Annual Publication | 3rd edition
Abramed Health expenditure Highlights Total health care expenditure Revenue on supplementary health Diagnostic medicine market 8.1 13.0 172.8 gross revenue (R$) billion billion billion 36.0 Abramed billion SUS Proportion of exam expenses Supplementary Health 2017 20.2% 2018 21.0% 2019 20.8% Jobs 264.2 THOUSAND The diagnostic medicine sector was responsible for maintaining jobs in 2019 Abramed companies employ over 11.5% 66 THOUSAND people of healthcare jobs are linked to diagnostic medicine Participation Diagnostic tests Participation of Abramed members in the 916.5 million number of exams performed in Supplementary Health 79% Others 56% Total Abramed in in Brazil Supplementary 516.8 million Health in associates with Abramed Exams Exams 981.6 million 21% 44%Total Abramed Other in Brazil laboratories in SUS
Revenue sources Health facilities Patients Health The associted companies have: The associated companies attended 80.9%plan 472 253imaging +37 million of 82centers patients in 2019 Out of execution labs in hospitals 61% 13.2%pocket 5.9%Public centers Women Access 1,481 39% collection Men 17.7% of exams were stations 15.9%No show accessed over rate: the internet Disallowance and average term Quality management 4.1% Average monthly percentage 4 certificates on average of disallowance: per associate of exams were not accessed 4.7% 3.5%Initial Final 90.7% Investments 3.3%Don't pay Average percentage of physicians with specialist titles 8.2% Companies Average payment to in associated companies invested days on average 45period from Satisfaction of their gross revenue in 2019 health insurance Net Promoter Distribution of investments in: Score (NPS) 63operators in 2019 Machines and equipment Information technologies Equipment 83.8% and communication Total diagnostic imaging Negative equipment in 2019 manifestations of patients: 3,695 3.8%
Summary Executive Board..................................7 Letter to the reader............................8 Abramed............................................ 10 Economic environment....................................60 Economic activity .............................................66 Labor market....................................................68 Population and Economic Supplementary demography environment Health Market in Brazil 18 58 72 Population and demography........................... 20 Supplementary Health Market in Brazil............................................. 74 Population ........................................................ 22 Operators............................................................................................ 76 Population projection....................................... 30 Beneficiaries....................................................................................... 85 Demography..................................................... 33 Hospitals and hospital beds...............................................................94 Population ageing............................................ 33 Total health expenditure....................................................................98 Tests needed for fast, accurate diagnosis – The future of health financing – the role of diagnostic medicine...112 chronic noncommunicable diseases...............40 Fertility and birth rates.................................... 47 Life expectancy at birth................................... 48 Basic sanitation in Brazil – Impacts on health... 50 Mortality and morbidity................................... 52
The sector of diagnostic medicine............................................................. 116 Abramed Panel......................................196 Health facilities........................................................................................... 119 Institutional profile................................198 Imaging diagnosis equipment...................................................................128 Human resources...................................210 Labor market in the diagnostic medicine sector..................................... 136 Care production.....................................216 Incorporation of new diagnostic exams .................................................. 141 The future of diagnosis and Care production in the diagnostic medicine sector..................................147 cancer treatment ................................ 222 Early diagnosis saves lives and reduces care expenditure.................... 154 Service evaluation................................ 226 Economic and financial performance....230 Corporate governance.......................... 238 The sector Abramed of diagnostic Panel medicine 194 114 Covid-19 156 Covid-19...............................................................................................................................158 The role of the diagnostic medicine sector ...................................................................... 161 Epidemiological profile .....................................................................................................162 Covid-19 diagnosys.............................................................................................................170 Covid-19 treatment.............................................................................................................175 Telemedicine in the fight against Covid-19......................................................................176 The role of regulating agencies........................................................................................ 180 The role of legislature........................................................................................................182 Use of healthcare plans .....................................................................................................183 The impacts on the diagnostic medicine sector...............................................................188 Abramed Members.........................244 Work methodology........................298 Bibliography....................................302
Editors Wilson Shcolnik – President of Abramed’s Administrative Council Priscilla Franklim Martins – Executive Director | Abramed Abramed Council Ademar Paes Júnior | Clínica Imagem Cesar Nomura | Hospital Sírio-Libanês Claudia Cohn | Dasa – Diagnósticos da América S.A. Eliezer Silva | Sociedade Beneficente Israelita Brasileira Albert Einstein Leandro Figueira | Alliar Médicos à Frente Lídia Abdalla | Sabin Medicina Diagnóstica Wilson Shcolnik | Grupo Fleury Content and Writing Álvaro Almeida | Abramed Project Direction Juliane Trevisan | MF Marketing & Business Advisor Graphic Project GD – Graphic Designers Photography Depositphotos
Executive 57 Board “In order to ensure proper “Abramed has become an management, we need to important stakeholder in transform data into intelligence. the health chain by bringing The Panel brings an under- quality data and discussing standing of the sector and the Brazil’s health problems strategic view tied to the health with transparency”. prominence of post Covid-19.” Cesar Nomura Ademar Paes Júnior Hospital Sírio-Libanês Clínica Imagem “The Panel was an ideal that “Abramed has been building consolidated the data with solid evidence of the impact credibility for members, health of diagnostic medicine on steakeholders and for the society. the health sector, helping institutions to strengthen their We assembled a team that has ethical, scientific, and quality delivered important information care cornerstones.” for the future of Brazil.” Eliezer Silva Claudia Cohn Sociedade Beneficente Israelita Dasa Brasileira Albert Einstein “Abramed has been building “The third edition of the Abramed solid evidence of the impact panel consolidates itself as a source of diagnostic medicine on of sectoral information, highlighting the health sector, helping the relevance of diagnostic institutions to strengthen medicine not only for the health their ethical, scientific, and of the population, but also for the quality care cornerstones.” economy of the country.” Leandro Figueira Lídia Abdalla Alliar Médicos à Frente Sabin Medicina Diagnóstica “Abramed understands the importance and maintains its commitment to publish relevant sectorial information that can guide decisions for the improvement of care and the health system in Brazil.” Wilson Shcolnik Grupo Fleury
