Avaliação do programa de redução do percentual de óbitos por causas mal definidas no Brasil em 2010

Abstract

INTRODUCTION: Mortality data is of fundamental importance for epidemiological studies and in assessing the health status of the population and for planning, monitoring, and health service evaluation. Therefore, causes of death data are the most used. However, a high proportion of deaths from ill-defined causes (IDCD) may compromise this analysis. The Mortality Information System (MIS), developed by the Ministry of Health (MoH), performs data collection on deaths and their causes in Brazil. Despite improvements in the quality of deaths information in this system, underreporting and the high proportion of IDCD in the North and Northeast regions remain a challenge. The North and Northeast regions, responsible for the highest proportion of IDCD in the country, have shown an important decrease in this proportion in the last decade, reflecting different initiatives and significant investments made by the MoH. Among these initiatives, it is important to highlight a specific program for the improvement of vital registration which introduced a specific methodology for IDCD investigation and established the goal of reducing the percentage of these deaths to less than 10% in States and municipalities of the North and Northeast regions. In this program the MoH form was introduced to investigate deaths from IDCD in health services and the verbal autopsy (VA) was introduced for home deaths IDCD investigation. OBJECTIVE: To evaluate the Program "Reduction of the percentage of deaths due to ill - defined causes of death" that implemented the methodology of investigation of deaths due to ill - defined causes in Brazil in 2010. METHODS: This thesis is presented in the form of three scientific papers that refer to the specific objectives of this study. The first article presents the results of a descriptive study using mortality data from MIS, available on the Internet, in order to describe the impact of the investigation of IDCD of individual States, State capitals and characteristics of how the investigations were carried out, also discussing relevant aspects and regional differences in relation to the IDCD investigation in Brazil in 2010. The second article presents field research results conducted in the State of Bahia, which evaluated IDCD investigation activities as a strategy to reduce IDCD. The objective was to estimate the adherence of municipalities, the use of recommended investigation forms, and the impact of investigations on the reduction of IDCD registered in the Mortality Information System. The use of the standardized Ministry of Health (MoH) form and the verbal autopsy (VA) questionnaire, and the proportion of reclassified causes of death (CoD) after investigation, were analyzed in sample of 27 municipalities in Bahia state interior, and the capital Salvador, in 2010. The third article presents and discusses the perception of professionals in technical reference in epidemiology and/or information system of the 28 municipalities on the processes involved in the MIS procedures that are related to the IDCD occurrence and the investigation process of these deaths in municipalities of the state of Bahia, Northeastern Brazil. The content analysis approach was used to understand the perceptions of these professionals, understanding that these are not decontextualized subjectivities, but reflective of complex experiences, materialized in the relationships established with certain health practices and present the conception of health professionals responsible for the MIS in the municipalities. RESULTS: The results of the first article demonstrated that there has been an improvement in data quality on cause of death resulting from these investigations. The proportion of IDCD was 8.6% in Brazil in 2010 and decreased to 7.0% after investigation and fell from 4.7% to 3.4% in state capitals after investigation; approximately 65% of the investigated cases were reclassified to a defined cause in states and state capitals, which resulted in a decrease in IDCD in MIS data. Nevertheless, regional differences persisted, and the North and Northeast regions still had a percentage of deaths due to IDCD above the Ministry of Healths objective - which should have been less than 10% of total reported deaths. The results of the second article demonstrated that of the 27 municipalities, approximately 50% used standardized forms to investigate deaths from IDCD. Of the 1092 deaths due to IDCD, 53.1% were investigated: in 40.5% of the cases only the MoH form was used, in 15.3% only the VA form was used, and in 14.3% of the cases both forms (VA and MoH) were used. The investigation of deaths due to IDCD made it possible to reduce the percentage of these deaths from 16.5% to 9.9% and proved to be more effective when performed using the recommended forms. The perceptions of professionals of technical reference in epidemiology and/or information system, presented in article three, demonstrated the necessity of strengthening primary care activities and the expansion of its coverage, conducting workshops and raising awareness, both for physicians in certifying the cause of death, as well as for health professionals involved in investigative activities. It can be observed that the technical cooperation and monitoring actions of the Regional Directorates of Health (DIRES) were fundamental in the reduction of the percentage of IDCD in municipalities that had difficulties in developing activities related to the investigative activities and should be encouraged. Finally, the definition of clear deadlines and goals, and the introduction of a reduced form for the investigation of deaths would make the process faster, permitting an increase in the number of investigations. CONCLUSIONS: The results of this study demonstrated that the Program "Reduction of the percentage of deaths due to ill-defined causes" led to an improvement in the data quality on cause of death recorded in the MIS, permitting a reduction in the percentage of deaths due to IDCD to less than 10%. It is clear, however, that the Program still needs to be improved through the strengthening of health surveillance, basic health care and technical cooperation activities between the regional directorates of health (DIRES in Portuguese) and municipalities; training programs and awareness of the medical professional in relation to the completion of the death certificate and the professionals involved in the investigative activities in relation to the importance of the investigations in the improvement of MIS data; and finally, improvement in the management of the information system, through the use of a reduced form, the definition of deadlines and targets for investigative activities. Investigations of IDCD deaths should be encouraged by managers until the quality of the cause of death data in MIS reaches satisfactory levels of quality, enabling health service actions to be in line with the needs of populations at all levels. A gradual decrease in the need for investigative activities is expected as the population has more access to adequate quality health care.