Health care of people in homelessness: a comparative study of mobile units in Portugal, United States and Brazil

Borysow, Igor da Costa; Conill, Eleonor Minho; Furtado, Juarez Pereira

doi:10.1590/1413-81232017223.25822016

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REVIEW • Ciênc. saúde colet. 22 (3) • Mar 2017 • https://doi.org/10.1590/1413-81232017223.25822016 copy

Health care of people in homelessness: a comparative study of mobile units in Portugal, United States and Brazil

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

This paper describes and analyzes the legal and normative framework guiding the use of mobile units in Portugal, United States and Brazil, which seek to improve access and continuity of care for people in homelessness. We used a comparative analysis through literature and documentary review relating three categories: context (demographic, socio-economic and epidemiological), services system (access, coverage, organization, management and financing) and, specifically, mobile units (design, care and financing model). The analysis was based on the theory of convergence/divergence between health systems from the perspective of equity in health. Improving access, addressing psychoactive substances abuse, outreach and multidisciplinary work proved to be common to all three countries, with the potential to reduce inequities. Relationships with primary healthcare, use of vehicles and the type of financing are considered differently in the three countries, influencing the greater or lesser extent of equity in the analyzed proposals.

People in homelessness; Health; Portugal; United States of America; Brazil

Indicators/countries	Portugal	United States	Brazil
Population, census 2010	10,562,178	308,745,538	190,732,694
Population estimated, 2015	10,427,301 (2013)	321,865,400	204,881,900
Population in homelessness Percentage in relation to the total population estimated for the referred year	Approx. 5,000 (2013) 0.04%	610,042 (2013) 0.20%	Approx. 50,000 (2008) 0.026%
Gross Domestic Product per capita, 2013 (US$)	22,080.90	54,629.50	11,384.60
Human Development Index, 2014	0.830	0.915	0.755
Gini Index	36.0 (2012)	41.1 (2013)	52.9 (2013)
Fertility rate, 2013	1.21	1.86	1.8
Potential years of life lost per 100,000 inhabitants – PYLL, 2010	3,492	4,629	7,576
PYLL defined by women / men 2010	2,230 / 4,841	3,447 / 5,814	5,037 / 10,216
Contribution rate of neuropsychiatric disorders in the global burden of disease in 2008	25.6%	30.9%	20.3%
Annual alcohol consumption per person in 2011	10.3 liters	8.8 liters	7.3 liters
Rate of people who consumed any drugs (except alcohol and tobacco) in the last year, in 2012 (Brazil in 2005)	2.7%	9.2% (last month)	10.3% (2005)
Rate of people infected by HIV / AIDS, 2009	0.40%	0.39%	0.31%
Incidence of tuberculosis cases per 100,000 population in 2014	25	3	44

	Characterization of health systems
	Type of system/ coverage	Service organization and management	Funding (2013)
Portugal	National health system - SNS Universal and comprehensive care as a citizenship right Insurance for certain professional categories and private insurance	Public services offered at the three levels of care through own services, public-private partnerships and private entities. SNS oversees public and private services 5 ARS responsible for the operationalization and transfer of resources, including for the Family Health Units. Private sector offers specialized, hospital services and some high technological density procedure. There is no specific health policy for PIH, only proposals for adaptation suggested by ENIPSA	Tax sources Total expenditure per capita: US$ 2,514 Public: 66.56% Private: 33.44%
EUA	Permissive or pluralistic corporate Compulsory private insurance to ensure care, with federal subsidies Retirees, people with certain chronic diseases, low-income population covered by Medicare (public insurance) and Medicaid (care); Public subsystems for indigenous people, children, military and civil servants	Fragmented provision of services through private insurance or public subsystems. Network more focused on specialties, hospital care and, with high technological incorporation. Federal government (DHHS) administers public insurance (Medicare) and regulates private insurance, state government administers Medicaid and private insurance manage the provision of managed care services they ensure. PIH-specific health policies are included in the McKinney-Vento Act	Tax sources, employer and worker contributions, direct family budget Total expenditure per capita: US$ 8,713 Public: 48.17% Private: 51.83%
Brasil	Unified Health System-SUS, public system of universal, comprehensive and free access, as a right of citizenship. Private subsystem consisting of regulated private services and insurance subsidized by the federal government.	Primary healthcare services offered mainly by the municipalities, States ensure hospital care and some specialized services and the Federal Government provides high complexity services. Organization at three levels of care: basic care, medium and high complexity. Establishment of coordinated networks of care in the areas of obstetrics and priority specialties. Shared management between levels of government, encouraging regionalization through Regional Inter-managerial Commissions (CIRs) Private network offers supplementary services focused on specialties, complementary examinations and hospital care, with high technological incorporation There are specific health policies for PIH, especially in PHC documents.	Tax sources, private insurance with employer and worker financing, and direct from families with federal subsidies (fiscal renunciation) Expenditure per capita: US$ 1,471 Public: 48.20% Private: 51,80%

	Characterization of mobile health units for PIH
	Design	Service Organization and management	Funding
Portugal – Street Teams	Harm reduction in psychoactive substances abuse, acting as mediator between users in the places of consumption and the health network Coordination provided with other sectors through the Planning and Intervention Center.	- Services offered: information, tools and harm- and risk-reduction programs, interaction with consumers, conducting referrals as needed, offering first aid in case of emergency and negligence. - No professional modalities were defined to work in - Members can be hired or volunteers	Public and private. Federal government defines the percentage of public fund financing, to be complemented by the institution that will perform the service.
USA – Mobile Outreach Clinics	Primary care including care for psychoactive substances users. It coordinates access to other health network points, and services of other sectors, when necessary.	- Services offered may vary according to teams’ composition - There is no definition for the professional categories, but they must respect the model of primary healthcare and of drug abuse treatment.	Public financing, and may be complemented with private funds via corporations. Federal government evaluates payment percentage, but local government needs to finance at least 25% of the total cost of the service.
Brazil – Clinic on the Street	Design focused on primary healthcare and harm reduction. It coordinates access to other health network points and services of other sectors, when necessary.	- Services offered: basic healthcare actions, first aid, rapid tests, qualified listening, psychological support, active outreach, educational and cultural activities, dispensing supplies. - Professional categories envisaged are nurses, psychologists, social workers, social agent, nursing technician or assistant, oral health technician, dental surgeon, professional / physical education teacher, professional with graduation in art and education, community health workers and physicians.	Public financing. The federal government defrays service expenses, except the supply of vehicles, whose responsibility lies with the municipal management.

ABRASCO - Associação Brasileira de Saúde Coletiva Av. Brasil, 4036 - sala 700 Manguinhos, 21040-361 Rio de Janeiro RJ - Brazil, Tel.: +55 21 3882-9153 / 3882-9151 - Rio de Janeiro - RJ - Brazil
E-mail: cienciasaudecoletiva@fiocruz.br

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[1] Collaborations

IC Borysow and JP Furtado worked on the theme design. The three authors, namely, IC Borysow, JP Furtado and EM Conill worked on the survey, methodology and final writing.