Pro Bono Air Transport of Human Organs (PBATHO)
Civil Aviation Secretariat/Ministry of Transports, Ports and Civil Aviation

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Describe in no more than 500 words the situation before the initiative began and why an innovative solution was required. What major problems and issues needed to be addressed and were they of public concern and/or did they affect a large group of the population? What social or other groups were affected and in what ways? Brazil has a system of organ transplants created based on the Spanish and American system, funded by the federal government through the Unified Health System - SUS. According to Brazilian Association for human Organs Transplant - ABTO (2012) and Council of Europe (2012), in absolute number of transplants performed, it is the second largest in the world, United States being the first. In Brazil, the Ministry of Health (MS) created the National Transplant System -SNT and the National Transplant Center – CNT in August 2000, to coordinate transplants of the National Health System. The purpose of the SNT / CNT is to coordinate with the State Notification, Collection and Distribution Centers (CNCDO's), providing means for the transportation of organs between states, with the aim of attending to the largest number of patients waiting for a transplant, as well as avoiding loss of organs without conditions of use in their origin. As in the United States, the large territorial dimension of Brazil makes it difficult to meet all the demands of the county´s regions on an effective and equalitarian way (Nunes et al, 2010). Consequently, air transport is of extreme importance for the transport of organs, tissues and medical teams across the country, used in 95% of the transports done by the SNT / CNT. In order to carry out the transport of organs and tissues by the CNT, national airlines have been transporting organs, tissues and equipment pro bono since December 13, 2000, when the first Technical Cooperation Agreement was signed. The document allowed the transportation, but was not very effective, the roles of all parties involved were not clear and communication between them was not organized. Later, in 2009, the partnership renewed, in a Technical Cooperation Agreement, involving the Ministry of Health and airlines, then represented by the National Union of Airline Companies - SNEA. Even with the signing of this term, the process lacked updating to guarantee a safe legal environment to those involved, as well as the need for broader discussion of the roles the subscribers in the process. There wasn´t a proper communication channel between CNT and the others involved in the transport and too few airline companies were subscribers, resulting on poor access to the national flight network and logistics issues involving CNT and airlines that sometimes resulted on loss of material. These problems had direct impact on the transport of human organs, tissues and medical teams across the country, having a serious impact on the lives of thousands of people annually.

B. Strategic Approach

 2. What was the solution?
The initiative is about: Increasing the access to pro bono air transportation by the Ministry of Health; Making sure that the organs, tissues and medical teams reach their destinations as soon as possible; The Ministry of Health, Defense and the Aviation Industry working together to save and/or improve quality of thousands of lives.

