Strengthening the inclusion of persons with disabilities in the health system in Brazi

残疾极为普遍-最新的巴西人口普查显示，近四分之一的人（24%）有某种残疾，6.7%有“严重”残疾。随着人口老龄化、健康行为恶化和致残性慢性病盛行，残疾患病率预计将进一步上升。残疾人是一个弱势群体，他们更有可能陷入贫困，平均而言有更高的医疗保健需求。尽管巴西拥有广泛而全面的卫生系统，巴西的政策和法律也大力支持将残疾人纳入这一卫生保健系统，但寨卡疫情暴露了在获得服务方面的差距。在获得医疗保健方面的这种限制侵犯了残疾人的权利，将导致健康状况更差，贫困和排斥现象加剧，并将使巴西难以实现全民健康覆盖。无论是在巴西还是在国际上，我们都仍然缺乏促进包容性的证据。我们建议对巴西的卫生系统进行全面和多层次的评估，以调查这些问题并确定可扩展的解决方案。在国家一级，我们将对向残疾人提供医疗保健进行政策分析。这将包括审查相关政策和约谈主要利益攸关方。同样在国家一级，我们将进行康复卫生系统评估，以确定其现状，并通过案头评估和访谈找出差距。我们将在三个州进行深入调查，这些州是为覆盖巴西的不同地区而选定的：东北部（伯南布哥）、中西部（联邦区）和东南部（圣保罗）。在每个州，我们将进行网络分析，以绘制为残疾人提供医疗保健的关键利益相关者的地图。我们将采用案例研究的方法来收集设施层面的信息，从农村和城市地区选择设施，以及不同层次的医疗保健提供（初级，中级和医院）。我们将通过观察、与不同干部的卫生专业人员进行深入访谈、与残疾人及其照顾者进行访谈和焦点小组讨论来收集数据。研究人员将分析数据以回答关键的研究问题，对不同来源的信息进行三角测量。将举办一个参与性利益攸关方讲习班，以制定政策和方案建议，改善残疾人在医疗保健系统中的包容性，包括加强提供康复服务。这些建议可包括卫生系统的改革（例如调整课程、改善无障碍环境）以及关于如何收集指标以监测将残疾人纳入卫生系统的建议。残疾人将在设计这些干预措施方面发挥中心作用，这项建议利用了巴西三个杰出的研究小组-在卫生系统（伯南布哥，巴西利亚）和残疾问题（圣保罗）方面具有专门知识-与LSHTM的残疾和卫生系统研究人员合作。它建立在现有关系的基础上，因为LSHTM与伯南布哥和巴西利亚之间已经有联合赠款，用于调查残疾儿童的保健需求。这些研究小组与巴西国内（如卫生部）和国际上（如世卫组织）卫生政策和规划的主要利益攸关方密切联系。该提案有助于大幅改善巴西残疾人的保健服务，为巴西其他弱势群体以及世界各地的残疾人提供重要的经验教训。加强这些弱势群体的卫生系统将改善为所有人提供的服务，从而在巴西各地获得经济和社会效益。

Disability is extremely common - the latest Brazil census showed that almost one on four people (24%) had some type of disability, and 6.7% have "severe" disabilities. The prevalence of disability is expected to rise further as the population ages, health behaviours worsen and disabling chronic conditions prevail.People with disabilities are a vulnerable group, who are more likely to be poor and on average have higher healthcare needs. Although Brazil has an extensive and comprehensive health system, and Brazilian policy and law strongly supports the inclusion of people with disabilities in this healthcare system, the Zika epidemic revealed gaps in access. This restriction in access to healthcare is an infringement of the rights of people with disabilities, will lead to poorer health and more poverty and exclusion, and will make it difficult for Universal Health Coverage to be achieved in Brazil. Evidence on what we need to promote inclusion is still lacking, both in Brazil and internationally.We propose to conduct a comprehensive and multi-layered assessment of the health system in Brazil to investigate these issues and identify scalable solutions. At the national level, we will conduct a policy analysis on the provision of healthcare for people with disabilities. This will include reviewing relevant policies and interviewing key stakeholders. Also at the national level, we will conduct a rehabilitation health system assessment to establish its current state and identify gaps through desk based assessment and interviews. We will conduct in-depth investigations in three States, selected to cover diverse areas in Brazil: Northeast (Pernambuco), Central-west (District Federal) and Southeast (Sao Paulo). Within each state we will conduct a network analysis to map key stakeholders in the provision of healthcare for people with disabilities. We will use a case-study approach to collect facility-level information, selecting facilities from rural and urban areas, and different levels of health care provision (primary, secondary and hospital). We will collect data through observation, in-depth interviews with health professionals of different cadres, and interviews and focus group discussions with people with disabilities and their carers. The researchers will analyse the data to answer the key study questions, triangulating information across different sources. A participatory stakeholder workshop will be held to formulate policy and programme recommendations to improve inclusion of people with disabilities in the healthcare system, which includes strengthening the provision of rehabilitation. These recommendations may include health system changes (e.g. restructuring curricula, improving accessibility) as well as proposals for how indicators can be collected to monitor the inclusion of people with disabilities in the health system. People with disabilities will have a central role in designing these interventions.This proposal draws upon three outstanding research groups in Brazil - with expertise in health systems (Pernambuco, Brasilia) and disability (Sao Paulo) - in partnership with disability and health systems researchers at LSHTM. It builds upon existing relationships, as joint grants are already in place between LSHTM and Pernambuco and Brasilia to investigate the healthcare needs of children with disabilities. These research groups are closely linked to key stakeholders in health policy and planning, both within Brazil (e.g. Ministry of Health) as well as internationally (e.g. WHO). This proposal can help to substantially improve health service delivery for people with disabilities in Brazil, with important lessons learnt for other vulnerable groups in Brazil, as well as for people with disabilities worldwide. Strengthening the health system for these vulnerable groups will improve the service delivery for all, and therefore reap economic and social benefits across Brazil.