takada, L. T., & Takahashi, D. Y. (2004). Incidence of dementia in a community-dwelling Brazilian population. Alzheimer Disease and Associated Disorders, 18(4), 241–246.

The data is available in Brazil for people aged 25 years and over through the PNAD 2017 (National Household Sample Survey) and shows that 59% of the population have completed primary education in Brazil. However, if we consider the proportion of people that have the primary education as their most advanced level of education, this proportion drops to 8.5% among people aged 25 years and older. There are 12.4% of women and 13.6% of men who completed primary education as their most advanced level of education (PNAD, 2017).  As mentioned previously, a systematic review conducted in 2011 showed that the prevalence of dementia increased with age and was inversely related to the socioeconomic status and number of years of education (Fagundes et al., 2011).

References:

Fagundes, S. D., Silva, M. T., Thees, M. F. R. S., & Pereira, M. G. (2011). Prevalence of dementia among elderly Brazilians: A systematic review. Sao Paulo Medical Journal, 129(1), 46–50. https://doi.org/10.1590/S1516-31802011000100009

PNAD. (2017). PNAD Contínua: Edição 2017. https://agenciadenoticias.ibge.gov.br/media/com_mediaibge/arquivos/05dc6273be644304b520efd585434917.pdf

These data are also available in Brazil for people aged 25 years and over through the PNAD 2017 (National Household Sample Survey). Data show that 46.1% of the population completed secondary education in Brazil. However, considering secondary education as one’s most advanced level of education, this amounts to 26.8%. Yet considering these data, there are 30.6% of women in Brazil who have secondary education, while this proportion is 30.2% for men (PNAD, 2017).

References:

PNAD. (2017). PNAD Contínua: Edição 2017. https://agenciadenoticias.ibge.gov.br/media/com_mediaibge/arquivos/05dc6273be644304b520efd585434917.pdf

According to the most recent version of the National Health Survey (PNS 2013, in Portuguese), 21.4% of the Brazilian population above 18 years were diagnosed with hypertension. A larger proportion of women (24.2%) self-reported the diagnosis compared with men (18.3%). The proportion of people living with hypertension increased with age reaching a peak of 55.0% among people aged 75 and over, followed by the proportion of 52.7% among those between 65 and 74 years old. Among those 60 and 64 years old 44.4% had a diagnosis of hypertension and among those aged 30 and 59 years it was 20.6%. Hypertension was mostly diagnosed among black people (24.2%) followed by white (22.1%) and mixed race people (20.0%) (Brazilian Ministry of Health, 2013b).

References:

Brazilian Ministry of Health. (2013b). Pesquisa Nacional de Saúde 2013: Percepção do estado de saúde, estilos de vida e doenças crônicas. https://biblioteca.ibge.gov.br/visualizacao/livros/liv91110.pdf

According to data from Vigitel 2018 (Surveillance System of Risk and Protection Factors for Chronic Diseases by Telephone Survey), 19.8% of adults were obese (with the body mass index greater than or equals to 30Kg/m²). This rate is slightly higher among women (20.7%) than men (18.7%). The proportion of obesity among adults increased with age up to 44 years for men (25.8%) and up to 64 years for women (27.7%). In both sexes, the frequency of obesity decreased with increased education, notably for women (Brazilian Ministry of Health, 2018h).

References:

Brazilian Ministry of Health. (2018h). Vigitel Brasil 2018: Vigilância dos fatores de risco e proteção para doenças crônicas por inquérito telefônico. http://portalarquivos2.saude.gov.br/images/pdf/2019/julho/25/vigitel-brasil-2018.pdf

Data from the PNS 2013 revealed that 1.1% of the population in Brazil experienced hearing loss. Regarding sex, this proportion was 1.0% among women and 1.2% among men. In the urban population, hearing loss was 1.1% while it was 1.4% among the rural population. The proportion among white people was 1.4%, while among black and mixed-race people it was 0.9%, for both groups. Hearing loss was more frequent among people aged 60 years and over (5.2%), compared with other age groups: 0-9 years (0.1%), 10-17 years (0.3%), 18-29 years (0.3%), 30-39 years (0.4%), 40-59 years (1.0%) (Brazilian Institute of Geography and Statistics, 2015a).

References:

Brazilian Institute of Geography and Statistics (Ed.). (2015a). Pesquisa nacional de saúde, 2013: Ciclos de vida: Brasil e grandes regiões. Instituto Brasileiro de Geografia e Estatística – IBGE.

According to the most recent version of the National Health Survey (PNS 2013, in Portuguese), 14.7% of the population smoked in 2013, with 12.7% smoking daily. The prevalence among men was 16.2% and among women was 9.7%. The proportion of those who consumed tobacco (smoked or not) was 15%. A larger proportion of men than women consumed tobacco (19.2% versus 11.2%). People within the age group 40-59 represented higher proportion of tobacco users (19.4%), followed by those aged 60 years and over (13.3%) (Brazilian Ministry of Health, 2013b).

References:

Brazilian Ministry of Health. (2013b). Pesquisa Nacional de Saúde 2013: Percepção do estado de saúde, estilos de vida e doenças crônicas. https://biblioteca.ibge.gov.br/visualizacao/livros/liv91110.pdf

Estimates from the WHO showed that, in 2015, 5.8% of the Brazilian population lived with depressive disorders (World Health Organization, 2017). According to the National Health Survey (PNS, 2013), 7.6% of Brazilians aged 18 years and over have been diagnosed with depression. The higher prevalence data were among urban areas (8.0% vs 5.6% in rural), women (10.9% vs 3.9% in men), and people aged 60 to 64 years old (11.1% vs 3.9% among those 19 and 28 years old) (Brazilian Ministry of Health, 2013b).

References:

Brazilian Ministry of Health. (2013b). Pesquisa Nacional de Saúde 2013: Percepção do estado de saúde, estilos de vida e doenças crônicas. https://biblioteca.ibge.gov.br/visualizacao/livros/liv91110.pdf

World Health Organization. (2017). Depression and Other Common Mental Disorders: Global Health Estimates. https://apps.who.int/iris/bitstream/handle/10665/254610/WHO-MSD-MER-2017.2-eng.pdf;jsessionid=F9B8AE77F2B1D3698E01577B2AFCBC03?sequence=1

According to the most recent version of the National Health Survey (PNS 2013, in Portuguese), 46.0% of the Brazilian population above 18 years were physically inactive (‘physically inactive’ defined as people who did not practice physical activity or who did practice it for less than 150 minutes per week, considering three domains: leisure, work, and commuting). Among people aged 60 and over, the proportion was 62.7%. In general, women showed higher proportions than men, varying from 50.3% in the Southern region to 53.4% in the Northern region. White people were more likely to be inactive (47.9%), compared to black (42.4%), and mixed race people (44.8%) (Brazilian Ministry of Health, 2013b).