Letter to the reader This year, 2020, was challenging. After the first Covid19 case confirmed in Brazil, the diagnostic medicine sector became even more essential in the patient’s care cycle. The private laboratories took the lead in develop- ing the molecular tests that were necessary to confirm the diagnosis of the disease, as recommended by the World Health Organization (WHO). In the absence of the molecular tests, the computed tomography, together with other laboratory tests, were essential to diagnose and monitor the most serious cases, which implicated in respiratory failure. Since then, innumer- able actions were performed to improve the diagnostic methods and fa- cilitate the Brazilian population access to them. Despite facing many difficulties, such as the lack of supplies and logistic issues due to the interruption of the airline network, the private laborato- ries kept on working to expand the testing capacity of the country, includ- ing partnerships with the public sector. The diagnostic tests, from laboratory or imaging, have performed and will keep on performing a fundamental role in the response to the Covid-19 pandemic. In addition to being able to conduct case management and as- sist with the necessary isolation measures to prevent a faster virus spread on the society, the ability of detecting the virus was essential to determine if a person was infected and assist in the prescription of the most suitable clinical treatment. In the regulatory framework, the diagnostic medicine sector was challenged on its technical basis. The Public Consultations (Consultas Públicas) nr. 911 and 912 from the National Health Surveillance Agency (Anvisa), regarding the review of the Collegiate Board Resolution (RDC) nr. 44 and the revocation of RDC nr. 302/2005, respectively, have brought huge concerns to the sector. Anvisa’s proposed legislation will
allow the performance of laboratory tests The year of 2020 has been character- 9 outside of the laboratory environment, ig- ized by new challenges, discoveries and a noring the need of evaluation and previ- lot of learning. Nevertheless, it also stands ous knowledge of the performance of the out for being a year of celebrations at devices and reagents, infrastructure and Abramed. On July 14th, we celebrated a de- the good laboratory practices that may cade of existence and take great pride in assure the quality and the reliability of the our history of performance and achieve- results. Such provision goes against the ments towards our associates and to the best regulatory practice in many devel- entire health sector. oped countries. In the imaging diagnosis sector, the clinic’s adjustments to the RDC Among several outstanding projects nr. 330/2019 have also represented a chal- of the Association, the “Abramed Panel lenge to the sector. – The DNA of the Diagnosis” reinforces our commitment to the sector’s transpar- Still in the regulatory framework, in ency, and with every edition of it, we pres- 2020 Abramed joined the Supplemen- ent an exclusive overview of the diagnostic tary Health Information Standardization medicine sector in Brazil. In its 3rd edition, Committee (COPISS), part of the National Abramed Panel brings new contents and Agency of Supplementary Health (ANS), sector indicators that contribute in a con- as the representative entity of the diagnos- sistent manner to the highlight even more tic medicine sector, contributing more and the relevance of the sector in the patient’s more to the development of the sector. care cycle. In the legislative field, the tax reform has Finally, I would like to thank everybody been another complex theme since 2019 who have accompanied us throughout this and has demanded from Abramed an even journey: the scientific societies, essential more intensive work in 2020. In the discus- partners in our business, represented here sions regarding the theme, Abramed has by the Brazilian College of Radiology and advocated in favor of the essential nature Imaging Diagnosis (CBR); Brazilian Society of the health sector – a constitutional right of Clinical Analysis (SBAC). Brazilian Soci- – and have relentlessly pleaded for the neu- ety of Pathology (SBP); Brazilian Society trality of the tax burden for the diagnostic of Clinical Pathology and Laboratory Med- medicine sector with the Government. icine (SBPC/ML); Radiology Society of São Paulo (SPR); besides all the representative Even facing a complex overview, in 2020 entities and agencies of the health sector. the diagnostic medicine sector has contin- I would also like to thank the members of ued to invest in research and development our Administrative Council for its brilliant to offer solutions for laboratory and imag- performance in fulfilling our institutional ing diagnosis, to speed up even more the mission. And thank you so much to all of digital transformation, the processes auto- Abramed’s employees for their dedication mation, the integration of electronic med- and for the results achieved in the last year. ical records, among others, Always aiming to provide outstanding services that con- Wilson Shcolnik tribute to improve the healthcare. President of Abramed’s Administrative Council
Abramed
11 10 years influencing health improvement in Brazil A bramed represents the leading institutions in the diagnostic medicine mar- ket, recognized for their high quality in service delivery, techno- logical innovation and known as a refer- ence in market management practices, governance, compliance and corporate responsibility. Its performance is man- aged by principles consistent with legal, technical and ethical standards.
12 The pillars of Abramed are: Abramed Panel | 2020 Ensure focus on patient care. Dialogue and establish positive agendas with the scientific societies of the sector. Acting objectively, with unity and impartiality in all matters related to Supplementary Health in Brazil.
Encourage dialogue and exchange of 13 technical, scientific and management knowledge among members. Influence the diagnostic market in the defense of ethical and transparent behavior. Represent the diagnostics segment before the government and regulatory agencies. Defend the interests of associates, always within ethical conduct and best compliance practices. Abramed
Abramed Panel | 2020 14
15 Ethics and Abramed Abramed Understanding the literal meaning of the Greek word ethos: ethics means “custom,” the set of prin- ciples, moral values, and conduct of an individual or social group or society – it seems simple to under- stand when applied to any segment, including the health sector, in which all actors should use practices that provide full reach of care excellence and maxi- mum patient safety. Achieving a strong commitment to transparency and integrity in a segment with complex and not al- ways synergistic interactions, from both the public and private sectors, as well as unequal information between providers, funders, and users, requires the adoption of habits that keep companies engaged in accordance with laws, rules and regulations and, in particular, with the values propagated in the mission of the institutions and their associations. At the sector level, compliance practices in the di- agnostic medicine segment contributes to a fairer and healthier market, with ethical and perennial com- panies, generating better results in healthcare. To this end, Abramed, committed to the ethical is- sues of all relationships involved in the health supply chain, has created important tools that contribute to the support and monitoring mechanism of compli- ance with practices primarily aimed at the patients’ interest and to keep the theme in discussions in all of its forums.
