Research
Past, present, and future of stroke in middle-income countries:
the Brazilian experience
Sheila Cristina Ouriques Martins1,2*, Octávio Marques Pontes-Neto3, Cloer Vescia Alves4,
Gabriel Rodriguez de Freitas5, Jamary Oliveira Filho6, Elza Dias Tosta7, and
Norberto Luiz Cabral8 on behalf of Brazilian Stroke Network
Background Stroke is one of the major public health challenges in middle-income countries. Brazil is the world’s sixth
largest economy but was clearly behind the milestones in the
fight against stroke, which is the leading cause of death and
disability in the country. Nevertheless, many initiatives are
now reshaping stroke prevention, care, and rehabilitation in
the country.
Aims The present article discusses the evolution of stroke care
in Brazil over the last decade.
Methods We describe the main characteristics of stroke care
before 2008; a pilot study in a Southern Brazilian city between
2008 and 2010, the Brazilian Stroke Project initiative; and the
2012 National Stroke Policy Act.
Results The National Stroke Project was followed by a major
increased on the number of stroke center in the country. The
key elements of the 2012 National Stroke Policy Act included:
definition of the requirements and levels of stroke centers;
improved reimbursement for stroke care; promotion of stroke
telemedicine; definition of the Line of Stroke Care (to integrate
available resources and other health programs); increased
funding for stroke rehabilitation; funding for training of
healthcare professionals and initiatives to increase awareness
about stroke within the population.
Conclusions The evolution of stroke care in Brazil over the last
decade is a pathway that exemplifies the challenges that
middle-income countries have to face in order to improve
stroke prevention, treatment and rehabilitation. The reported
Brazilian experience can be extrapolated to understand the
past, present, and future of stroke care in middle-income
countries.
Key words: middle-income country, organized stroke care, stroke, stroke
management, stroke systems, stroke unit
Correspondence: Sheila Cristina Ouriques Martins*, Rua Engenheiro
Olavo Nunes, 99/ 703. Bela Vista., Porto Alegre, RS 90440-170, Brazil.
E-mail: [email protected]
Facebook: www.facebook.com/CampanhaAVC
1
Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
2
Hospital Moinhos de Vento, Porto Alegre, Brazil
3
Hospital das Clínicas de Ribeirão Preto, Ribeirão Preto, Brazil
4
General Coordination of Urgency and Emergency, Ministry of Health
2007–2009, Brasília, Brazil
5
D’Or Institute for Research and Education (IDOR), Rio de Janeiro,
Brazil
6
Stroke Service, Federal University of Bahia, Salvador, Brazil
7
Hospital de Base do Distrito Federal, Brasília, Brazil
8
Joinville Stroke Register- Univille, Joinville, Brazil
Funding: None.
Conflict of interest statement: The author declares no potential conflict of
interest.
DOI: 10.1111/ijs.12062
© 2013 The Authors.
International Journal of Stroke © 2013 World Stroke Organization
Introduction
Brazil is a multiethnic country with almost 200 million people
that has been growing at an average annual rate of 1·7% since
1990. In the last two decades, the growing economy and the
implementation of major social programs have shifted 50% of
population of this middle-income country above the extreme
poverty line (1). Recent news also suggests that the Brazilian
population is reassessing its battle against stroke, still the country’s number one killer (2).
Since the 1988 Brazilian Constitution, which reshaped the
country after more than 20 years of military dictatorship, all
Brazilians have granted access to the public healthcare system.
However, the deep and historical social inequality (one of the
most pronounced in the planet) and the growing prevalence of
obesity, diabetes, and hypertension are barriers that challenge the
national public health agenda (3). Only one fourth of the population can afford the benefits of additional private healthcare
insurance (3). As in other middle-income countries, stroke care
follows the social disparities that divide Brazil into two different
‘countries’: the more wealthy part that shares the same profile of
developed countries and is able pay for high-quality stroke care
resources; and the majority of the population that has several
limitations to access stroke prevention, acute treatment, and rehabilitation.