References:

Brazilian Ministry of Health. (2013b). Pesquisa Nacional de Saúde 2013: Percepção do estado de saúde, estilos de vida e doenças crônicas. https://biblioteca.ibge.gov.br/visualizacao/livros/liv91110.pdf

According to the most recent version of the National Health Survey (PNS 2013, in Portuguese), 6.2% of the Brazilian population above 18 years old were diagnosed with diabetes. The proportion was higher in women (7.0%) than in men (5.4%) and increased with age from 0.6% in the age group 18-29 years to 19.9% among people aged 64 and 75 years old. For those over 75 years old, the proportion of diagnosed diabetes was 19.6%. There was no significant difference among ethnic groups: black people (7.2%), white (6.7%) and mixed race (5.5%). The lower the educational level, the higher the proportion of diabetes (9.6% among people with less than 4 years of formal education) (Brazilian Ministry of Health, 2013b).

References:

Brazilian Ministry of Health. (2013b). Pesquisa Nacional de Saúde 2013: Percepção do estado de saúde, estilos de vida e doenças crônicas. https://biblioteca.ibge.gov.br/visualizacao/livros/liv91110.pdf

The proportion of the population aged 18 years and over who consumed alcohol at least once a week in 2013 was 24.0%. Among men, this proportion was 36.3% and among women it was 13.0%. Besides, 30.5 % of people with university degree consumed alcohol compared with 19.0% of people with less than 4 years of education. Among age groups, those aged 18-24 years represented 27.1% of the population consuming alcohol, people between 25-39 years old accounted for 28.5%, those between 40 and 59 years old for 23.4% and those with 60 years and older represented 14.2% (Brazilian Ministry of Health, 2013b).

References:

Brazilian Ministry of Health. (2013b). Pesquisa Nacional de Saúde 2013: Percepção do estado de saúde, estilos de vida e doenças crônicas. https://biblioteca.ibge.gov.br/visualizacao/livros/liv91110.pdf

The PNS 2013 showed that 12.5% of people aged 18 years and over were diagnosed with high cholesterol. The estimated proportion in urban areas was 13.0%, while in rural areas it was 10.0%. The proportion was higher among women (15.1%) than men (9.7%). The frequency of people who referred diagnosis of high cholesterol was more representative in the older age groups: 25.9% among those aged 60 to 64 years, 25.5% among people aged 65 to 74 years, and 20.3% between those aged 75 years and older. The proportion of white people who reported altered cholesterol (13.4%) was higher than for black (11.2%) and mixed race (11.8%) people (Brazilian Ministry of Health, 2013b).

References:

Brazilian Ministry of Health. (2013b). Pesquisa Nacional de Saúde 2013: Percepção do estado de saúde, estilos de vida e doenças crônicas. https://biblioteca.ibge.gov.br/visualizacao/livros/liv91110.pdf

In the public health system (SUS) diagnosis would typically follow a pathway where a case would initially be identified by a GP at a Primary Care Unit and would be referred to a specialist for confirmation (usually neurologist or geriatrician). Yet in the public health system, people may also be diagnosed at other levels of care when people access them for other reasons, and clinicians may suspect of dementia (A&E, general hospital, other specialities outpatient care). In the private sector, the typical pathway is that families/patients who are suspecting that something is wrong, may take the patient directly to a specialist, usually a neurologist. As in the public services, clinicians from the private sector may identify cases also in other levels of care (hospital outpatient care).  It is important to remember that rates of underdiagnosis are high in Brazil.

We do not have high quality data on this, but according to our own study, more than 70% of people living with dementia in Brazil do not have a diagnosis (Nakamura et al., 2015).

References:

Nakamura, A., Opaleye, D., Tani, G., & Ferri, C. P. (2015). Dementia underdiagnosis in Brazil. The Lancet, 385(9966), 418–419. https://doi.org/10.1016/S0140-6736(15)60153-2

Such information was not found.

We do not have data on this for the country, neither for smaller areas. According to our previous study conducted in one city (São José dos Campos, in São Paulo state), we found that rates of under diagnosis were lower in the rich areas of the city (Nakamura et al., 2015).

References:

Nakamura, A., Opaleye, D., Tani, G., & Ferri, C. P. (2015). Dementia underdiagnosis in Brazil. The Lancet, 385(9966), 418–419. https://doi.org/10.1016/S0140-6736(15)60153-2

We do not have standard long-term care for people living with dementia. Within the public sector, people living with dementia who are diagnosed, can get medication for free and will have to get prescription every few months. They would need to come for an assessment by a specialist (neurologist or geriatrician) every 6 months and get a new prescription. Primary care units offer outreach services for those in late stages (health care team visits the patient).

No, there is no such service specifically dedicated to dementia. However, any person can have access to mental health care if they need.

The links may exist, but they are not well coordinated and integrated. However, there is the Family Health Strategy that facilitates integration between the three levels of care and that supports any type of healthcare needed by the population.

They are initiated by a health assessment at the primary care service and, based on that, people may be sent to more specialized services.

There is the Family Health Strategy Policy. Usually in the public service the primary care unit covered by this program has several healthcare teams. Each team covers an area and is responsible for the health of those living in that area.

Public health services (SUS) are free of charge and include medication (anticholinesterases). Those using the private sector may have health insurance which can be paid by employers or privately by themselves. It is also usual, for those who can afford it, to go directly to a well-known specialist for diagnosis and to pay the doctor directly for the consultation (usually very expensive). Sometimes, people do that in the beginning but end up in the public services as they cannot afford subsequent consultations or exams.

We do not have a clear path for long-term care for people living with dementia specifically. But it is likely that this first access will be through primary healthcare units in the public services, and they will provide the long-term care together with the family. We have only few long-term institutions for people living with dementia or other conditions in the public sector, so we may consider that this does not exist. A small proportion of people may access philanthropic long-term care institutions. The private LTC sector is growing, but it is extremely expensive.

There are some studies estimating the costs in Brazil. According to a cross-sectional study conducted with people living with dementia who attended an outpatient health care in a hospital in São Paulo, dementia direct and indirect costs were US$1,012.35, US$1,683.18, and US$1,372.30 per patient/month, respectively, for mild, moderate, and severe stages of dementia. These included the unpaid care costs, expenditures with transport, diapers, medication, use of emergency services, health insurance, hospital stay, etc. (Ferretti et al., 2018). Using a similar list of variables a study conducted with 93 caregivers being followed up by an outpatient clinic from the University of São Paulo Clinical Hospital, calculated a total monthly indirect care cost of US$1,122.40, US$1,508.90, and US$1,644.70, for mild, moderate, and severe stages of dementia, respectively (Ferretti et al., 2015). Another study revealed that R$90,108,885.14 (US$22,860,464.56) were spent with medication to Alzheimer’s disease by the Brazilian Unified Health System (SUS) between 2008 and 2013 (Costa et al., 2015). A more recent study conducted a cost-effectiveness analysis from the SUS perspective between donepezil and rivastigmine therapy for mild and moderate Alzheimer’s disease (AD). The study showed the annual cost (in Brazilian reais) for donepezil is 30,556.45 and for rivastigmine is 32,685.77. According to the current Brazilian clinical guidelines for AD, it is estimated that rivastigmine is less cost-effective (0.39 QUALY/32,685.77 Brazilian reais) than donepezil (da Silva et al., 2018).

