This presentation has been prepared by:

1. LCE LCE Communications Montreal . Canada This presentation has been prepared by: • Infotelmed Communications Inc www.infotelmed.ca • LCE Communications reg www.LCE.ca • with the collaboration of the Edumed Institute, Campinas, State of Sao Paulo, Brazil www.edumed.net Infotelmed and LCE

2. But Brazil, like Canada, has health care challenges: • Luiz, can you fill in some challenges here, these are just examples: • For telemedicine to be useful, the most important statistic is health care facilities and personnel - in 1996 (latest WHO stats) there were 127 physicians per 100 000 pop – I couldn’t find a more recent statistic. In Canada in 1998 we had 185 physicians per 100 000. But most of these doctors are located in cities and not where rural and remote populations are. How are these remote people served? • How many hospital beds per population compared, say to the US or Canada. • How similar is the geographic dispersion of the people. Canada is like Australia –in 2001 we had 3.3 persons per sq km but of course that gets really thin in a place like Nunavut - meaning some people are really far away from a doctor or a hospital which is also true in Brazil? • What are the main diseases – among indigenous people for instance. What do they die from? Do you have any stats for them? • How do poor people pay for their health care since so little is spent from public monies for the poor and how many are there • How healthy is the average Brazilian – you can estimate this through the infant mortality rates and the life expectancy rates – but no need to overdo it • The above listed stats would be for some proposal to CIDA Infotelmed and LCE

3. Demographics, Brazil 2002 • 8,511,965 sq km (slightly smaller than the USA) • Largest country in South America; shares common boundaries with every South American country except Chile and Ecuador • 14,691 km land boundaries, 7,491 km coast line • 182,032,604 inhabitants, median age 27 yrs, 17.67 births/1,000 population, 6.13 deaths/1,000 population. Growth 1.15% per year. • 86% literacy. 30% of the Brazilian population has less than 8 years studies, 27% less than 4 years Infotelmed and LCE

4. Population Distribution • A country very similar to Canada: vast expanses at North and Midwest, with densities of less than 1 per sq.km.; highest concentration along coastline and capitals (Rio de Janeiro: 291 inhab/sq.km • Average: 17 inhabitants per sq.km., 76% urban, 24% rural. • 5,656 counties, 89% have less than 50,000 inhabitants, 65% less than 20,000. Infotelmed and LCE

5. Distribution of Wealth • National average: 29% below poverty level. Minimum wage is US$ 80. About 40% of working force gets this. • Varies from 12 to 19% in the richest Southern states, can be as high as 59% in the poorest Northeast states • The income of the 20% richest is 27 times the income of the 20% poorest Infotelmed and LCE

6. Health Status • Life expectancy at birth: male: 67.16 years female: 75.3 years • Infant mortality (less than 1 yr age): national average is 10 per 1,000 born alive. In the Northeast is thrice (18) that of the South (6). • Deaths due to infectious and parasitary diseases is now less than 5,5% of all causes, chronic and degenerative diseases account for 57% to 65%. Infotelmed and LCE

7. Aboriginal Population • Populated the area 30,000 years ago. Neolithic level, much inferior to North American natives • Thought to have reached 8 million inhabitants at the time of Discovery; • Now less than 600,000. Large part has been accultured but stands among the poor of the poorest in the country. Have special civil “protected” status, large Indian reservations in the North. Primitive and even undiscovered nations still exist Infotelmed and LCE

8. Aboriginal Health • There is a National Indian Health Service under the National Health Foundation; • A hierarchical public health service has been set up and is under construction, using family health concepts, barefoot community health agents (recruited among natives) and primare care; • Disease profile is still much related to poverty and to low immune defenses, such as tuberculosis, dengue, malaria and other tropical diseases, diarrhea, undernutrition, respiratory diseases, etc. AIDS and chronic diseases due to change of nutrition and of habits, alcoholism are in the rise Infotelmed and LCE

9. Healthcare Professionals 2002 • 360,000 physicians (208 per 100,000) • 170,000 dentists (96 per 100,000) • 90,000 registered nurses (52 per 100,000) • 500,000 nurse assistants (289 per 100,000) • 170,000 other allied health • TOTAL ca. 1,290,000 professionals Infotelmed and LCE

10. Large Regional Disparities • 65 to 554 physicians per 100,000 (regions) • Highest density 1,000 physicians per 100,000 • North and Northeast with less physicians, South and Southeast with more • State of São Paulo alone has 95,000 physicians (26,5%) • 160 largest counties have 93% of physicians, the 7% remaining are in 3,400 counties • 2,400 counties (43%) have less than 10 resident physicians, 2,100 counties (38%) have no resident physicians Infotelmed and LCE

11. Healthcare Resources 2002 • 6,000 hospitals with 450,000 beds • 2.05 to 3.33 beds per 1,000 inhabitants Infotelmed and LCE

12. Health Care Systems • Three largely separate systems: • The Unified Health System (SUS) is public, at municipal, state and country levels, free for all citizens. Paid by public budget. Covers about 75% of the population; • The private health plan system, covers 23% of the population, includes medical insurance, medical cooperatives, self-management health plans, community health plans. Paid by contributions from the beneficiaries • Private medical care, covers 2% of the population, self-paid. Infotelmed and LCE

13. Status of Health Care System • Private medicine and public university-based tertiary care ranks among the best in the world, particularly in certain areas such as AIDS/HIV and infectious diseases, cardiology and cardiac surgery, oncology, plastic and reconstructive surgery, immunology, etc. • Public health is mostly in a sorry state, due to the low level of wages for healthcare professionals, low per capita investment and excessive political and burocratic interferences • However, it is improving steadfastly in efficiency and coverage, due to IT investments, education and training, managerial reform, societal external control, etc. Infotelmed and LCE

14. Telehealth Status • Still in the beginning. Large and rich private hospitals and excellence centers in public universities were the pioneers • Telehealth remains largely unadopted by the public health sector, but a few succesful experiments are underway. Interest is growing very fast, though • The potential is enormous due to many factors (size of the country, inequality of distribution of resources and of quality of service, etc.) • There are no large stakeholders, keyplayers or distribution network for products. Field is open, particularly for satellite-based initiatives Infotelmed and LCE

15. Opportunities for Canadian telehealth (TH) expertise and products • For a proposal to Industry Canada or International trade the most important stats you have provided plus maybe a little more information on the state of Brazil ’s hospital and health care system – how advanced, how modern etc. • Is there a distribution network for any telehealth products that we are going to introduce ? Infotelmed and LCE