In this article, our aim is to describe the evolution of stroke care
in Brazil over the last decade: the main characteristics of stroke
care before 2008; the pilot study in a Southern Brazilian city
between 2008 and 2010, which generated the Brazilian Stroke
Project; finally, the key points of the 2012 National Stroke Policy
Act. We believe that the reported Brazilian experience can be
extrapolated to understand the past, present, and future of stroke
care in middle-income countries.
Stroke care before 2008
The burden of stroke for Brazilian society is huge. Stroke has been
the leading cause of death in the last 30 years (4). In 2006, cardiovascular diseases were the third main reason for all national
hospital admissions, and in 2007, the World Bank estimated that
Brazil lost US$ 2·7 billion of gross domestic product on health
care related to cardiac diseases, stroke, and diabetes (4,5).
Since 1980, stroke mortality has been decreasing all over the
country (6). The 30-day case fatality for all strokes ranged from
20% to 25% in population-based studies (7). The actual trends
of stroke incidence in the country are still unknown. One
population-based study undertaken in the city of Joinville located
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S. C .O. Martins et al.
in the more developed southern region of Brazil showed a onethird decrease in incidence of first-ever stroke from 1995 to
2005·(7). Whether those results can be extrapolated to the poorest
regions of the country is questionable. In fact, Joinville was the
first city of the country to have a stroke unit, which was created by
1997·(8).
Intravenous thrombolytic therapy for ischemic stroke was
approved in the country in 2001 by the National Agency of Sanitary Vigilance (2). Since then, some academic hospitals started to
organize stroke teams and units across the country. Nevertheless,
when we consider Brazil’s continental size, the availability of
stroke units and access to stroke intravenous thrombolysis were
still incipient until 2008. In fact, until June 2008, only 35 stroke
centers were active and they were working largely isolated
(Fig. 1a).
At a national level, programs to control arterial hypertension
and diabetes were underpowered and did not focus on adherence
for high-risk patients. Therefore, those programs had questionable impact in stroke incidence and mortality. Despite the effort
of the Federal Government to provide essential medications for
preventive treatment of cardiovascular diseases among patients
within the public health system, those resources were irregularly
distributed to the population.
Important aspects of acute stroke care, secondary prevention,
and rehabilitation were still largely neglected (9). Alarming lack of
awareness about stroke among the population and also healthcare
professionals was the rule (10). Despite several attempts by the
Brazilian Academy of Neurology and the Brazilian Stroke Society
to mobilize the Federal Government about the problem, there
were no concrete actions to improve the hospital provision of care
and most of the resources were used to pay for the treatment of
complications and disability after stroke (11).
Other problems that challenged the implementation of acute
stroke care in the country include: overcrowded emergency
a
b
Fig. 1 (a) Distribution of stroke centers before the Brazilian stroke program. (b) Distribution of stroke centers after the Brazilian stroke program.
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S. C .O. Martins et al.
rooms; the low availability of intensive care unit (ICU) beds;
paucity of physicians adequately trained to treat stroke; poor
awareness about stroke symptoms in the population; and low
availability of recombinant tissue plasminogen activator (rtPA) in
the majority of public hospitals (11).
The Brazilian Stroke Project: 2008–2010
In June 2008, the Department of Urgency and Emergency Care of
the Brazilian Ministry of Health started a project to improve the
care of patients with stroke and myocardial infarction, the first
and second causes of death in Brazil, respectively. The National
Stroke Project included a task force of stroke neurologists who
founded the Brazilian Stroke Network, aimed at providing scientific support to the establishment of a nationwide network to
improve the education, care, and research about stroke in the
country. This nongovernmental organization would soon after
expand and incorporate other medical specialties, nurses, nurse
assistants, physiotherapists, psychologists, speech therapists,
occupational therapists, health authorities, and patients and their
caregivers working together to decrease the impact of stroke in
Brazil.