References:

Costa, R. D. F. da, Osorio-de-Castro, C. G. S., Silva, R. M. da, Maia, A. de A., Ramos, M. de C. B., & Caetano, R. (2015). Aquisição de medicamentos para a Doença de Alzheimer no Brasil: Uma análise no sistema federal de compras, 2008 a 2013. Ciência & Saúde Coletiva, 20(12), 3827–3838. https://doi.org/10.1590/1413-812320152012.11542015

da Silva, L. R., Vianna, C. M. M., Mosegui, G. B. G., Peregrino, A. A. F., Marinho, V., & Laks, J. (2018). Cost-effectiveness analysis of the treatment of mild and moderate Alzheimer’s disease in Brazil. Revista Brasileira de Psiquiatria, 41(3), 218–224. https://doi.org/10.1590/1516-4446-2017-0021

Ferretti, C., Nitrini, R., & Brucki, S. M. D. (2015). Indirect cost with dementia. A Brazilian study. Dementia & Neuropsychologia, 9(1), 42–50. https://doi.org/DOI:10.1590/S1980-57642015DN91000007

Ferretti, C., Sarti, F. M., Nitrini, R., Ferreira, F. F., & Brucki, S. M. D. (2018). An assessment of direct and indirect costs of dementia in Brazil. PLoS ONE, 13(3). https://doi.org/10.1371/journal.pone.0193209

Health and long-term care in community-based settings are provided through SUS and SUAS for all people who need them in the country. People living with dementia may access these services the same way people without dementia do. Health (SUS) is a right by the Brazilian constitution, whereas social care (SUAS) is means/needs tested.

Usually, the GP refers those he/she suspects that have dementia to a specialist (psychiatrist, neurologist, or geriatrician) under secondary care, but may opt to conduct neuropsychological tests, as well as ask for the blood tests and tomography directly if possible.

This may be done, but there is no standard protocol. The neurologist or geriatrician is likely to do this during consultation. For the prescription of free anticholinesterase the specialist has to do the CDR (severity) and MMSE (cognition), but nothing regarding BPSD.

Yes, but not specifically for people living with dementia.

Yes, but not specifically for people living with dementia.

Yes, they are beginning to be implemented, but not specifically for people living with dementia.

Yes, but not specifically for people living with dementia.

Primary care units exist even in small towns/villages, rural and urban areas in Brazil, but there are greater numbers in big cities. There are efforts by the government to reach areas of difficult access. In some regions of the country the primary care unit is mobile, for example, it can be a big boat that goes on the river to reach small villages.

Community based services are mainly provided by public services.

No.

No.

There are no mainstream dementia-specific non-pharmacological interventions for carers or people living with dementia through the public sector. Private services are available, such as cognitive stimulation therapy, respite care, occupational therapy, arts therapy, etc. There are psychosocial activities through the primary health sector and social care sector for older people in general, such as older people’s centres, older people’s gyms, arts and craft groups, etc. Pharmacological treatment exist and are prescribed through GPs or specialists through a special pharmaceutical scheme called ‘high cost’ (or ‘alto custo’, in Portuguese). These are free of charge for service users; however, the process involved with getting this medicine monthly are often complicated and demands image tests (tomography, MRI), blood tests, neuropsychiatric assessment, and clinical assessment. It is common for people to take over one year to be able to get the pharmacological treatment through SUS due to the need to wait for all these documents, which also need to be regularly updated.

Not specifically for dementia. We are now working on the implementation of CST, but only locally in Sao Jose dos Campos, and still under research (state of São Paulo).

It is very likely that community-based services in rural areas and areas of difficult access (when existing) lack resources and well-trained health professionals.

Yes. Regarding community-based services, the provision of home care services is offered by the SUS in terms of (1) home care visits through the Primary Care Program (that provides orientations about family structure, home infrastructure etc.), and (2) through the program “Better at Home” (Melhor em Casa) that provides domiciliary health care to people who need equipment and other health resources.  It is noted, however, that the provision of these services are less available in small towns and rural areas (Brazilian Ministry of Health, 2019a, 2019j). The family health strategy incorporates primary healthcare teams which are composed at least of one doctor (GP), one nurse, and several general health workers. General health workers visit all households under their responsibility for monitoring and education. Doctors and nurses can make visits to patients with mobility difficulties for a general health assessment, monitoring, or for a specific situation identified by the team. Home care services are also provided by private companies, such as formal care by demand (hourly paid), nursing care, home-based invasive treatment (intravenous antibiotics, oxygen therapy), physiotherapy (respiratory and motor), nutritional assessment, among other services. The family may also hire a formal care independently and pay for it informally (per hour) or formally as domestic employee (through formal employment that includes all the constitutional rights).

References:

Brazilian Ministry of Health. (2019a). Atenção Domiciliar.

Brazilian Ministry of Health. (2019j). SAGE – Sala de Apoio à Gestão Estratégica. http://sage.saude.gov.br/

Healthcare service is a constitutional right in Brazil, and everyone should have access to it regardless of their age, gender, ethnicity, socioeconomic class, or geographic location. Social care, however, is provided depending on the individual needs identified by social care workers jointly with healthcare staff, as well as the socioeconomic condition of the family/person in need. There are only a few public care homes nationally, and access to such facilities is limited to very poor people. Formal day-to-day home care is not provided by the public sector, and is usually taken over by the family.

Yes. There is one federation (FEBRAZ) composed of four associations.

FEBRAZ has a national office.

They are only volunteers.

Awareness campaigns, home care services, training and support for carers, training for healthcare professionals and community health agents, activities for people living with dementia.

No.

No. However, FEBRAZ and local associations are now being involved in the dementia policy development as part of STRiDE activities.

Although there are services available in most regions of Brazil, the availability is higher in the Southern regions and the accessibility is easier in urban areas. One association also offers a distance service: Helpline – with counselling app, which benefits people from several Brazilian zones, including Brazilians abroad. There are no systematic activities in rural areas. There is limited attention in more distant areas, such as in the Amazon region.

No, there is no associated cost.

The NGOs in Brazil should provide services to people of all social classes and educational levels. However, the majority of people who are currently supported by the associations have average educational attainment (>8 years of education), are from middle class, and are predominantly from urban areas. The NGOs provide a lot of information, in different ways, and use a variety of different media which can be useful for people despite their educational and economic status. Because of the diversified dissemination tools, it is difficult to estimate the exact number of individuals served. However, media engagement is usually high, and the on-site raising awareness activities reach approximately twenty thousand people a year.

