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

残疾非常普遍--巴西最新的人口普查显示，近四分之一(24%)的人患有某种类型的残疾，6.7%的人患有“严重”残疾。随着人口老龄化、健康行为恶化和残疾慢性病的盛行，残疾患病率预计将进一步上升。残疾人是一个弱势群体，他们更有可能贫穷，平均而言，他们有更高的医疗需求。尽管巴西拥有广泛和全面的医疗体系，巴西的政策和法律也大力支持将残疾人纳入这一医疗体系，但寨卡疫情暴露了在准入方面的差距。这种对获得医疗保健的限制是对残疾人权利的侵犯，将导致更差的健康和更多的贫困和排斥，并将使巴西难以实现全民医疗覆盖。无论是在巴西还是在国际上，我们仍然缺乏关于我们需要什么来促进包容性的证据。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推广的解决方案。在国家层面，对残疾人医疗保健服务进行政策分析。这将包括审查相关政策和约谈关键利益攸关方。同样在国家一级，我们将进行康复保健系统评估，以确定其现状，并通过基于案头的评估和访谈找出差距。我们将在巴西东北部(伯南布哥)、中西部(联邦区)和东南部(圣保罗)三个州进行深入调查。在每个州内，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图。我们将使用案例研究方法收集设施级别的信息，选择农村和城市地区的设施，以及不同级别的卫生保健提供(初级、二级和医院)。我们将通过观察、深入采访不同干部的卫生专业人员、与残疾人及其照顾者进行访谈和焦点小组讨论等方式收集数据。研究人员将分析这些数据，以回答关键的研究问题，对不同来源的信息进行三角测量。将举办一次参与性的利益攸关方讲习班，以制定政策和方案建议，以改善将残疾人纳入医疗系统的情况，其中包括加强康复服务的提供。这些建议可能包括卫生系统改革(例如，调整课程、提高可及性)，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核心作用。这项建议借鉴了巴西的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(圣保罗)方面拥有专门知识--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建立了联合赠款，以调查残疾儿童的医疗保健需求。这些研究小组与卫生政策和规划方面的关键利益攸关方密切联系在巴西国内(例如卫生部)以及国际上(例如世卫组织)。这项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全世界的残疾人吸取了重要教训。加强这些弱势群体的卫生系统将改善向所有人提供的服务，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.