A task force framed by the Brazilian Stroke Network, the Brazilian Stroke Society, the Brazilian Academy of Neurology, the
Research
Brazilian Medical Association, the Brazilian Society of Cardiology, and the Brazilian Emergency Network created a National
Stroke Project that included five main components: (a) educational campaigns; (b) training emergency medical services;
(c) development of stroke centers inside secondary and tertiary
hospitals across the country; (d) improvement on prevention
of cerebrovascular risk factors in public outpatients’ clinics;
(e) implementation of programs for early rehabilitation and
family support.
The implementation of the National Stroke Project started with
the organization of acute stroke care in the country (Table 1). The
initial focus was placed on the development of acute stroke
centers and training of the components of prehospital, hospital
acute care, and transport. The SAMU, which stands for Serviço de
Atendimento Móvel de Urgência, is a prehospital emergency
medical system in Brazil that covers approximately 70% of the
population and can be activated by a free call to a unique nationwide phone number (192) (12). The involvement of SAMU into
the stroke care was a decisive step to raise the awareness about
stroke among health professionals.
Stroke research also contributed to increase awareness about
stroke in Brazil (10). An important research landmark was the
confirmation of safety and efficacy of thrombolytic therapy for
stroke in the Brazilian population by a collaborative effort
Table 1 Steps for organization of acute stroke care in Brazil
Step 1. Acknowledgment and assess of the situation of stroke assistance in the country
1. Visits to every state to meet with the State Secretary of Health and the City Secretaries, directors of hospitals, chief of the emergency services,
coordinator of local prehospital.
2. Assessment of which hospitals were already responsible for the stroke assistance in each main city.
3. Face-to-face visits to every hospital to evaluate physical structure of emergency room, ICU, diagnostic resources, local staff, number of stroke
patients assisted, and number of hospital beds.
Step 2. Development of the stroke centers
After visiting all hospitals, plans for the local networks were established according to the needs and available resources, including suggestion for
changes on structure and facilities of the local hospitals, when necessary. Each hospital had to be equipped with an organized emergency
room, 24 h laboratory and CT scanner, ICU, and a stroke team including multidisciplinary rehabilitation professionals.
1. The place, the number of beds, and the staff for acute stroke care were defined in the emergency room of each hospital. Whenever possible,
the organization of a stroke unit was recommended.
2. Alternatively, to attenuate the problem of overcrowded emergency rooms, mixed vascular units were organized – defined as a geographic area
of the emergency department with several monitored beds for all kinds of acute vascular diseases such as stroke, myocardial infarction, aortic
diseases, and pulmonary embolism. The vascular units combine the benefits of acute stroke units and chest pain units. The aim was to have a
trained emergency team activating the stroke protocol and calling the neurologist available 24 h a day, seven-days a week, to evaluate and
treat the stroke patients.
Step 3: Training for stroke care
1. Training of stroke teams, emergency services, and ICU staff of all hospitals with implementation of basic stroke care protocols.
2. Training of all staff for intravenous thrombolysis in level A, B, and C hospitals (see text for definitions).
3. Training of staff for advanced stroke protocols in level A hospitals.
4. Training of SAMU and organization of the local network for faster triage to the appropriate level hospital.
5. Training of level C hospitals for the use of telemedicine.
6. Training of the basic health professionals to activate the SAMU after recognizing the acute stroke signs.
7. Training of the healthcare professionals to improve primary and secondary prevention of stroke.
Step 4. National stroke registry
In order to ensure quality and minimal standards during the development of the stroke network, hospitals of the National Stroke Program were
invited to participate in a national stroke registry, linked to the Ministry of Health (MH), and Sociedad Iberoamericana de Enfermedad
Cerebrovascular and Safe Implementation in Treatments in Stroke (SIECV-SITS) Stroke Registry.