16 Abramed Initiatives Abramed Panel | 2020 Ethics Committee In order to encourage the diagnostic medicine industry to adopt policies and procedures that ensure ethical and regulatory compliance, Abramed formed its Ethics Committee to direct and approve compliance policies and guidelines within the Association, as well as investigating possible reports of violations. Code of Conduct The first code of conduct in the diagnostic medicine sector, released by Abramed in 2017, guides, encourages and requires from its associates, behav- iors and practices that inspire all links in the chain, contributing directly so that health institutions take responsibility in providing the best diagnostic informa- tion to their patients, thus elevating the quality of care delivery services. Abramed Regulation for Competition Practices Set of norms that clarify to the Association’s employees and their associates what can be discussed and how to deal with sectorial issues in the associative scope, including points that are not approachable, such as competitively sensi- tive information. Antitrust Regiment Rules to protect associates against competition law.
17 Abramed Compliance Booklet – Good Practice Guide for the Diagnostic Medicine Industry The institution’s most recent initiative, the booklet was developed so that associates and other companies in the diagnostic medicine sector have simplified and objective information about the process of creating a compliance program, where to start and what points to work on. Reporting Channel Exclusive channel (www.canaldedenuncia.com.br/abramed) for safe and anonymous commu- nication of actions that violate Abramed’s Code of Conduct and best practices, or applicable law. These reports are submitted to the Ethics Committee for review and referral deliberation, which may include guidance to the associate, or even, in more serious cases, punitive measures defined by collaborating with specialized entities. Governance, Ethics and Compliance Working Group Formed by members of the associated companies, the group aims to discuss and evaluate the development of actions aiming at the dissemination and training on codes, rules and ethical is- sues on the diagnostic medicine sector.
Population and demography
Population and demography
21 The pace of population growth has reached the lowest level in the last decade T he population data did not show meaningful variation in the short term, especially in the period between one year and the other. However, these data can be analyzed on different as- pects, considering the information set available each year. That way, the third edition of Abramed Panel will present the developments of the pop- ulation contingent under different aspects from those presented in pre- vious years.
Abramed Panel | 2020 22 Population
The Brazilian population has surpassed the acle”, characterized by high rates of growth in 23 211.8 million inhabitants1 in July 2020 and it the economic activity and a fast pace indus- shows a deceleration in the population growth trialization process. However, in the following each year. Between de 1950s and 1970s, the decades, in accordance with the transition to population reached its peak, with an average lower levels of fertility, it is possible to observe rate of 2.96% a year. In that period, the mor- a faster decrease, and in the last ten years, the tality rate had presented a systematic reduc- geometric average growth rate2 was of 1.05%, tion and the fertility rate was high. This is the the lowest rate ever seen since the beginning period known as the “Brazilian economic mir- of historical series. Table 1 Population on the dates of the Census, average rate of annual growth and variation of the growth rate – Brazil – 1872-2020 Source: IPEADATA – Resident population – Inhabitant – Brazilian Institute of Geography and Statistics, Department of Population and Social Indicators. Division of Studies and Analysis of the Demographic Dynamics (IBGE/Pop) – DEPIS_POP 2020: IBGE/Research Directory. Coordination of Population and Social Indicators. Management of Studies and Analysis of the Demographic Dynamics. Obtained in July/2020. Designed by Abramed. Year Population Geometric rate of Rate variation annual change 1872 9,930,478 n.d. n.d. 1890 14,333,915 2.06 n.d. 1900 17,438,434 1.98 -3.89 1920 30,635,605 2.86 44.33 1940 41,236,315 1.50 -47.62 1950 51,944,397 2.34 56.02 1960 70,070,457 3.04 30.11 1970 93,134,846 2.89 -5.01 1980 119,011,052 2.48 -14.01 Population and demography 1990 144,825,152 1.98 -20.12 2000 169,799,170 1.60 -19.11 2010 190,755,799 1.17 -27.00 2020 211,755,692 1.05 -10.31 ∆(1920/2019) 181,120,087 1.81 n.d. 1. IBGE/Research Directory. Coordination of Population and Social Indicators. Management of Studies and Analysis of the Demographic Dynamics. 2. Often used to describe proportional and exponential or mixed variations, being more appropriate than the arithmetic mean, as it shows the evolution of growth over a given period.
24 One the main population growth as- tween 1940 and 20203, considerably el- pect it is associated to the process of evating the population density, bringing urbanization, resulting from, among direct consequences on the pace of the other factors, the increase on the in- infectious diseases’ transmission. It can be dustrial activity in the country. Until the said that the country has been through 1940s, the largest portion of the pop- epidemiological changes during the last ulation used to live in the rural areas, decades, when it stopped being predom- with the exception of the Southeast re- inantly rural to be in the current situation, gion that already had 39.4% of its popu- with the biggest portion of its population lation in the urbanized areas. From 1960 residing in the urban areas. Naturally, this on, more than half of the population process resulted in an increased prev- was condensed in the urban areas due alence of several risk factors related to to the job offers and the concentration the incidence of chronic diseases. On the of many economic activities. other hand, this concentration of popula- tion contributed to the creation of a wider The resident population rate in the care network, with great variety of care urban areas went from 31,2% to 88.1% be- services, as we will see ahead. Graph 1 Urbanization rate in Brazil – 1940-2020 Source: IBGE, Demographic Census 1940-2010. Until 1970 the data were obtained from: Statistics of the 20th century. Rio de Janeiro: IBGE, 2007 on the Statistical Yearbook of Brazil, 1981, vol. 42 1979. Notes: Dates of the demographic censuses: 01.08.1872; 31.12.1890; 31.12.1900; 1.09.1920; 01.09.1940; 01.07.1950; 01.09.1960; 01.09.1980; 01.09.1991; 01.08.1996; 01.08.2000. 2020 Abramed’s projection. Designed by Abramed. 100 95.6 89.8 91.2 88.1 Abramed Panel | 2020 80 78.7 78,9 Urban population share (%) 60 39.4 27.73 21.52 31.24 27.75 23.42 40 20 0 North Northeast Southeast South Midwest 1970 1980 1991 2000 2010 2020 Brazil 1940 1950 1960 3. Designed by Abramed.