5,779 in the year 2020 (Conselho Federal de Medicina, 2020).

References:

Conselho Federal de Medicina. (2020). Demografia Médica no Brasil. https://www.fm.usp.br/fmusp/conteudo/DemografiaMedica2020_9DEZ.pdf

2,143 geriatricians in the year 2020 (Conselho Federal de Medicina, 2020).

References:

Conselho Federal de Medicina. (2020). Demografia Médica no Brasil. https://www.fm.usp.br/fmusp/conteudo/DemografiaMedica2020_9DEZ.pdf

Medical schools must follow a national teaching guideline designed by the Ministry of Education and the Federal Medical Council, which currently does not standardise any specific training on dementia. The national curricula broadly mentions ‘healthcare for older people’, ‘neurological conditions’, and ‘psychiatric illnesses’ (Ministry of Education, 2014). Medical students are likely to have contact with people living with dementia or with dementia as a learning subject within the departments of clinical neurology, geriatrics, and psychiatry. Only approximately 42% of the Brazilian medical schools offer teaching in Geriatrics nationally. In the South-Eastern region where the largest number of older people live, 36% of institutions taught Geriatrics to their students (Jacinto et al., 2015).

References:

Jacinto, A. F., Leite, A. G. R., Lima Neto, J. L. de, Vidal, E. I. de O., & Bôas, P. J. F. V. (2015). Teaching medical students about dementia: A brief review. Dementia & Neuropsychologia, 9, 93–95. https://doi.org/10.1590/1980-57642015DN92000002

Ministry of Education. (2014). Diretrizes Curriculares—Cursos de Graduação. http://portal.mec.gov.br/escola-de-gestores-da-educacao-basica/323-secretarias-112877938/orgaos-vinculados-82187207/12991-diretrizes-curriculares-cursos-de-graduacao

Neurologists, geriatricians, and psychiatrists should have theoretical and practical training on diagnosing and treating people living with dementia during their residency. The Societies linked to each specialty, such as such the National Academy of Neurology, the Brazilian Society of Geriatrics and Gerontology, and the Brazilian Association of Psychiatry, also help specialists to keep trained and updated about dementia and other related conditions.

Yes. Dementia should be part of the undergraduate and graduate courses under the umbrellas of cognitive functioning/assessment, cognitive rehabilitation, and cognitive training (Ministry of Education, 2004). There are also continued education programmes and clinical practice training for graduated psychologists (e.g. CICLOCEAP).

References:

Ministry of Education. (2004). Conselho Nacional de Educação. Câmara de Educação Superior. Resolução n 8, 7 de março 2004. http://portal.mec.gov.br/index.php?option=com_docman&view=download&alias=7690-rces004-08-pdf&category_slug=marco-2011-pdf&Itemid=30192

The Ministry of Education and the Professional Councils demands that undergraduate training of speech language therapy, physiotherapy, and occupational therapy include ‘health and care for older people’ and neurological illnesses; however, it is not clear whether dementia is a topic included in such guidance (Ministry of Education, 2001b). Again, specialised continued training and updating is available via in isolated options (e.g., one day courses), via postgraduate programmes, society-led initiatives, and through service improvement actions.

References:

Ministry of Education. (2001b). Diretrizes nacionais curriculares dos cursos de graduação em fisioterapia, fonoaudiologia e terapia ocupacional. http://portal.mec.gov.br/cne/arquivos/pdf/pces1210_01.pdf

Similar to the course of medicine, nursing training should include the topics ‘health and care for older people’, ‘neurological conditions’, and ‘psychiatric illnesses’, which are broadly mentioned in the national curricula (Ministry of Education, 2001c). However, this does not guarantee that students are effectively having training and practice on dementia care. Again, specialised continued training and updating, for example, is available via isolated options (e.g., one day courses), via postgraduate programmes, society-led initiatives, and through service improvement actions.

References:

Ministry of Education. (2001c). Diretrizes nacionais curriculares dos cursos de graduação em enfermagem. http://portal.mec.gov.br/cne/arquivos/pdf/CES03.pdf

Apparently no – this information was not found in the national curriculum of pharmaceutical and dentistry sciences (Ministry of Education, 2001a). Specialised continued training and updating, for example, is available via isolated options (e.g., one day courses), via postgraduate programmes, society-led initiatives, and through service improvement actions.

 References:

Ministry of Education. (2001a). Diretrizes Curriculares Nacionais dos Cursos de Graduação em Farmácia e Odontologia. http://portal.mec.gov.br/cne/arquivos/pdf/CES1300.pdf

Ageing is often offered as an optional undergraduate module, but there is no information about the inclusion of dementia as a topic of study. However, continuing educational programs in gerontology are offered by few private hospitals aiming at training social workers and other professionals (e.g., Albert Einstein Hospital).

There might be some training through private or philanthropic services, but this is not systematised through a national curriculum, therefore we cannot affirm whether dementia is included.

Education and training programmes are not systematised and not specific for dementia within the LTC public services, but staff receive different kinds of training within professional development schemes. Individuals who have an interest can pay for courses privately or have their companies paying for it. Free of charge or paid for courses are also offered by universities, philanthropic services, and private services. The assessment of such trainings is also varied through practical and written assessments.

Care agencies, public/policy services, universities, and other institutions may provide basic training for untrained care workers. However, we do not know whether that includes dementia and to what extent such courses are of good quality. Families may require informal care workers to be trained, but there is not a national/local regulation about this. The Ministry of Education ensures the quality (content, length, delivery mode) of such courses, which can be delivered online, including by the Ministry of Education itself through the Federal Institutes of Research.

It is not common. Some other professionals may wish to pursue dementia training if they wish, or if it is a workplace policy. In such cases, the training would be offered possibly by associations or private services.

Yes, but in a small number.

Yes, but in a small number.

Not specifically for dementia, but they exist and can be used by older people in general (only by those who are independent). It is more for health promotion than for care.

Yes, but in a small number.

In 2014, there were 1,451 long-term care facilities registered with the Brazilian Ministry of Citizenship (Camarano & Barbosa, n.d.). Approximately 33% of these institutions are philanthropic, 64% are private, and 6.6% are public or mixed. No information about the number of beds was found. It has been mentioned by the Ministry which regulates care homes in Brazil that there are several care homes who are currently ‘clandestine’ or unregistered nationally (CNMP, 2016). Moreover, the Ministry of Health webpage shows the distribution of officially registered care homes around the country and indicates a higher concentration of these institutions in the South and South-Eastern regions.

