Palliative Care Network in Brazil

*Juliana Guimarães Lima Munis, Juliana Dias Reis Pessalacia, Jacqueline Resende Boaventura, Ana Paula Da Silva, Luciana Ferreira Da Silva, Aires Garcia dos Santos Júnior and Adriano Menis Ferreira*

### **Abstract**

Brazil is a country with great diversity and distinct realities, so there is a proportional challenge and complexity in offering a unified and integrated system which is accessible, of quality, and effective. Population aging and the increased incidence of chronic-degenerative noncommunicable diseases (NCDs) increase the need for palliative care (PC); however, public policies still need to be implemented so that this care encompasses adequate funding, professional training, and guaranteed medication. The first national policy for PC was recently proposed, providing guidelines for the organization of PC, emphasizing the importance of integration between the different levels of care and services in the Brazilian health system (SUS). Nevertheless, the challenges of this policy include the training of professionals, communication in the network, the absence of integrated health information systems, and effective mechanisms to finance this new modality of care.

**Keywords:** palliative care, health services, primary healthcare, health policy, community integration

#### **1. Introduction**

Populations have specific health preferences and needs, with characteristics manifested in demographic and epidemiological analyses. Health systems are organized according to each demand of this process [1].

Demographic data show that Brazilian population, mostly composed of young people, is changing. Life expectancy is simultaneously growing with the number of elderly people, while the number of births is decreasing [2].

Population aging results in a greater demand for health services and palliative care (PC). Chronic conditions, strongly related to this process, require special attention, and the reorganization of the system aimed at health promotion and healthy living habits is part of this new reality [3].

Currently, the Brazilian care model is fragmented, and there is an imbalance between preventive and curative actions, with predominance of medical care and focus on acute conditions [4].

The challenge and the complexity of providing a unified and integrated system which is accessible, of quality, and effective are proportional to the size of a country with great diversities and distinct realities [5].

#### *Palliative Care*

All this complexity includes social plurality, more than one level of multidisciplinary and multiprofessional care, which receives resources from various sources and presents structural and technological inequality [4].

The organization of health has isolated levels that do not communicate with each other. Primary healthcare (PHC) is not related to secondary care, and none of them are related to tertiary care [1]. Thus, the lack of communication between healthcare levels prevents comprehensive care [6].

Comprehensiveness is part of the guidelines of the Unified Health System (SUS). It is a guiding concept of care that aims at treating each individual with respect, in his/her totality, valuing his/her needs and characteristics [7].

The healthcare networks (HCN) emerge within this context, mainly to interconnect the care levels and to integrate care itself [4].

The concept of HCN proposes a polyarchy, i.e., democratic, person-centered structure where health services communicate at all levels, and no level is more or less important than the other. It allows comprehensive care with promotional, preventive, curative, caregiving, rehabilitative, and palliative interventions. Thus, it offers a humanized and quality service to the population [8].

The Administrative Rule 4279, of December 30, 2010, regulates HCNs. It establishes guidelines for the organization of HCNs within the scope of the SUS. The networking system was necessary for a better health policy, a new structure based on the covenants for health, life, and in defense of the SUS, which assume responsibility for the regionalization and the health situation of Brazil and for strengthening the policy, principles, and guidelines of the SUS. PHC is the major coordinator of care, the gateway and communication center between users and health professionals. It distributes and redistributes assistance for all levels of healthcare horizontally, according to the needs. This explains the concept of networks [5].

The basic elements for the development of networks are well-defined population, based on registers performed on primary care level; operational structure, i.e., the relationship between the three different care levels of the network; care models, which are characterized in acute conditions that need technologies and also depend on the physiological response of each individual/community; and models of chronic conditions, in which promotion, prevention, rehabilitation, and palliative care actions take place [9].

Structurally, the heath network presents the following aspects: management to articulate PHC activities with the other levels, support systems, pharmaceutical assistance, health information systems, logistic systems, user identification, clinical records, systems of regulated access to care, and transport systems, as well as a communication center that coordinates flow and counterflow in the care system [3].

The network system is quite innovative when compared to the fragmented one currently disseminated; however, obstacles are expected in new deployments, both due to the simple fact of the change and due to old unresolved problems in health. It is necessary to know the needs of the population to establish a fluid and organized flow of work. This adaptation allows healthcare levels not to be isolated and provides for the movement of people through the network. However, the reality is somewhat different, as the operation is complex, bureaucratic, and disjointed, often compromising the speed of service and its potential for problem-solving [4].

The care level that is closest to people's lives is the primary care, playing a vital role within the system. On the other hand, primary care has not been adequately qualified. Moreover, the difficulty to access the secondary level, specialized consultations, and diagnostic and therapeutic support services also demonstrates the fragility of the HCN [6].

Structural and bureaucratic issues are factors that hinder the comprehensiveness of care, as well as the passivity in the actions of the PHC [9].

**71**

*Palliative Care Network in Brazil*

articulation [9].

medications [10].

HCN for palliative care in Brazil.

the human being based on a holistic approach [11].

care by families and institutions [12].

life-threatening health situations [13].

functionality, and applicability of PC.

assigned for such care [15].

months and even years [16].

tom control [16].

symptom relief are crucial in this context [14].

