In view of the pandemic of the new coronavirus, which has already infected more than 2.6 million people and left almost 190 thousand dead worldwide, special attention must be paid to health professionals, especially in Brazil. “We do not have a health workforce in quantity and capacity to attend to the degree of need that the pandemic is demanding. In addition, the pandemic is beginning to hit health professionals very strongly,” he says. Mario Dal Poz, researcher at the Institute of Social Medicine at the State University of Rio de Janeiro (UERJ) and leader of a WHO collaborating center for information and planning of human resources in the area of health.
This month, a report by the World Health Organization revealed that 8 out of 10 nurses are in nations that represent half of the world population. Therefore, the other 50% of humanity has only 20% of nursing professionals. Mario Dal Poz, who coordinated the entity’s area of human resources in health for ten years and has over 40 years of experience in the area, defends an immediate political action by both the Ministry of Health and the secretariats in the elaboration and implementation of a set of technical standards for protection and care for professionals in the field.
And a survey by the newspaper O Globo shows that there are difficulties in the country in hiring professionals. According to the report, based on public notices issued since March, there are at least 3,668 vacancies available to doctors that have not yet been filled. Below, the complete interview.
What is the scenario of the new coronavirus pandemic in Brazil today?
Very complex and serious, because although each state has a different pace and speed, we do not have adequate and quality information and monitoring on how the epidemic is developing. The measure of social isolation is being carried out in different ways in different regions, so that some states are already beginning to reach the limit of the capacity to care for patients in the health system, particularly in public services, and this tends to have serious consequences , both in terms of hospitalization and deaths. It is a very critical moment and all analyzes show a pandemic peak at the end of this month and beginning of May.
Why is that?
The most serious is the absence of diagnostic tests and the logistical, technological and human resources difficulties of SUS. And this results from the limitations of the international market itself or for other reasons, such as the weaknesses of SUS and political disputes. The Ministry of Health did not harmonize this process. There are states fighting with other states or municipalities. There are situations of all kinds, including non-governmental or private organizations offering tests, some of which appear to be of low sensitivity.
Here in Rio de Janeiro, as in other states, there is a lack of coordination between the various public entities. The perspective, considering this disarticulation and lack of coordination, does not seem good. If, from the point of view of contamination, some places seem to be managing to slow the spread of the virus, there is great pressure from certain sectors of society – and the president – for activities to return to normal. This expectation is unaware of the contamination power of this virus.
What is known about this virus that is different from the others?
As far as is known, the extremely large pathogenic potential is an important difference. The potential for transmission of the virus, for which there is no vaccine or effective treatment yet, also poses a very big challenge for scientists, but also for health managers. Since many people may have no clinical signs and still transmit the virus, the speed and potential for spread need to be estimated, as there is no information on how many people are actually infected or not.
Some field hospitals have been set up, teams have been strengthened. What is your assessment of this?
It is a commendable effort for emergency intervention. But, as it is a reactive, unplanned action, there seems to be a lack of coordination between the various public agents. Many colleagues have recalled that there are a large number of disabled beds, which could perhaps be reactivated. This is the case of the federal chain here in Rio de Janeiro, where large hospitals previously considered to be a reference, are totally out of this effort to assist patients with covid-19.
The Ministry of Health registered volunteers. Former Minister Mandetta even referred to possibilities of mobilizing specialists from different areas to cover regions with deficits, but no one knows how this can work properly. Evidently, it is not possible to transfer or acquire clinical skills or abilities in such a short period of time.
We do not have a health workforce in quantity and capacity to attend to the degree of need that the pandemic is demanding. In addition, the pandemic is beginning to affect health professionals very strongly, both through the mechanism of community transmission and through the very exposure to patient care. Thus, the issue of human resources is of great concern.
How is the preparation of professionals?
The various professionals need to have technical preparation, specific skills, and be mobilized to work as a team, one knowing what the other is going to do. Trends in the expansion of the disease alert to the number of cases among health workers. About 10% of the total cases reported in China occurred among these workers.
In Italy, the data varies between 9% and 22%, in Portugal and Spain it is more than 13% and 14%, respectively. In Brazil, it is estimated, by the numbers that we will have about 40% of leave of health professionals due to covid-19 and other diseases.
Thus, nursing technicians, nurses and doctors, among others, often work in two, three hospitals or clinics, whether public or private. If that person gets infected, he will walk away from all these services. As the beds and ICUs are getting full, these people will be missed. It is necessary, in the short or medium term, to better understand the dynamics and flow of the health labor market in Brazil, so that it is possible to develop appropriate responses to the problems of deficit and distribution by level of care and geographical situation, establishing parameters for financing , remuneration and incentives for health workers.
You have experience working with health systems. During the period at the World Health Organization, he observed closely how they work in less developed countries. How do you see the impacts of the pandemic in poorer regions?
This epidemic hits health systems hard. And the more fragile the system, if there is no regularity and sustainability of financing, the more serious the problems will be. Think of Mozambique, Angola, Ecuador, where health systems are very fragile. If this pandemic has the same behavior in these countries as it did in Europe, not only will people with covid-19 suffer, the number of deaths will be large, but also people who normally need care will not have access.