References:

Camarano, A. A., & Barbosa, P. (n.d.). Instituições de Longa Permanência para Idosos no Brasil: Do que se está falando? (pp. 479–514). Retrieved July 17, 2019, from http://repositorio.ipea.gov.br/bitstream/11058/9146/1/Institui%C3%A7%C3%B5es%20de%20longa%20perman%C3%AAncia.pdf

CNMP. (2016). Manual de Atuação Funcional—O Ministério Público na Fiscalização das Instituições de Longa Permanência para Idosos—Conselho Nacional do Ministério Público. https://www.cnmp.mp.br/portal/publicacoes/245-cartilhas-e-manuais/9984-manual-de-atuacao-funcional-o-ministerio-publico-na-fiscalizacao-das-instituicoes-de-longa-permanencia-para-idosos

We could not find this information specifically for people living with dementia. However, it has been estimated that around 100,000 people live in such facilities, of which 84,000 are older people, and the remaining are younger people with mental illness or disabilities (Camarano & Kanso, 2010).

References:

Camarano, A. A. & Kanso, S. (2010). As instituições de longa permanência para idosos no Brasil. Revista Brasileira de Estudos de População, 27(1), 232–235. https://doi.org/10.1590/S0102-30982010000100014

No.

Yes. But the number of geriatric-specific beds could not be found.

The health information systems in Brazil track the number of people living with dementia who have been hospitalised nationally via SUS. The notification of dementia-related admissions is not mandatory, which means that people living with dementia are likely to have their secondary causes for hospitalisation registered, such as infection, stroke, or dehydration, for example, instead of dementia as being the main cause. This creates an underestimation of the number of people living with dementia who have been hospitalised. In addition, the high number of people living with dementia who are currently undiagnosed (77%) (Nakamura et al., 2015), and the difficulty in differentiating acute delirium from dementia, might also have an effect on the absolute numbers of hospitalisation related to dementia.

The more advanced the age group is, the higher the number of admissions related to dementia. For instance: in the age group 50-59, a total of 50 admissions occurred; between 60 and 69 years old, this number increased to 293, in the age group 70-79 the number was 835, and for the age group 80 plus, the number reached 1,769 admissions. A total number of 13,723 admissions occurred between January 2008 and November 2019 (Brazilian Ministry of Health, 2019n). The study from Santos et al. (2017) using data from the same public source shows an even smaller number – a total of 9,843 hospitalisations of older people (aged 60+) living with dementia over the period between 2008 and 2014 nationally. In this study, dementia was the main cause of hospital deaths (33%) compared to other mental disorders.

References:

Brazilian Ministry of Health. (2019n). TabNet Win32 3.0: Morbidade Hospitalar do SUS – por local de internação—Brasil. http://tabnet.datasus.gov.br/cgi/tabcgi.exe?sih/cnv/niuf.def

Nakamura, A., Opaleye, D., Tani, G., & Ferri, C. P. (2015). Dementia underdiagnosis in Brazil. The Lancet, 385(9966), 418–419. https://doi.org/10.1016/S0140-6736(15)60153-2

Santos, D. F. B. dos, Carvalho, E. B. de, Nascimento, M. do P. S. S. do, Sousa, D. M. de, & Carvalho, H. E. F. de. (2017). ATENÇÃO À SAÚDE DO IDOSO POR CUIDADORES INFORMAIS NO CONTEXTO DOMICILIAR: REVISÃO INTEGRATIVA. SANARE – Revista de Políticas Públicas, 16(2). https://doi.org/10.36925/sanare.v16i2.1181

Long-term care institutions for older people are not evenly distributed throughout the country. In the South-eastern region of Brazil there are 57.6% of the institutions, followed by the Southern region with 20% of them (Camarano & Barbosa, n.d.).

References:

Camarano, A. A. & Barbosa, P. (n.d.). Instituições de Longa Permanência para Idosos no Brasil: Do que se está falando? (pp. 479–514). Retrieved July 17, 2019, from http://repositorio.ipea.gov.br/bitstream/11058/9146/1/Institui%C3%A7%C3%B5es%20de%20longa%20perman%C3%AAncia.pdf

Generally, social centres offer activities for people from childhood to older ages. The services provided are aimed to promote a sense of citizenship, so the services are: cultural activities, sports, courses that may promote a source of income (sewing, cooking), and social assistance according to the National Policy for Social Assistance (Brazilian Ministry of Citizenship, 2005).

References:

Brazilian Ministry of Citizenship. (2005). Política Nacional de Assistência Social PNAS/2004 Norma Operacional Básica NOB/SUAS. http://www.mds.gov.br/webarquivos/publicacao/assistencia_social/Normativas/PNAS2004.pdf

No dementia-specific programmes exist.

Yes, in a small proportion. The psychiatric reform in Brazil that happened in the last few decades reduced substantially the number of psychiatric hospitals, especially those that kept patients living there for many years. However, there are still some mental hospitals that continue to serve as residence for people with mental health that may include people living with dementia.

Yes. These are: donepezil, galantamine, rivastigmine, and memantine.

Yes.

Yes.

Yes. Any person who needs assistive technology may receive it for free from SUS as long as a doctor from SUS prescribes it. For example, the person may contact the Municipal Health Secretary with the doctor’s prescription and personal documents to require a wheelchair.

No, but they may receive advice on what should be done to the house.

Yes, all of them are available for free via SUS (Brazilian Ministry of Health, 2017d).

References:

Brazilian Ministry of Health. (2017d). Relação Nacional de Medicamentos Essenciais 2017 (RENAME). http://bvsms.saude.gov.br/bvs/publicacoes/relacao_nacional_medicamentos_rename_2017.pdf

Not in the public system, but it is available in the private sector via out-of-pocket payments. For example, cognitive training, cognitive stimulation, exergaming, physiotherapy, and psychotherapy.

No. In Brazil technology for dementia is still very incipient. Some initiatives might exist in the private sector.

The prices of the medicines vary per state according to federal/state taxation rates (as shown in the table below), and per laboratory. They are available for free in the SUS, but there is a bureaucratic and specific place where they can be obtained. Private patients may buy medication in pharmacies.

The Brazilian Health Regulatory Agency (ANVISA) establishes the maximum price a costumer can pay for each medicine. It may happen that a laboratory sells the same drug with different “brand names” which may impact on the final price of the medication. People living with dementia can get all these medications free of charge through the SUS.

According to the Brazilian Annual Report of Social Information (Relação Anual de Informações Sociais), ‘informal care worker’ was the occupation with the largest growth rate between 2007 and 2017, growing over 500%, from 5,263 to 34,051 registered individuals (Brazilian Ministry of Economy, 2018). However, we do not know how many of these individuals provide care specifically for people living with dementia. It is also common that people who have low-paid jobs also work as informal care workers (generally informally) as a source of extra income.

A study  published in 2017 using data from the National Health Care Survey (PNS 2013, in Portuguese) showed that among older people who needed help to carry out at least one daily life activity, 81.8% received informal care only, 5.8% received paid care only, 6.8% received both paid and unpaid care, and 5.7% did not receive any care (Lima-Costa et al., 2017). Care homes in Brazil usually hire informal care workers and these individuals are not necessarily trained to perform that role and ‘learn in service’ about how to care for someone living with dementia. Care workers are commonly hired privately by people from middle and high socio-economic classes. However, we do not have official data on the specific characteristics of these people.