Analyzing the distribu- 25 tion of the population accord- ing to the regions and number of municipalities, the South- east stands out with 42.0% of the population distributed in 1,688 municipalities, followed by the Northeast with 27.1% of the country’s population dis- tributed in 1,794 municipalities. Together both regions con- centrate more than two thirds of the country’s population, while the other regions, Mid- west, North and South concen- trate 30.9% of the population in 2,108 municipalities. Table 2 Distribution of resident population, municipalities and demographic rate by region (amount and percentage distribution – Brazil – 2020) Source: IBGE. Research Directory – DPE – Coordination of Population and Social Indicators – COPIS. Note: 1Esimates of the resident population in the Brazilian municipalities with reference date of July 1st 2020. Designed by Abramed. Region Population1 Distribution (%) Municipalities Distribution (%) Density (inhabitants per km2) Midwest 16,504,303 7.8 467 8.4 10.3 Northeast 57,374,243 27.1 1,794 32.2 37.0 North 18,672,591 8.8 450 8.1 4.8 Southeast 89,012,240 42.0 1,668 29.9 96.3 Population and demography South 30,192,315 14.3 1,191 21.4 53.6 Brazil 211,755,692 100.0 5,570 100.0 24.9 Regarding the demographic rate, the South- in the beginning of the colonization and, since east and South regions present a bigger number then, they hold the biggest part of the economic of inhabitants per km2. The occupation of Brazil’s activities and the sector that are extremely la- municipalities is mainly focused on the coastal bor-intensive. While the other areas in the coun- area (dark areas of the map), with an extension tryside show a smaller demographic rate, being of approximately 520 kilometers towards the occupied essentially by activities such as agricul- countryside. These were the first areas occupied ture and mining, which are less labor-intensive.
26 Map 1 Demographic rate by municipality (Brazil – 2020) Source: IBGE. Designed by Abramed. Abramed Panel | 2020 Inhabitants by km2 25 - 30 Up to 5 35 - 45 05 - 10 45 - 70 10 - 15 70 - 150 15 - 20 > 150 20 - 25
Only 5.9% of the 27 municipalities Consequently, in the municipalities with concentrate 57.6% high demographic rate the probability of oc- of the country’s currence of infectious and parasitic diseases is population. higher, due to the quickness of the transmission in these environments, the demographic, socio- economic and basic sanitation characteristics. Graph 2 Demographic rate of the Brazilian capitals and hospitalization by infectious diseases (2020) Sources: IBGE and MS/SVS/CGIAE – System of Information about Mortality – SIM. Designed by Abramed. Number of inhabitants per km2 9,000 35,000 Hospitalizations – Some infectious and parasitic diseases 8,000 30,000 Population and demography 7,000 6,000 25,000 5,000 20,000 4,000 15,000 3,000 2,000 10,000 1,000 5,000 BRieloodSFHeãooJorritazPanloaeeinulrztaoeo Recife CaFJPlmPoooRroprãiitrBoSootaToSoCaoAGePMnMBGlPãBCarurMVArrBoaaaróvilerouVilaeaaiateNciVasnapelectâscisLóalnaaisiíanmdoésgaetnrluljhicdpobbtniiriauíioaaáoóssoaeáasmsalarueaa Inhabitants per km2 Hospitalizations Another significant point is that only few lion inhabitants –, which represents only 57.6% municipalities concentrate the biggest portion of the total in 2020. Considering the munici- of inhabitants. It can be observed that only palities (49) with more than 500 thousand in- 5.9% of the municipalities (326) with more than habitants, 0.9% of the total concentrate 67.0 100 thousand inhabitants concentrate more million inhabitants, which amounts to 31.9% of than half of the Brazilian population – 121.9 mil- the population.
Table 3 Distribution of the resident population and municipalities according to the range of inhabitants (quantity and percentage distribution – Brazil – 2020) 28 Source: IBGE. Research Directory – DPE – Coordination of Population and Social Indicators – COPIS. Note: 1Esimates of the resident population in the Brazilian municipalities with reference date of July 1st 2020. Designed by Abramed. Inhabitants Population1 % cumulative Municipalities % cumulative % % Up to 5,000 4,186,350 2.0 2.0 1,249 22.4 22.4 From 5,001 to 10,000 8,547,533 4.0 6.0 1,200 21.5 44.0 From 10,001 to 20,000 19,063,867 9.0 15.0 1,334 23.9 67.9 From 20,001 to 50,000 33,828,245 16.0 31.0 1,110 19.9 87.8 From 50,001 to 100,000 24,150,422 11.4 42.4 351 6.3 94.1 From100,001to500,000 54,457,497 25.7 68.1 277 5.0 99.1 More than 500,000 67,521,778 31.9 100.0 49 0.9 100.0 Total 211,755,692 100.0 – 5,570 100.0 – Map 2 Distribution of the resident populations by municipality and region (number of inhabitants – Brazil – 2020) Source: IBGE. Research Directory – DPE – Coordination of Population and Social Indicators – COPIS. Note: 1Esimates of the resident population in the Brazilian municipalities with reference date of July 1st 2020. Designed by Abramed. Abramed Panel | 2020 Inhabitants Percentage of municipalities Up to 5,000 22.5% 5,001 to 10,000 21.5% 10,001 to 20,000 23.9% 20,001 to 50,000 19.9% 50,001 to 100,000 6.3% 100,001 to 500,000 5.0% 500,001 to 12 million 0.9%
3,783 Brazilian On the other hand, the biggest portion of 29 municipalities the Brazilian municipalities (67.9%) have up have up to to 20 thousand inhabitants and concentrates 20 thousand 15.0% of the country’s population (31.8 mil- inhabitants. lion inhabitants). The municipalities with more than 20 thousand inhabitants represent 32.1% of the total and concentrate 84.8% of the population. The following map shows, in the darker areas, the municipalities with up to 20 thousand inhabitants and, in the lighter areas, the municipalities with more than 20 thou- sand inhabitants. Map 3 Municipalities with up to 20 thousand inhabitants (dark areas of the map) and more than 20 thousand inhabitants (Brazil – 2020) Source: IBGE. Research Directory – DPE – Coordination of Population and Social Indicators – COPIS. Note: 1Esimates of the resident population in the Brazilian municipalities with reference date of July 1st 2019. Designed by Abramed. Municipalities Population and demography Up to 20 thousand – 3,783 (67.9%) Above 20 thousand – 1,787 (32.1%)