Countries that have been successful in combating the pandemic have adopted a unified response to the virus. How important is that at this moment?
Very important, as these non-drug intervention measures, such as social isolation and personal hygiene, require technical and scientific consensus and changes in individual and social behavior. At the moment, this does not happen in Brazil. The resignation of Minister Mandetta expresses very dramatically these conflicts of opinion that opposed sectors of society and the Presidency of the Republic with the recommendations of scientists and experts, despite the success of the countries that have adopted social distancing nationally.
It is this intervention that will progressively allow the health system to be able to serve everyone, in due time, and not be forced to make Sofia’s choices. In Brazil, we have an additional difficulty regarding the characteristics of our health system. SUS has three components: federal, state and municipal, which requires permanent negotiated articulation. In addition, we have a disproportionate private sector in relation to other countries. In the last few decades, the private sector has grown, with different mechanisms, but particularly through health plans. Thus, a very large leadership of the Ministry of Health is necessary to articulate and coordinate the various agents of the SUS.
How do you see the World Health Organization (WHO) emergency response system?
I joined WHO in 2000 to work with health systems, coordinating the area of human resources in health. It was a small department, but the area was developing and gaining visibility and importance due to the increase in situations in which the health issue was imposed. In 2006, we made a worldwide report showing the existence of a global human resources crisis, with a critical deficit of doctors and nurses in at least 57 countries.
Subsequently, this area gained greater visibility with resolutions of the World Health Assembly. In parallel, situations in which national health systems were severely affected by humanitarian crises, both due to the occurrence of epidemics and due to environmental accidents, such as the tsunami, grew significantly. , earthquakes or even resulting from political or military crises such as civil wars, with populations forced to flee.
Thus, the need for WHO to respond to these situations has grown enormously, building efficient partnerships for emergency management and ensuring that they are properly coordinated, developing evidence-based guidelines for all phases of emergency work in the health sector and ensuring capacity to support countries in responding to emergencies, through training and capacity building.
Why has this area grown?
In 2007, the international health regulation came into force, which requires countries to notify certain outbreaks of diseases and public health events. With this instrument, WHO has greatly increased its capacity for global disease surveillance, alert and response. And it is this mechanism that has been mobilized to articulate a network of specialists and to mobilize different actors around the world in the fight against covid-19. But it is also this mechanism that has enabled WHO to support and cooperate with countries that have their health and disease surveillance systems weakened by regional wars,
by the flight or forced migration of populations from situations of hunger and misery, often taking with them diseases prevalent elsewhere. So, this expansion was and is very important for the work of WHO.
How do you see the issue of WHO underfunding?
It is a serious issue and has been going on for a long time. This threat by the American president to withdraw funds is not the first. In the past, during the Bush son administration, the USA blocked resources for the maternal and child area due to disagreement with the guidelines and technical norms related to abortion care. At the time, the pressure came clearly from religious groups. The situation only improved in the Obama administration. So this action by the US is nothing new, and it has been criticized by almost all of the world’s leaders.
WHO receives regular contributions from countries whose value has not changed in decades. Extra-budgetary or voluntary resources occur as donations or support for specific projects, and have been growing over the years. These resources are transferred by certain groups of countries, such as the Nordic countries, Japan or foundations (the most important is the Bill and Melinda Gates foundation) or cooperation agencies such as the American, British or others, which often respond to specific calls, such as to combat tuberculosis, malaria and HIV-AIDS, the development of vaccines, or even the realization of certain events or campaigns.
This method of transferring voluntary resources has greatly expanded, becoming greater than that of regulars. And this is a problem, as it leaves WHO in a situation of great vulnerability and difficulty in establishing long-term strategies.
What do you think of the criticisms of the entity?
It is necessary to clarify how WHO works. Not being a research institution, it needs people who do research to be able to support countries with the best knowledge about health problems and the factors that trigger or lead to the spread of diseases, for example. But it operates in conjunction with research institutions and researchers and, most importantly, with all member countries. Decision-making processes are based on scientific consensus and the approval of resolutions by the World Health Assembly.
One country’s solution is not always good for the other, even if it is technically or scientifically correct. Thus, countries and experts are learning from each other, adapting, evaluating the possibilities of implementation and trying to get the best out of each example. The lessons learned later are used by countries, according to the reality of that country. So everyone benefits.
Do you think the entity was wrong in responding to the coronavirus?
Difficult to say, as just 2 days after China recognized the seriousness of the threat, WHO spoke with the support of a group of experts indicated by the countries. And the same occurred in the declaration that it was a pandemic.
What reforms and changes do you suggest in the entity?
Around 2010, WHO initiated a reform process by decision of the member countries and a resolution passed at the World Health Assembly, still under the management of Margaret Chan. These processes have perhaps been limited, due to WHO’s resource constraints and, due to some organizational characteristics, such as the election of regional directors.
Thus, the WHO, which was fundamentally technical, has increased political and diplomatic mechanisms for negotiation and discussion, particularly at the World Health Assembly. If this trend can be questionable in some situations, it has been quite positive on issues such as the negotiation and implementation of Framework Convention on Tobacco Control, which is the first international public health treaty, developed under the auspices of WHO.
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