Step 5. Stroke educational campaigns
Campaigns to improve stroke awareness among the population were started after the organization of the acute stroke care in each center.
ICU, intensive care unit; CT, computed tomography.
© 2013 The Authors.
International Journal of Stroke © 2013 World Stroke Organization
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S. C .O. Martins et al.
between three stroke centers in the cities of Porto Alegre and
Salvador (13). After adjusting for stroke severity, etiology, and
time of stroke onset, the results showed that Intravenous (IV)
thrombolysis for stroke increased 2·54-fold the odds of independent outcome with no increase on death rates and a rate of hemorrhagic transformation that was similar to clinical trials (5·8%).
Another relevant motivation for health authorities was the demonstration of the cost-effectiveness of this treatment in the
country (14).
Pilot study and Porto Alegre stroke network
Once the feasibility, safety, and cost-effectiveness of thrombolytic
therapy were confirmed in different academic medical centers in
the country, a critical step was to evaluate the actual impact of
introducing the new therapy in the public health system. A pilot
intervention was then planned to provide data for the National
Stroke Project. Porto Alegre, a Southern Brazilian city with population of four million inhabitants living in the metropolitan and
suburban area of 9800 km (2) was selected for the pilot intervention, which was performed between June 2008 and June 2009. A
prehospital team for rescue and transport of stroke patients
(SAMU) and five stroke centers were trained on acute stroke
protocols including thrombolysis. With the pilot intervention, the
proportion of stroke patients treated with IV thrombolysis
increased from 1·7% (65/3824) to 5·3% (206/3860). Moreover, in
Porto Alegre stroke centers, the mean thrombolysis rate was 14%
(range from 12% to 18%) and after three-months, 53% (109/206)
of treated patients had minimal or no disability (modified Rankin
scale: 0–1), the rate of symptomatic intracranial hemorrhage
(SIH) was 4% and the mortality rate was 11% (15,16).
Telemedicine
As part of the pilot intervention, stroke telemedicine was introduced in the country. The first hospital supported by stroke telemedicine was Hospital de Pronto Socorro in Canoas, a city near
Porto Alegre, covering a population of 323 827 inhabitants.
Within the first year, 35 patients with the median baseline NIHSS
score of 10 (IQR 7–13) were treated and after three-months, 57%
(20/35) of the patients were independent (modified Rankin scale:
0–2), 2·9% (1/35) had SIH, and 5·7% (2/ 35 patients) died.
Practical lessons from the pilot project in Porto Alegre
• The organization of a regional network to assist stroke
increased the number of thrombolysed patients.
• The establishment of a program to assist stroke, including
thrombolytic treatment in the public health, is feasible, safe, and
effective and can be expanded to other regions of the country,
including neurology evaluation by telemedicine.
The project in the whole country
The acute stroke project in Brazil included many cities. In each
one, the program was tailored according to the local conditions
and was developed together with local health authorities. Over
three-years, 15 stroke neurologists visited, organized, and classified 90 hospitals in 21 of 26 Brazilian states. Even though those
hospitals were already providing treatment to stroke patients,
most of them had only a minimal structure and no defined protocols before the National Project. Table 2 shows the improvement in the Brazilian stroke system, and Fig. 1 shows the
distribution of stroke centers before (Fig. 1a) and after (Fig. 1b)
the Brazilian Stroke Project.
National actions 2011–2012
In February 2011, the Federal Government started a new program
to control hypertension and diabetes, increasing the distribution
of medications for these conditions to the population without
cost in more than 20 000 popular pharmacies. After one-year, the
number of people that received free medication increased 264%
(from 853 thousand per month to 3·2 million per month) (17). In
2011, the Brazilian Ministry of Health started a negotiation to
reduce the amount of salt in the processed food.