30 Population projection Abramed Panel | 2020
Brazil has been going through sig- ulation, that currently is of nearly 28.3% 31 nificant changes in its population’s age (60.2 million), will be of 19.7% (45.2 mil- structure every decade, reflecting on lion) in 2050, and of 17.6% (31.7 million) the population projection. Such changes in 2100. essentially derive from a decrease in its young population (0 to 19 years old), Naturally, this phenomenon will bring a combination of lower fertility rate deep consequences e both social and and an increase of the elderly popula- economic challenges, especially for the tion (60 years old or higher), which are health and social welfare sectors. The the result of life expectancy increase. relevance of the growing demand in The proportion of the elderly popula- healthcare, due to the populational age- tion that in 2020 represents nearly 14% ing, it is given by the number of elderly (29.8 million) of the total population will people with chronic health issues. It can be, by 2050, 29.4% (67.3 million), and by be estimated that approximately 80% of 2100, 40.1% (72.4 million). On the other the population over 60 years old has, at hand, the proportion of the young pop- least, one chronic disease4. Graph 3 Population projection by age groups (Brazil – 1950-2100) Source: United Nations, Department of Economic and Social Affairs, Population Division (2019). World Population Prospects 2019, Online Edition. Rev. 1. Designed by Abramed. Note: 1Estimates of the population living in Brazilian municipalities with the baseline date of 1 July 2020. Designed by Abramed. Projection for the year 2100 – United Nations, Department of Economic and Social Affairs. 250,000 200,000 Population (per thousand) 150,000 121,581 117,775 Population and demography 100,000 59,976 66,265 50,000 48,892 0 30,197 2222211222121222121222121121222010009909009090009009090090900048609386059512779280973876615455500500555000505005555050005050 Total 0–19 20–59 60+ 4. National Household Sample Survey – PNAD 2008.
32 One of the main consequences 1940, for every 100 people in active of the demographic transition is the age, there was 7.6 elderly people. In change of the population’s age struc- 2050, this ratio will be of 100 people ture. These changes can be observed in active age to 52.1 elderly people. through the dependency ratio, that is, the ratio of the population consid- One example of the impact of the ered inactive (0 to 14 years old and increase of the costs in healthcare, 65 years old or older) over the po- due to the populational ageing, it is tentially active population (15 to 64 given by the number of elderly peo- years old). From an economic point ple with chronic health issues. In ad- of view, the demographic depen- dition to that, some studies show dency ratio5 – which assumes that the that the average number of hospi- young and the elderly part of a pop- talization of the elderly population ulation are economically dependent is frequently superior – up to three of the others – tends to put pressure times higher – to the average of the on the country’s health financing. In younger population6. Graph 4 Total demographic dependency ratio, under 15 years old and over 60 years old – Brazil (1940-2050) Source: IBGE, Demographic Census 1940/2000 and Brazil’s Population Projection by Gender and Age for the Period 1980-2050 – Review 2008. Data obtained from the National Atlas of Brazil Milton Santos, IBGE, 2008: 121. Designed by Abramed. Abramed Panel | 2020 100 50.9 79.9 52.1 90 87.5 75.1 80 Ratio Total dependency 20.6 70 30.3 7.6 60 23.0 50 Ratio Elderly (60 or over) dependency 40 Ratio Under 15 dependency 30 20 10 0 1940 1950 1960 1970 1980 1991 2000 2010 2020 2030 2040 2050 5. Ratio between the age group defined as economically dependent (smaller than 15 years old and 60 years old and over) and the age group potentially productive (between 15 and 59 years old), in the resident population in a given geographic space, in the year mentioned. 6. Demography and Health Demography and Health: Contribution for Situation Analysis and Tendencies Contribution for Situation Analysis and Tendencies.
Demography 33 Population ageing In lockstep with the develop- Population and demography ing countries, Brazil shows an accel- erated population ageing process, which represents an elevated num- ber of elderly population in com- parison to the other age groups. In general terms, this process can be described in four cycles. On the first cycle, the birth and mortality rates are elevated, which results in a low population increase and age structure in the shape of a pyramid – more children and less elders. On the second cycle, there is a reduc- tion of the child mortality combined with an increase on the fertility rate, which generates population growth and it is called demographic bonus, also increasing the population with economically active age. On the third cycle, there is an increase on the fertility rate, which results on the narrowing of the pyramid’s base, in- creasing the average age of the pop- ulation. Finally, in the last cycle, the fertility and mortality rates are in low and controlled levels and the popu- lation growth is stable, with a higher ratio of elderly people.