*DOI: http://dx.doi.org/10.5772/intechopen.85169*

Health professionals, as the key elements of the care system, experience all these complex obstacles in daily basis. They do not recognize the role they play within the

Another study on the knowledge of professionals about this subject points out their lack of information regarding the healthcare levels available and their

Currently, the aforementioned population aging and the increased incidence in chronic-degenerative noncommunicable diseases have increased the need for palliative care. However, it is still necessary to implement public policies for the

This chapter aims to present the political perspectives for the organization of a

**2. Political perspectives of palliative care in the healthcare network**

The term "palliative" comes from the Latin term *pallium*, whose definition is "blanket," "cover." It was used to describe the robes offered to the pilgrims when they left the hospices. The purpose of this clothing was protecting them from the weather during the trips. At present, the word "palliative," besides encompassing the notion of embracement and protection, contemplates the valuation of care to

Population aging causes the expansion of chronic-degenerative and incapacitating diseases, a fact that interferes in public health and in the capacity of provision of

Statistics released in 2012 by the Worldwide Palliative Care Alliance indicate that

Thus, PC in the twenty-first century basically consists in a skill that health professionals develop to care for the suffering of patients and their families facing

about 18 million people died on the planet suffering irrelevant pain due to inappropriate access to pain treatment. In Brazil, PC was introduced in the 1980s, and palliative medicine became a recognized medical area in 2011. Quality of life and

However, in Brazil, the practice of PC has been evolving since the late 1990s.

Although primary care is the lowest cost strategy and has full impact on public

The origin of the philosophy of PC is linked to the emergence of hospices (guesthouses). Hospices originated in the Middle Ages, and their outbreak influenced the pilgrimages of Christians to the holy places, due to the long distances traveled for

The first hospice that demonstrated a holistic view of the human person was the St. Christopher's Hospice, in London. It was created in the 1960s, in the twentieth century, by a nurse, physician, and social worker called Cicely Saunders. Saunders's concern was to provide humanized care through pain relief and symp-

In view of this deficiency of care measures in primary care, it is necessary to raise the population's awareness. However, this awareness will only happen through the expansion of knowledge about PC, clarifying the history, implementation,

Official information from the National Academy of Palliative Care (NAPC) published in 2006 pointed out about 40 influential teams and 300 hospital beds

health, the provision of PC in Brazil is still hospital-centered [13].

network and are still attached to bureaucratic and inflexible routines [4].

adequate financing of care, training of professionals, and provision of

#### *Palliative Care Network in Brazil DOI: http://dx.doi.org/10.5772/intechopen.85169*

*Palliative Care*

All this complexity includes social plurality, more than one level of multidisciplinary and multiprofessional care, which receives resources from various sources

The organization of health has isolated levels that do not communicate with each other. Primary healthcare (PHC) is not related to secondary care, and none of them are related to tertiary care [1]. Thus, the lack of communication between healthcare

Comprehensiveness is part of the guidelines of the Unified Health System (SUS). It is a guiding concept of care that aims at treating each individual with respect, in

The healthcare networks (HCN) emerge within this context, mainly to intercon-

The concept of HCN proposes a polyarchy, i.e., democratic, person-centered structure where health services communicate at all levels, and no level is more or less important than the other. It allows comprehensive care with promotional, preventive, curative, caregiving, rehabilitative, and palliative interventions. Thus, it

The Administrative Rule 4279, of December 30, 2010, regulates HCNs. It establishes guidelines for the organization of HCNs within the scope of the SUS. The networking system was necessary for a better health policy, a new structure based on the covenants for health, life, and in defense of the SUS, which assume responsibility for the regionalization and the health situation of Brazil and for strengthening the policy, principles, and guidelines of the SUS. PHC is the major coordinator of care, the gateway and communication center between users and health professionals. It distributes and redistributes assistance for all levels of healthcare horizon-

The basic elements for the development of networks are well-defined population, based on registers performed on primary care level; operational structure, i.e., the relationship between the three different care levels of the network; care models, which are characterized in acute conditions that need technologies and also depend on the physiological response of each individual/community; and models of chronic conditions, in which promotion, prevention, rehabilitation, and palliative care

Structurally, the heath network presents the following aspects: management to articulate PHC activities with the other levels, support systems, pharmaceutical assistance, health information systems, logistic systems, user identification, clinical records, systems of regulated access to care, and transport systems, as well as a communication center that coordinates flow and counterflow in the care system [3]. The network system is quite innovative when compared to the fragmented one currently disseminated; however, obstacles are expected in new deployments, both due to the simple fact of the change and due to old unresolved problems in health. It is necessary to know the needs of the population to establish a fluid and organized flow of work. This adaptation allows healthcare levels not to be isolated and provides for the movement of people through the network. However, the reality is somewhat different, as the operation is complex, bureaucratic, and disjointed, often

compromising the speed of service and its potential for problem-solving [4].

of care, as well as the passivity in the actions of the PHC [9].

The care level that is closest to people's lives is the primary care, playing a vital role within the system. On the other hand, primary care has not been adequately qualified. Moreover, the difficulty to access the secondary level, specialized consultations, and diagnostic and therapeutic support services also demonstrates the

Structural and bureaucratic issues are factors that hinder the comprehensiveness

and presents structural and technological inequality [4].

his/her totality, valuing his/her needs and characteristics [7].

offers a humanized and quality service to the population [8].

tally, according to the needs. This explains the concept of networks [5].

nect the care levels and to integrate care itself [4].

levels prevents comprehensive care [6].

**70**

actions take place [9].

fragility of the HCN [6].

Health professionals, as the key elements of the care system, experience all these complex obstacles in daily basis. They do not recognize the role they play within the network and are still attached to bureaucratic and inflexible routines [4].

Another study on the knowledge of professionals about this subject points out their lack of information regarding the healthcare levels available and their articulation [9].

Currently, the aforementioned population aging and the increased incidence in chronic-degenerative noncommunicable diseases have increased the need for palliative care. However, it is still necessary to implement public policies for the adequate financing of care, training of professionals, and provision of medications [10].

This chapter aims to present the political perspectives for the organization of a HCN for palliative care in Brazil.