During the 2011 World Stroke Awareness Campaign, an important mobilization was seen all over the country. The campaign
created by the World Stroke Organization and organized in the
country by the Brazilian Stroke Society, Brazilian Stroke Network,
Brazilian Academy of Neurology, and Brazilian Stroke Association
involved a common agenda of activities in 51 cities, spread over 22
out of the 26 states, mainly support by nongovernmental organizations. During that campaign, for the first time, the Brazilian
Minister of Health addressed the nation on TV and radio specifically about stroke (video is available at: http://www.youtube.com/
watch?v=ZTIeWkDEwoM&feature=youtu.be). Motivated by the
repercussion of the campaign, the Minister of Health emphasized
the social burden of stroke and announced a new policy for stroke
care in the country.
The Brazilian National Stroke Policy Act
Published by the Brazilian Ministry of Health in April 12, 2012,
the act establishes the battle against stroke as a national health
Table 2 Structure of the Brazilian stroke system before and after the implementation of the National Stroke Program
Number of states with active stroke center
Number of stroke centers
Private
Public
Number of stroke units or vascular units
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Before program
(May 2008)
After program
(April 2012)
Increase
10
35
20
15
5
19
82
37
45
17
1·9¥
2·3¥
1·9¥
3¥
3·4¥
© 2013 The Authors.
International Journal of Stroke © 2013 World Stroke Organization
Research
S. C .O. Martins et al.
Table 3 Project targets before and after the National Stroke Policy Act
Hospitals
Stroke reimbursement
supported by the MH
rtPA
Costs of rtPA treatment
Education for health
professionals
Before national policy
After national policy (today)
No investments in hospitals from the MH. Investments
in some cities were from the hospitals or from the
health secretaries
US$400 – 7–14 days hospitalization included two CT
scans plus echocardiogram and carotid duplex
Investment in stroke units from the MH
Paid by local health authorities and hospitals (no
reimbursement by MH)
US$2000 per patient
Brazilian Stroke Society
US$190 per day of hospitalization for patients assisted
in stroke units + separate reimbursement for CT and
echocardiogram and carotid duplex
Reimbursed by MH
US$540 per patient
MH + Brazilian Stroke Society, Brazilian Academy of
Neurology, Brazilian Stroke Network, and Brazilian
Medical Association
MH, Ministry of Health; CT, computed tomography; rtPA, recombinant tissue plasminogen activator.
priority (18). The main elements of the policy can be summarized
as follows:
• The creation of stroke centers classified in three types according
to the hospital complexity. All acute stroke patients have to be
assisted in the stroke centers;
• Improved reimbursement rates for stroke patients assisted in
stroke units;
• Centralized reimbursement of rtPA by the Ministry of Health;
• Telemedicine support for hospitals without neurologist available 24 h;
• The creation of the Line of Stroke Care (a local network) where
each city/region has to organize the whole assistance for stroke
including primary/secondary prevention, prehospital care, and
acute and postacute assistance in the hospital and rehabilitation;
• The stroke patients assisted in any component of the network
will be transferred to the stroke center by SAMU, which is responsible for acute stroke network regulation;
• The dispatcher doctor in the Regulation Centre of SAMU will
be the responsible to dispatch the ambulances and to coordinate
the distribution of the cases to the stroke centers;
• Establishment of home care assistance;
• Training for all healthcare professionals together with medical
societies;
• Improvement of the rehabilitation system with a budget to
establish new centers; and
• Education for the population.
Table 3 summarizes the objectives and targets planned by the
Brazilian Ministry of Health regarding stroke care in the near
future.
What has already been implemented? (July 2012)
All over the country, free medication for hypertension and diabetes are now available by a federally funded program in over 20 000
popular drugstores nationwide. The regulation for the reimbursement of rtPA in public hospitals was approved and launched. The
cost of the 50 mg ampoule of rtPA was decreased by half. Since
May 2012, ampoules of 10 and 20 mg of rtPA are available in
Brazil after an agreement between the government and the pharmaceutical company.