34 Graph 5 Ratio of people aged 18 years old or more that who report medical diagnosis of the selected diseases – (Brazil – 2013) Source: IBGE, Research Directory, Coordination of Labor and Income, National Health Research 2013. Designed by Abramed. 60.0 50.0 52.751.8 44.4 Proportion of people diagnosed (%) 40.0 Abramed Panel | 2020 30.0 28.9 14.916.016.6 4.8 11.9 11.5 25.9 25.5 19.9 20.6 20.0 26.6 25.5 4.1 4.3 5.7 2.7 9.0 17.7 17.1 2.8 10.0 19.9 5.6 1.3 3.4 13.3 14.5 0 0.5 1.4 2.0 2.9 2.1 8.7 0.9 2.8 5.0 5.7 5.9 5.1 5.8 0.6 3.7 2.9 0.3 1.3 0.1 1.1 i Cmhpraiornimcernetnal Cancer Chprroonbilcebmack rheuArmtahtiristism or Asthma Stroke heaSrot dmiesekiansde of High cholleesvteelrol Diabetes pHriegshsublroeod From 18 up to 29 years old From 30 up to 59 years old From 60 up to 64 years old From 65 up to 74 years old Older than 75
The ratio of elderly people in the Brazilian population has tripled in the 35 last 50 years. In 1970, the portion of people over 60 years old represented nearly 5.5% of the population. Whereas in 2020, according to the esti- mates, 29.9 million people are over 60 years old, which represents 14.0% of the population. With the population ageing, the chronic diseases are the main health issue and account for the growing and significant demand for health ser- vices. The occurrence of chronic diseases is higher on the age groups from 60 years old or more. It is interesting to note that the proportion of diagnosed people with a certain disease can indicate an access pattern to the health services and diagnostic procedures. When a doctor informs a patient of the ex- istence of a pathology or a need of follow up, this necessarily implies in accessing the health services. That way, an increase in the prevalence and performance of diagnostic tests may be a positive indicator of ac- cess, as long as followed by a proper treatment. Graph 6 Ratio of people aged 18 years old or more that have never taken diagnostic exam and that have taken them after a diagnosis – (Brazil – 2013) Source: IBGE, Research Directory, Coordination of Labor and Income, National Health Research 2013. Designed by Abramed. 100.0 89.0 90.0 91.9 95.2 94.9 94.6 96.4 96.6 92.4 90.0 85.7 80.0 70.0 60.0 Share of people (%) 50.0 Population and demography 40.0 30.0 24.3 20.0 19.4 12.2 9.9 6.6 4.2 3.3 10.0 6.9 5.5 4.7 0 Never had blood Medical diagnosis of Never had blood Medical diagnosis of tests for cholesterol hypertension, and for tests to measure diabetes, and for which and triglycerides which additional tests were blood glucose additional tests were required, required, and were able to do and were able to do all the tests as requested all the tests as requested From 18 up to 29 years old From 30 up to 59 years old From 60 up to 64 years old From 65 up to 74 years old Older than 75
36 For that reason, and among other on the population’s life expectancy. ones, an increase on the number of Usually, most of the imaging exams exams in convergence with epide- are from people aged 50 years old or miological aspects can be estimated more, except ultrasounds which are and, mainly, they will follow the demo- mainly used during the reproductive graphic changes causing an increase stage for women. Graph 7 Ratio of imaging procedures performed at SUS by age group (2019) Source: Ministry of Health – System of Outpatient Information of SUS (SIA/SUS) Designed by Abramed. 16.0% 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% Abramed Panel | 2020 446536224573711800555050550050051ttttttttttttttoootytoooooooooooeoo43265716345127a4944449999949449Lresyyyyyyyyyyyyyyyyseeeeeeeeeeeeeeeeosraaaaaaaaaaaaaaaatrrrrrrrrrrrrrrrrohssssssssssssssssladoooooooooooooooollllllllllllllllnedddrddddddddddddd1 Ultrasonography Radiology CT Scan MRI
An increase on the number of 37 exams in convergence with epidemiological and demographic aspects can be estimated. The following graph shows the in- of the 20th century, the pace of ageing crease in the elderly population in ab- occurred slowly, whereas in the first solute numbers and the percentage half of the 21st century it occurred in participation over the total population a faster pace. The pace should remain to the age groups: 60-65, 65-80, over the same up until the second half of 80 years old. During the second half the 21st century. Graph 8 Population projection and ratio by age groups over 60 years old (Brazil – 1950-2100) Source: United Nations, Department of Economic and Social Affairs, Population Division (2019). World Population Prospects 2019, Online Edition. Rev. 1. Designed by Abramed. 90,000Elderly population (absolute numbers)18.4% 20.0% 80,000 1950 18.0% 70,000 1955 60,000 1960 15.6% 16.0% 50,000 1965 14.0% 40,000 1970 12.0% 30,000 1975 10.0% 20,000 1980 8.0% 1985 19906.0% 1995 20006.0% 20054.0% 2010 2015 2020 2025 2030 2035 2040 2045 2050 2055 2060 2065 2070 2075 2080 2085 2090 2095 2100 Proportion of elderly over the total population (%) Population and demography 10,000 2.0% 0 0.0% %60+ 65+ 80+ %60+ %65+ %80+
38 Graph 9 Distribution of population by gender, according to age groups (Brazil – 2020-2050) in million Source: IBGE/Research Directory. Coordination of Population and Social Indicators. Management of Studies and Analysis of the Demographic Dynamics. Brazil’s Population Projection by Gender and Age for the Period 2010-2060. Designed by Abramed. Abramed Panel | 2020 Age Men 90+ 2020 2050 85 a 89 265 1,148 80 a 84 471 1,718 75 a 79 953 2,864 70 a 74 1,542 4,022 65 a 69 2,399 5,469 60 a 64 3,337 6,702 55 a 59 4,351 7,333 50 a 54 5,306 7,619 45 a 49 6,041 8,034 40 a 44 6,576 7,544 35 a 39 7,575 7,197 30 a 34 8,347 7,222 25 a 29 8,533 7,327 20 a 24 8,484 7,190 15 a 19 8,713 6,896 10 a 14 8,042 6,603 5a9 7,564 6,340 0a4 7,492 6,125 7,537 5,948 Men 2020 Men 2050 Women 2020 Women 2050
39 Women Total By 2020, the Population and demography 2020 2050 2020 2050 share of people 550 2,490 815 3,638 over 60 represents 788 2,830 1,259 4,548 about 14.3% of 1,414 4,115 2,367 6,979 the population. By 2,072 5,259 3,614 9,281 2050, according to 3,010 6,641 5,409 12,110 IBGE estimates, this 4,012 7,676 7,349 14,378 proportion will be 5,033 8,000 9,384 15,333 28.4%. Over that 5,951 8,059 11,257 15,678 period, the number 6,577 8,221 12,618 16,255 of elderly people will 7,076 7,563 13,653 15,107 rise by 119.4% from 8,028 7,123 15,603 14,320 30.2 million in 2020 8,679 7,077 17,027 14,298 to 66.3 million 8,672 7,128 17,205 14,455 in 2050. 8,501 6,950 16,986 14,140 8,520 6,626 17,233 13,521 7,749 6,313 15,791 12,916 7,242 6,050 14,805 12,390 7,159 5,842 14,650 11,966 7,194 5,672 14,730 11,620 211,756 232,933
Abramed Panel | 202040 Tests needed for fast, accurate diagnosis – chronic noncommunicable diseases T he economic impact of hospitalizations and loss of productivity due to Non-communicable Diseases (NDC) represent a massive challenge to the health systems, families and companies, considering the social and economic impacts especially in the low-income de- veloping countries. Some chronic diseases are silent and health issues become known only after experiencing symptoms. The best way to face these diseases is through prevention, tracking measures and early diagnosis. In most of the cases, the confir- mation of the diagnosis is made by a combination of many lab- oratory and imaging exams.