References:

Brazilian Ministry of Economy. (2018). RAIS 2018. http://www.rais.gov.br/sitio/index.jsf

Lima-Costa, M. F., Peixoto, S. V., Malta, D. C., Szwarcwald, C. L., Mambrini, J. V. de M., Lima-Costa, M. F., Peixoto, S. V., Malta, D. C., Szwarcwald, C. L., & Mambrini, J. V. de M. (2017). Cuidado informal e remunerado aos idosos no Brasil (Pesquisa Nacional de Saúde, 2013). Revista de Saúde Pública, 51. https://doi.org/10.1590/s1518-8787.2017051000013

Informal care workers may have formal employment relationships (e.g., with national insurance), but they can also work informally receiving hourly payments, without any employment rights. Because care workers are currently considered to be solely an occupation (without being a regulated profession), they do not have a professional council that can audit the quality of care provided. It is common to find some health care assistants or technical nurses who have difficulty in finding a specialised job to be employed as care workers (formally employed or not); however, in these cases, the nursing council would hold no responsibility upon these individuals.

Baseline data from a national randomised epidemiological study (ELSI-Brasil) showed that general informal care workers for older people in Brazil (not specifically providing care for people living with dementia) are mainly women, with a mean age of 48 years, married, and who have basic reading and writing skills (Giacomin et al., 2018).

References:

Giacomin, K. C., Duarte, Y. A. O., Camarano, A. A., Nunes, D. P., & Fernandes, D. (2018). Care and functional disabilities in daily activities – ELSI-Brazil. Rev. Saúde Pública, 52(Suppl 2). https://doi.org/10.11606/S1518-8787.2018052000650

We have not been able to find any official information about this, but emigration for low-skilled jobs is not common. In times of Brazilian financial crises, there is a small proportion of women who emigrate to other countries to work as informal care workers (legally or illegally) (IEA USP, 2017). Regarding within country migration, this may happen generally from poorest regions (northeast and north) towards the richest ones (southeast). We do not believe this has had an impact on the availability of informal care workers in Brazil.

References:

IEA USP. (2017). Fenômeno da migração também tem relação com idosos—IEA USP. http://www.iea.usp.br/noticias/fenomeno-da-migracao-tambem-tem-relacao-com-idosos

According to the ELSI-Brazil (2018) study, out of the total caregivers interviewed (n=828), 25.8% reported stopping working or studying to perform this role, and only 9.2% were paid (non-family members or family members) (Giacomin et al., 2018).

References:

Giacomin, K. C., Duarte, Y. A. O., Camarano, A. A., Nunes, D. P., & Fernandes, D. (2018). Care and functional disabilities in daily activities – ELSI-Brazil. Rev. Saúde Pública, 52(Suppl 2). https://doi.org/10.11606/S1518-8787.2018052000650

The average monthly salary is minimum wage R$ 1,039.00 (US$ 248.60 – 24.01.2020).

Family carers of people living with dementia have access to free support services, such as carer psychosocial support meetings and training about dementia through all the four Alzheimer’s Associations affiliated to the Brazilian Federation of Alzheimer’s Associations (FEBRAZ). Such meetings also provide information and advice on legal rights. However, services tend to be provided mostly in urbanized and high-income areas (located mostly in the Southern and South-Eastern regions), meaning that people from poorer and rural areas often have limited access to support. All associations affiliated to FEBRAZ have some partnerships established with a number of other institutions, such as private hospitals (e.g., Hospital Nove de Julho in Sao Paulo), Secretariats of Health, Lions Clubs, Military Police, among others, that might provide support for carers. There is no availability of respite services or financial benefits/social (security) protection for carers in Brazil. In some cases, people living with dementia may receive disability allowance through court orders.

No.

No.

Some.

Some.

No.

Yes.

We have information on informal care used by the general population, not specifically for people living with dementia. According to the first nationally representative study of older people published in 2018 (ELSI-Brazil), 94.1% of the care is provided by family members at home, of which 72.1% are provided by women (Giacomin et al., 2018). An integrative review conducted among Brazilian studies between 2011 and 2016 also revealed that the majority of informal carers of older people (not specifically carers of people living with dementia) are women (usually daughters), aged 56.3 years (on average), married, and who dedicated themselves exclusively to caring (Santos et al., 2017).

In Brazil, there is a social expectation that women (the first choice would be the spouse; and the second, a daughter or daughter-in-law) would be the primary caregiver. Care homes are not accepted by the general population due to stigma and poor regulatory systems of the quality of such care services (Camarano & Barbosa, n.d.). In addition, there is a very limited number of care homes which are public; the majority of them are private services which need to be paid for by the families. This contributes to the maintenance of unpaid care as the main source of care for older people nationally.

References:

Camarano, A. A. & Barbosa, P. (n.d.). Instituições de Longa Permanência para Idosos no Brasil: Do que se está falando? (pp. 479–514). Retrieved July 17, 2019, from http://repositorio.ipea.gov.br/bitstream/11058/9146/1/Institui%C3%A7%C3%B5es%20de%20longa%20perman%C3%AAncia.pdf

Giacomin, K. C., Duarte, Y. A. O., Camarano, A. A., Nunes, D. P., & Fernandes, D. (2018). Care and functional disabilities in daily activities – ELSI-Brazil. Rev. Saúde Pública, 52(Suppl 2). https://doi.org/10.11606/S1518-8787.2018052000650

Santos, D. F. B. dos, Carvalho, E. B. de, Nascimento, M. do P. S. S. do, Sousa, D. M. de, & Carvalho, H. E. F. de. (2017). ATENÇÃO À SAÚDE DO IDOSO POR CUIDADORES INFORMAIS NO CONTEXTO DOMICILIAR: REVISÃO INTEGRATIVA. SANARE – Revista de Políticas Públicas, 16(2). https://doi.org/10.36925/sanare.v16i2.1181

An integrative review about family care in Brazil showed that the carer role resulted in mental, physical, and financial overload, but that this situation was usually seen as both negative (due to the stress of caring for house chores and for the needed person) and positive (given the feelings of love, gratitude, and companionship towards the cared person) by the carers. In the same review, authors found signs of depression and stress among the carers. It is important to point out that this review is about older people’s carers in general, and not specifically about carers of people living with dementia (Oliveira & D’Elboux, 2012). Regarding impacts on employment and education, many of the unpaid carers stopped working or studying after assuming the carer role (Giacomin et al., 2018). No documented impacts on social protection were found.

References:

Giacomin, K. C., Duarte, Y. A. O., Camarano, A. A., Nunes, D. P., & Fernandes, D. (2018). Care and functional disabilities in daily activities – ELSI-Brazil. Rev. Saúde Pública, 52(Suppl 2). https://doi.org/10.11606/S1518-8787.2018052000650

Oliveira, D. C., & D’Elboux, M. J. (2012). Estudos nacionais sobre cuidadores familiares de idosos: Revisão integrativa. Revista Brasileira de Enfermagem, 65(5), 829–838. https://doi.org/10.1590/S0034-71672012000500017

No. No such policies were found on this regard.