© 2013 The Authors.
International Journal of Stroke © 2013 World Stroke Organization
The current classification of stroke centers stratifies centers in
three major categories according to the complexity of stroke care:
Type I, as the primary stroke center, which has the basic conditions
for thrombolysis, neurologist available 24 h a day (in the local, on
call or by telemedicine); Type II, which additionally requires an
acute stroke unit, with exclusive beds to stroke care; and Type III,
with an integral stroke unit, which includes exclusive beds to acute
care and rehabilitation until 14 days. A budget of around US$ 200
million was approved to establish new stroke centers in 25 main
cities in Brazil and their metropolitan area. The National Educational Program was launched in June 20, 2012, starting in the 10
main cities in Brazil in July. By the time of the submission of this
manuscript, 82 stroke centers were active in Brazil (all with thrombolytic therapy), including 45 public hospitals.
In November 2011, Porto Alegre became the first city to establish the Line of Stroke Care. This system, which is responsible for
70% of all patients assisted in stroke centers, including three
public and two private hospitals, has been working integrated
with prehospital transport (SAMU). All hospitals in the city
(including the nonstroke centers) and all nonhospital emergency
care units (called UPA, which stands for Unidade de Pronto Atendimento) were trained to assist stroke and to call the SAMU. The
basic healthcare units started the training for primary and secondary prevention. Three other Brazilian cities have their emergency medical network already organized.
The future
Brazil is a country of continental dimensions and widespread
social inequalities. Universality and equity are among the constitutional principles that provide the foundations for its public
health care system. To decrease the social burden of stroke, interventions need to be coordinated among society, healthcare professionals, and public health administration. Guided by an
evidence-based medicine approach, those interventions also need
to be integrated with local reality and available resources. In
Brazil, public resources should be targeted to improve public
stroke awareness; to improve primary and secondary prevention;
and to increase the numbers of stroke units, which are, from the
standpoint of public health, the most cost-effective interventions
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of contemporary neurology. In addition, the Brazilian Stroke
Society understands that population-based studies are necessary
in all major regions of the country, from Amazonia to the south,
in order to provide more reliable information about the impact of
stroke care policies. Case-fatality proportions and Disability
Adjusted Life Years (DALY’S) could be used to measure the impact
of stroke units and thrombolysis implementation.
One additional aspect that needs to be addressed is stroke
rehabilitation within the Brazilian public health. In general wards
or in stroke units, each day, doctors are faced with the dilemma of
what is the best time to discharge their patients. The problem will
grow in the next decades, as the prevalence of stroke patients and
life expectancy increases. Historically, Brazilian medicine does not
have the option of nursing home hospitals. Stroke medicine also
needs be more integrated among different health professionals,
encompassing all issues from university training, basic and
clinical research support to reimbursement of all healthcare
professionals.
Conclusions
The evolution of stroke care in Brazil over the last decade is a
pathway that exemplifies how creativity and perseverance can
be used to face the challenges of stroke care in middle-income
countries, in order to implement substantial improvement in
stroke prevention, treatment, and rehabilitation. The Brazilian
experience reported here can be used as an example of how to
understand the past, present, and future of stroke care in middleincome countries.
Acknowledgements
We thank Dr Werner Hacke and Dr Vladimir Hachinski for the
official advice given to the Brazilian National Stroke Project and
for the support in the Organization of the Brazilian Stroke
Network. We thank Dr Bo Norrving for the continuous support to
improve stroke in Brazil on behalf of the World Stroke Organization. We thank Dr Nils Wahlgren and Dr Nikolaos Kostulas for the
support in the Safe Implementation of Treatments in Stroke
(SITS) Registry in Brazil and we thank Dr Pablo Lavados for
reviewing this manuscript and for all those who supported the
Brazilian Stroke Network and Brazilian Academy of Neurology.
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International Journal of Stroke © 2013 World Stroke Organization