41 Neoplasm Population and demography The neoplasms (cancer) constitute the second main cause of death in Brazil. According to the National Institute of Cancer (INCA), the number of deaths according to the primary location of the tumor varies between men and women. The two most common types of neoplasm between both genders are trachea, bronchus and lungs, colon and rectum. For men, the number of deaths by prostate can- cer stands out. For women, breast cancer prevails. Trachea, Bronchus and Lungs The most common diagnosis for cancer detection in these areas occurs via imaging exams and some other specific ones such as flex- ible bronchoscopy or via biopsy. Lung cancer is the second most common type of cancer in the country and it is one of the lethal types. Usually, the diagnosis is made by chest x-ray together with computed tomography. According to a study conducted by researchers from the Fundação Oswaldo Cruz (Fiocruz)7, the expense on lung cancer treatment in 2020 was of R$ 3.3 million for a patient population of 277 people. The study shows an average treatment expense that var- ies between R$ 6,210.79 and R$ 24,220.78 according to the patients’ lifespan during treatment8. INCA projects a total of 30.200 deaths in 2018. Considering the study premises, the estimate is that the ex- penses for lung cancer treatment surpasses R$ 510 million in 2018. 7. Estimate of care expenditures for advanced lung cancer in public reference. 8. Values deflated by the average of the IPCA index for the years 2011 to 2019 (Abramed).
42 Direct costs associated with treatment in stages 2 and 3 reach three to five times the cost observed in stage 1”. Abramed Panel | 2020
Breast 43 According to the National Institute of Cancer (INCA), estimates around 66.3 thou- sand new cases of breast cancer will happen in Brazil in 2020. For a precise and ac- curate diagnosis, the methods chosen can vary depending on the physical exam, size of the tumor and symptoms presented. Overall, this type of cancer can be seen on chest x-rays, computed tomography, magnetic resonance, ultrasound, pet/scan and bone scan9. When performed regularly the exams shows a bigger probability of diag- nosis and lower costs. In this regard, the Ministry of Health recommends that women between 50 and 69 years old have a mammography-tracking exam every two years. In addition to that, other imaging exams such as ultrasound or magnetic resonance can be indicated to confirm the existence of cancer. The expenses related to the treatment of premenopausal cancer on stages 2 and 3 can cost from three to six times the amount spend on stage 1. While the treatment on stage one can reach R$ 12.9 thousand, on the stage two it reaches R$ 38.9 thou- sand, and on stage three it reaches R$ 62.5 thousand10. Graph 10 Direct costs of breast cancer treatment by stage (Brazil – 2016) Source: Data obtained from the article: Quanto custa tratar um paciente com câncer no SUS – Brazilian Association of Lymphoma and Leuchemia (Abrale). Adapted by Abramed. Note: Values deflated by the average of the IPCA index for the years 2016 – 2019 (Abramed). 105,667 82,076 Cost per case (R$) 62,471 Population and demography56,038 38,878 12,899 2 3 1 Cancer Staging Pre Menopause Post Menopause 9. American Cancer Society 10. https://observatoriodeoncologia.com.br/quanto-custa-tratar-um-paciente-com-cancer-no-sus-em-2016/
44 Colon and rectum Colon and rectum cancer usually affect men and women around 50 years old. It is a disease that develops itself slowly and quietly and it is diagnosed through fecal occult blood, in which it is possible to identify if there is blood in the feces. Another fre- quently indicated exam is the colonoscopy, because it is able to examine the colon via imaging and, if necessary, a tissue sam- ple can be collected for a biopsy. Another possibility is a con- trast-enhanced radiography, which shows the intestinal walls. The average cost for the colon and rectum cancer treatment can increase more than 18 times between stages 1 and 3. The costs go from R$ 4.6 thousand, in average, to over R$ 88.0 thousand. Graph 11 Direct costs of colon and rectum cancer treatment by stage (Brazil – 2016) Source: Data obtained from the article: Quanto custa tratar um paciente com câncer no SUS – Brazilian Association of Lymphoma and Leuchemia (Abrale). Adapted by Abramed. Note: Values deflated by the average of the IPCA index for the years 2016 – 2019 (Abramed). 86,961 3 89,494 Abramed Panel | 2020 5,083 2 Cancer Staging 7,244 4,710 1 4,571 Cost per case (R$) Colon Cancer Rectal Cancer
Prostate 45 Prostate cancer in the most frequent type of tumor for men, especially men over 45 years old, and most cases are diagnosed through screening. The disease can be confirmed through a biopsy after suspicion detected by the blood test (PSA), rectal examination, and pelvic imaging exams such as ultrasound, computed tomography or magnetic resonance. Like most cancerous diseases, the early detection can reduce the high costs arising from the treatment of the cancer in ad- vanced stages or metastatic disease. Even in face of this sce- nario, 27.9% of men do not follow up with their urologist after the prostate cancer diagnosis11. Graph 12 Follow up with the urologist after the prostate cancer diagnosis by age group. Source: Research from the Oncogui Institute “Conhecendo a realidade dos pacientes com câncer de próstata” (2015). Adapted by Abramed. Note: Sample of 61 subjects from the reasearch. 4.9% 27.9% 34.4% Population and demography 32.8% Thirties Fourties Fifties No follow-up 11. Research from Instituto Oncoguia “Conhecendo a realidade dos pacientes com câncer de próstata” (2015).