Yes. There is evidence that family carers of older people present signs of depression and stress (Oliveira & D’Elboux, 2012).

References:

Oliveira, D. C., & D’Elboux, M. J. (2012). Estudos nacionais sobre cuidadores familiares de idosos: Revisão integrativa. Revista Brasileira de Enfermagem, 65(5), 829–838. https://doi.org/10.1590/S0034-71672012000500017

The key providers of free information and support are the Alzheimer’s Associations. Some secondary level health services provide carer support through outpatient clinics across the country. There are also several services for which people can pay for support privately.

No. Such technologies are starting to be explored for use in Brazil by the industries and universities; however, they are still incipient and are purchased mainly by wealthy people. There is also an important barrier for approval of commercialization of such devices by the government due to unknown reasons, but we speculate this might be due to e.g., bureaucracy, concerns about safety, and political interests. There is no official information about this for consultation.

There is the Continuous Cash Benefit (Benefício de Prestação Continuada – BPC) which is an income transfer benefit for people of any age with disability or for people aged 65 and over with long term cognitive or physical impairments. The value of the BPC reflects one national minimum wage. In order to receive this benefit, the monthly per capita household income must be equivalent to up to ¼ of the value of the monthly national minimum wage (Rodrigues, 2019a).

References:

Rodrigues, A. (2019a). Benefício de Prestação Continuada—BPC [Capa]. MINISTÉRIO DA CIDADANIA Secretaria Especial do Desenvolvimento Social.

Regarding employment protection, there is no specific mechanism for people living with dementia. However, both the Older People’s Statute and the People with Disability’s Statute guarantee the right to perform any type of job as long as the person manages to carry out her or his duties. No discrimination is tolerated in relation to age or impairment, the person has the right to an inclusive and adapted work environment and to receive the same opportunities and wages as the other workers. In cases of a tie in a public selection for a job, for instance, older people have priority to be hired for the vacancy (Presidency of Republic of Brazil, 2003).

References:

Presidency of Republic of Brazil. (2003). Estatuto do Idoso. Presidency of Republic of Brazil; National Congress of Brazil’s Information System. http://www.planalto.gov.br/ccivil_03/leis/2003/l10.741.htm

There are no specific mechanisms for carer’s benefits. However, currently being a carer of an older person is recognized as an occupation and as such, it has the benefits according to each type of signed contract/regimen (CLT, self-employed caregiver, domestic caregiver, or volunteer caregiver) (Brazilian Ministry of Economy, 2019). Besides, the norms that will regulate the caregiver as a proper profession have been approved (under the Law Project N. 11, 2016) by the Congress House but they were then refuted by the current president of Brazil. The matter is awaiting for a final decision by the Congress House (Brazilian Chamber of Deputies, 2016). If sanctioned by the president, the profession will incorporate the labour rights as other formal professions. Unpaid carers are not entitled to receive any specific social protection benefit.

References:

Brazilian Chamber of Deputies. (2016). Projeto de Lei da Câmara n° 11, de 2016—Pesquisas—Senado Federal. https://www25.senado.leg.br/web/atividade/materias/-/materia/125798

Brazilian Ministry of Economy. (2019). Classificação Brasileira de Ocupações—Relatório da Familia—4.0.15. http://www.mtecbo.gov.br/cbosite/pages/relatorio/relatorioTemplateWordFamilia.jsf

No protection mechanisms regarding this matter exist.

No protection mechanisms regarding this matter exist.

No tax allowances have been found, apart from the income tax payment waiver.

There is the Law Project N. 61 (2017) which is under consideration and establishes that people with Alzheimer’s disease will receive income tax waivers (Brazilian Federal Congress, 2017). While this matter has not been decided in court, many people living with Alzheimer’s disease have pleaded for the tax waiver in court and have obtained it.

References:

Brazilian Federal Congress. (2017). Projeto de Lei do Senado n° 61, de 2017—Pesquisas—Senado Federal. https://www25.senado.leg.br/web/atividade/materias/-/materia/128350

Older people (aged 65 or plus, regardless of living with dementia) are entitled to use urban and semi-urban collective public transportation free of charge. In relation to interstate collective transportation system, there is the “Free Pass” (Passe Livre) program. It is a national program that guarantees free fares for people who have proven to be in financial need (total household per capita monthly income lesser than one national minimum wage) and who live with disability (mental, physical etc.) (Brazilian Ministry of Infrastructure, 2019).

References:

Brazilian Ministry of Infrastructure. (2019). Passe Livre—Como Pedir. http://portal.infraestrutura.gov.br/passelivre/passe-livre/?como-pedir

There is no regulation about free fares for people accompanying older people in urban and semi-urban regions. Some people file a lawsuit to get this benefit. The interstate collective public transportation (the Free Pass program) warrants free companion fares once one proves not having financial means for paying the companion’s tickets. When a medical report states the need of a companion, the accompanying person is entitled to receive free fares (Brazilian Ministry of Infrastructure, 2019).

References:

Brazilian Ministry of Infrastructure. (2019). Passe Livre—Como Pedir. http://portal.infraestrutura.gov.br/passelivre/passe-livre/?como-pedir

The Ministry of Citizenship (Social Development) offers a service entitled “Specialized Protection and Support for Families and Individuals” (Proteção e Atendimento Especializado a Famílias e Indivíduos – PAEFI). This service aims to help families and individuals who are at social risk situations (child labour, abandonment, homeless etc.) or who had their rights violated (suffered from physical or psychological violence, prejudice, negligence etc.) through guidance, support, and monitoring. In this service, social assistants, psychologists, and lawyers work to promote access to rights and to strengthen people’s social and family relationships (Rodrigues, 2019b). Another service also offered by the Ministry of Citizenship is the “Special Social Protection Service for People Living with Disabilities, Older People, and their Families” (Serviço de Proteção Social Especial para Pessoas com Deficiência, Idosas e suas Famílias). This service aims to help older people with some degree of dependence, people living with disabilities, their carers, and family members through professional care in their homes, day centres, or Specialized Reference Centre for Social Assistance (CREAS) (Brazilian Ministry of Citizenship, 2014).

References:

Brazilian Ministry of Citizenship. (2014). Tipificação Nacional de Serviços Socioassistenciais. https://www.mds.gov.br/webarquivos/publicacao/assistencia_social/Normativas/tipificacao.pdf

Rodrigues, A. (2019b). Proteção e Atendimento Especializado a Famílias e Indivíduos (PAEFI) [Página]. MINISTÉRIO DA CIDADANIA Secretaria Especial do Desenvolvimento Social.