Abramed Panel | 2020 46
Fertility and 47 birth rates The demographic transition is social countries, it is estimated that the demo- phenomenon resulting from historical graphic transition of the Brazilian popula- processes developed throughout space tion is coming to an end, with a fast and and time in addition to the combination of generalized decrease in the fertility rate. In demographic variables. The general de- Brazil, the fertility rate shows a systematic crease in the fertility rate, combined with reduction since 1960, time when the oral the reduction on the mortality rate, has es- contraceptives methods were brought in sentially contributed to significant changes to the country. The intensification of these in the age structure of the country’s pop- methods has contributed to the decrease ulation. Just like in other Latin America in the fertility rate in the 1980s. Graph 13 Brazil: mortality rate and birth rate behavior in the evolution of the population (1890-2100) Source: Brazilian Institute of Geography and Statistics (IBGE), Historical Series 1890 to 2000 (available on: <https://seriesestatisticas. Population and demography ibge.gov.br/series.aspx?no=10&op=2&vcodigo=CD109&t=taxas-brutas-natalidade-mortalidade>); The United Nations (2017), from 2010 to 2100. Designed by the authors. Obs: Extrapolations for 1910 and 1930, due to the fact that the Census. did not happen those years. 50 250 45 40 200 35 30 150 25 20 100 15 10 50 5 00 Rates (per thousand) Population (in millions) 1890 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2015 2020 2025 2030 2035 2040 2045 2050 2055 2060 2065 2070 2075 2080 2085 2090 2095 2100 Population GNR GMR
48 Life expectancy at birth In Brazil, life expectancy at birth the Brazilian Institute of Geography increased by about 30.8 years be- and Statistics (IBGE), in 1940 the tween 1940 and 2018 as a conse- life expectancy at birth was of 45.5 quence from the decrease in the years: 42.9 years for men and 48.3 child mortality rate, especially be- years for women. In 201812 the life ex- tween 1980 and 2001. During this pe- pectancy at birth went up to approx- riod, there was a decrease of 65% in imately 76.3 years in average, with the fatalities amongst children under 72.8 years for men and 79.9 years 10 years old. According to data from for women. Table 4 Life expectancy at birth (Brazil – 1940-2018) Sources: 1940, 1950, 1960, 1970 – Tables built under the Management of Studies and Analysis of the Demographic Dynamics. 1980 and 1991 – ALBUQUERQUE, Fernando Roberto P de C. and SENNA, Janaína R. Xavier “Tábuas de Mortalidade por Sexo e Grupos de Idade – Grandes e Unidades da Federação – 1980, 1991 and 2000”. Texts for discussion, Research Directory, IBGE, Rio de Janeiro, 2005.161p. ISSN 1518-675X; n. 20. 2000 – IBGE/Research Directory. Coordination of Population and Social Indicators. Management of Studies and Analysis of the Demographic Dynamics. Brazil’s Population Projection by Gender and Age for the Period 2010-2060. 2010 onwards – IBGE/Research Directory. Coordination of Population and Social Indicators. Management of Studies and Analysis of the Demographic Dynamics. Brazil’s Population Projection by Gender and Age for the Period 2010-2060. Year Total Man Woman Gender gap (years) 1940 45.5 42.9 48.3 5.4 1950 48.0 45.3 50.8 5.5 1960 52.5 49.7 55.5 5.8 Abramed Panel | 2020 1970 57.6 54.6 60.8 6.2 1980 62.5 59.6 65.7 6.1 1991 66.9 63.2 70.9 7.7 2000 69.8 66.0 73.9 7.9 2010 73.9 70.2 77.6 7.4 2018 76.3 72.8 79.9 7.1 ∆ (1940/2018) 30.8 29.9 31.6 7.1 12. Most recent data.
The increase of life expectancy is as- 49 sociated with the general improvements of the health conditions and the devel- opment of medicine. Is this way, we can highlight the importance of the diagnostic exams in medicine. In many situations, the exams can identify a health condition be- fore the occurrence of symptoms. In 1940, when a person would turn 65 years old, they had a life expectancy of 10.6 years, which means that they would live an aver- age of 75.6 years. With the decrease in the mortality during this period, a 65 years old individual would have a life expectancy of 18.8 years in 2018, hoping to live an aver- age of 83.8 years, which means 8.2 years more than an individual with the same age in 1940. Table 5 Life expectancy at 65 years old (Brazil – 1940-2018) Sources: 1940, 1950, 1960, 1970 – Tables built under the Management of Studies and Analysis of the Demographic Dynamics. 1980 and 1991 – ALBUQUERQUE, Fernando Roberto P de C. and SENNA, Janaína R. Xavier “Tábuas de Mortalidade por Sexo e Grupos de Idade – Grandes e Unidades da Federação – 1980, 1991 and 2000”. Texts for discussion, Research Directory, IBGE, Rio de Janeiro, 2005.161p. ISSN 1518-675X; n. 20. 2000 – IBGE/Research Directory. Coordination of Population and Social Indicators. Management of Studies and Analysis of the Demographic Dynamics. Brazil’s Population Projection by Gender and Age for the Period 2010-2060. 2010 onwards – IBGE/Research Directory. Coordination of Population and Social Indicators. Management of Studies and Analysis of the Demographic Dynamics. Brazil’s Population Projection by Gender and Age for the Period 2010-2060. Year Total Man Woman Gender gap (years) 1940 10.6 9.3 11.5 2.2 1950 10.8 9.6 11.8 2.2 1960 11.4 10.1 12.5 2.4 Population and demography 1970 12.1 10.7 13.4 2.7 1980 13.1 12.2 14.1 1.9 1991 15.4 14.3 16.4 2.1 2000 15.8 14.2 17.2 3.0 2010 17.6 16.0 19.0 3.0 2018 18.8 17.1 20.3 3.2 ∆ (1940/2018) 8.2 7.8 8.8 1.0
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