There is a national research plan called “Priority Research Agenda of the Ministry of Health” (Agenda de Prioridades de Pesquisa do Ministério da Saúde – APPMS). This Agenda outlines the need for research in the health area in Brazil. Among the priority topics, there is the need to investigate the epidemiological profile of people living with dementia living in Brazil as well as to understand risk factors associated with dementia (Brazilian Ministry of Health, 2018a). The APPMS was published in 2018 and it will cover the next 2 to 3 years.

References:

Brazilian Ministry of Health. (2018a). Agenda de Prioridades de Pesquisa do Ministério da Saúde. http://bvsms.saude.gov.br/bvs/publicacoes/agenda_prioridades_pesquisa_ms.pdf

Yes. The Brazilian government has been investing in dementia research in the last years. By April 2019, the Department of Science and Technology in the Ministry of Health invested a total of U$5,397,116.92 in 66 research projects. However, we do not have access to the amount of money invested in the last fiscal year (Brazilian Ministry of Health, 2019g). At local level, agencies have been financing a number of studies on dementia. For example, the agency FAPESP (based in São Paulo) has allocated 421 scholarships and research funds for dementia research, and when it comes to Alzheimer’s disease, this number rises to 884. However, we do not have information on the corresponding amount of money invested (FAPESP, 2019). It is important to mention that this investment is not FAPESP initiative through specific calls but related to dementia researchers applying for funds.

References:

Brazilian Ministry of Health. (2019g). Pesquisa Saúde. https://pesquisasaude.saude.gov.br/

FAPESP. (2019). FAPESP : Fundação de Amparo à Pesquisa do Estado de São Paulo. http://www.fapesp.br/

It is not a common practice in Brazil, although there are individual initiatives, such as STRiDE, where the involvement of people living with dementia can be attested. However, it is still not an adopted practice among Brazilian research institutions, but specific research initiatives.

Partially. After looking at Brazilian research funding agencies (CAPES, CNPQ, FAPESP, FAPERJ, FAPMIG, FACEP, etc.), it was not possible to find specific funding for dementia research. Nevertheless, these agencies provide funding for students and researchers applying for scholarships at different graduate levels (e.g., master’s and PhD’s) where research in dementia may be developed. In terms of international funding, there are some, but usually through partnership of Brazilian researchers with researcher from countries where the funding comes from.

No initiatives specific for dementia were found. As a matter of extra information, research in cognitive impairment and dementia conducted by Brazilian universities (both alone or in partnerships with international universities) has increased in number and improved in quality in the last years. A study has shown that between 2003 and 2013 there was a 4.98-fold increase in the output of Brazilian researchers in cognitive disorders. However, even though this growth seems positive, the number is still low in comparison with international standards (Toledo et al., 2014).

References:

Toledo, A. A. S. F., Nitrini, R., Bottino, C. M. de C., & Caramelli, P. (2014). Brazilian research on cognitive impairment and dementia from 1999 to 2013. Dementia & Neuropsychologia, 8(4), 394–398. https://doi.org/10.1590/S1980-57642014DN84000015

There is no such type of information, specifically for dementia. In Brazil, we have the Datasus, a huge public dataset with information regarding health care in general, that includes mortality information on Alzheimer’s disease. There is also the National Health Survey (PNS, in Portuguese, its first edition was in 2013) which is planned to happen every five years as a population-based survey where part of the data will be followed longitudinally.

Data from these research datasets can help to analyse the performance of the health system based on availability and accessibility of services, frequency of consultations etc. However, there is lack of data regarding dementia, specifically. Based solely on these surveys, not much is known about epidemiology, challenges, and healthcare services provided for and used by people living with dementia and their carers. Health Services research is a weak area of research in Brazil.

• Although dementia is included in the portfolio of the Ministry of Health and people living with dementia are included in policies for older people, there is no established policy/plan specific for dementia. However, a national dementia plan has been discussed and approved by the Senate.
• There is no dementia-specific representative in the government.
• There is a lack of clear information on whether and how families/carers of people living with dementia are involved in the development of any policy/plans/document related to dementia.
• There is lack of information on targets, indicators, timelines, and assessments regarding policies and plans.
• There needs to exist more dementia-specific documents operationalized at subnational levels.
• There is no description relating to the key actors and stakeholders of the healthcare policy documents.
• In general, there is no explicit addressing of sustainability (i.e., financing, political & social commitment) in the policies that include older people.
• There is lack of policies and plans that include actions for dementia research and innovation.
• There is no legislation aiming to end discrimination against people living with dementia and their family carers.
• There is no policy or care pathway specifically developed for people living with dementia.
• There is a lack of support for family/unpaid care such as social protection, payments (cash transfer), and respite services for carers as well as lack of employment policies for family/unpaid carers.
• Regarding people living with dementia, there is a lack of these social protection mechanisms: employment protection, credit social contributors, tax allowances, free companions’ fares.

• There is need of good trainings on dementia for the health and long-term care workforce. Other than health and long-term care workforce, there are members of the public that do not receive training/education on dementia, but should receive it given their professions, such as: police and fire services, first responders/paramedics, community/city workers (public transport staff, librarians), bankers, financial service staff, retail, and hospitality staff (restaurants, grocery store).
• There is neither coordinated planning (in terms of service delivery) nor resourcing of care specifically for people living with dementia.
• There is no typical path for people to get diagnostic assessment for dementia. In the same way, there is no information on the proportion of people who receive a diagnostic assessment neither on differences in diagnostic regarding geographical region, socioeconomic status, etc.
• No clear links between primary care services, specialist care services, and community/institutional care services exist to support people living with dementia.
• There is lack of co-ordinated care for people living with dementia, particularly across health and long-term care.
• Family and other unpaid carers are not recognised/registered as part of dementia diagnostic services.
• Social media and technology are still very incipient in caring for people living with dementia in Brazil.

• There is no official community-friendly document about dementia prevention and risk reduction.
• There is a lack of information systems for monitoring dementia. For instance: there is no monitoring of the number of people living with dementia by the Ministry of Health, neither by other ministries/department nor research-led institutions nor non-governmental organizations.
• There is lack of data on the proportion of the population that incurs out-of-pocket expenditure when purchasing long-term care services, the amounts of out-of-pocket expenditure on LTC and on the numbers of people incurring catastrophic levels of out-of-pocket expenditure.
• There is lack of data on the current incidence of dementia by region, sex, ethnicity, etc. There is no data on the YLL, YLD, DALY with dementia in Brazil, regarding the average life expectancy of people living with dementia, the average age of dementia onset in Brazil, and the prevalence/incidence of subgroups with specific dementias, e.g., HIV-dementia.
• There are no public campaigns specifically to reduce risk of dementia.
• There is no information about the number of people who receive community-based care.
• No current and precise number of residential long-term care facilities and users in Brazil are available.
• There is not enough data on social demographic conditions of informal workers in dementia.
• Very little involvement of people living with dementia in the research development process.