 3. How did the initiative solve the problem and improve people’s lives?
The main goals were to make the transport of human organs safe and agile while expanding the reach of the ministry of Health, making sure CNT´s team would have access to reliable information to ensure items were allocated to viable routes and were transported on the fastest routes possible, helping to maximize human organ utilization and to enable better human organ quality for transplantation, consequently increasing utilization and survival rates. The following problems were identified as the most significant, after discussions: • Difficulty of articulation between CNT/Carrier/Airport/Air Navigation; • Loss of organs due to unfavorable transportation logistics; • Longer transport times and consequently higher possibilities of unfavorable outcome for a survival of the recipient; • Difficulty in guaranteeing security against acts of unlawful interference; • Choice of non-viable routes / flights; • Limited access to flight network, limiting the scope of the CNT's operations over national territory. To this end, a working group was created with the participation of the Ministry of Health, Ministry of Transports Ports and Aviation Civil, Ministry of Defense, National Civil Aviation Agency (ANAC) and representatives of major airports and the largest brazilian domestic airlines. One of the Working group´s findings was that the lack of clear rules made the communication confusing for airlines, airports and the CNT itself, who sometimes had to use non-institutional contacts to enable the transport to prevent loss of material. Another problem was the choice of transport logistics without knowledge of important information, such as the operational situation of flights (cancellations, delays) and meteorological situation at airports, a practice that sometimes led to the choice of unviable routes, jeopardizing the effectiveness of transport and possibly the lives of potential recipients awaiting the organs. In view of the scenario found, the following initiatives were adopted to address the problems: • Update the Cooperation Agreement for the transportation of human Organs, tissues and medical teams - clearly and precisely describing the obligations and attributions of those involved; • Invite more Airlines companies to increase access to flight network on national level; • Use the "Collaborative Decision Making (CDM)" model, successfully used by the civil aviation sector since 2010 in the operational management of air navigation in the national territory. The agreement provided the necessary legal environment to those involved, together with the details of the operational obligations and definitions needed to improve the transportation of organs with agility and safety. The document expands the coverage of the provision of the free service by the airlines involved, responsible for 99.6% of the seating capacity in domestic passenger flights, as well as regulating transportation in both normal situations and in calamity situations. In order to operationalize the agreement, the CDM model was adopted, which consists on maintaining all players at the same location, 24/7 and guaranteeing access to high quality, timely information for decision-making in a collaborative way, with the greatest possible agility. On that context, the innovation consisted on allowing CNT access to the facilities of the Air Navigation Management Center - CGNA, in Rio de Janeiro, where it would be possible to articulate directly with all parties involved. The ease of communication with all the involved entities opened a range of possibilities that were not available before, for example: • Previous verification of the meteorological conditions of the destination airports, avoiding human organ losses by the allocation of non-viable routes; • Prior consultation on the operational situation of the flights (delays, cancellations, maintenance), avoiding the allocation of non-viable flights; and • Priority requests made by CNT, speeding up the transit of the medical teams / human organs and tissues through the terminals as well as of aircraft during the taxi and approach stages.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
The initiative integrates the Aviation, Defense and Health sectors with the purpose of saving and/or improving quality of thousands of lives through the transportation of human organs, by using Collaborative Decision Making CDM techniques. In addition, it is a genuinely collaborative initiative, which has the support of all involved, without any public funding, of any kind, even without legal obligation to the parties. • The initiative uses available room at commercial aircrafts to transport human organs, tissues and medical teams, pro bono; • The initiative granted access to the Ministry of Health to a high technology air navigation command center to help management human organ transportation; • The initiative allows transportation of blood and medical teams, free of bureaucracy on calamity events. • The initiative allows previous verification of the meteorological conditions of the destination airports, avoiding human organ losses by the allocation of non-viable routes; • The initiative allows previous consultation on the operational situation of the flights (delays, cancellations, maintenance), avoiding the allocation of non-viable flights; and • The initiative allows priority requests made by CNT, speeding up the transit of the medical teams / human organs and tissues through the terminals as well as of aircraft during the taxi and approach stages.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The initiative was implemented by a working group coordinated by the Civil Aviation Secretariat – SAC, in which took part: • Ministry of Health (represented by the National Transplant System - SNT and the National Transplant Center – CNT) • Ministry of Transports Ports and Aviation Civil (represented by the Civil Aviation Secretariat – SAC) • Ministry of Defense (represented by the Department of Airspace Control - DECEA) • National Civil Aviation Agency (ANAC) • Representatives of the largest domestic airlines (GOL, LATAM, AZUL, AVIANCA and PASSAREDO) • Brazilian Airline Companies Association - ABEAR. • Representatives of the main airport operators (INFRAERO, GRUAirports, BHAirport, INFRAMERICA, RIOGaleão International Airport, and Viracopos Airport) • National Association of Airport Administrators (ANEAA) CNT manages the logistics for human organs, tissues and medical teams, according to the agreement signed, through collaborative decision making with the help of airlines, airports and Air traffic control. Every month, CNT uses an average of 370 flights to transport an average of 570 items, in 2016 alone CNT moved close to 7.500 items, among those 1525 medical team members and over 4.000 human organs and tissues (52 hearts, 251 livers, 871 kidneys, 179 bone marrows, 1289 corneas, and others). Between 2013 and 2016, CNT transported close to 30.000 items, among those 4.000 organs and 12.000 tissues (cornea, bone marrow, bones, skin…).
 6. How was the strategy implemented and what resources were mobilized?
Diagnostic Initially, a group of professionals from SAC / MTPA, Infraero and SNT / CNT were created to run a diagnostic of the system. The group identified the key stakeholders in the process, their expectations and needs, and the technical feasibility of the project. It was clear that the discussion should be broad and involve the airport operators INFRAERO and the private operators, summing up the 66 largest airports, concentrating more than 90% of domestic air traffic. Subsequently, the concessionaires of the Airports Granted to the private initiative were involved. In addition, it was defined that the focus should be the domestic carriers TAM, GOL, AZUL, AVIANCA and PASSAREDO, responsible for 99.6% of the market. Action plan An action plan was defined to map and design flow charts for the main processes in 2011, to understand the processes and the system, and to identify problems and their possible causes. During this period, a database was created containing the history of the number of items transported and flights used, by airline, which enabled the establishment of indicators to monitor the results of the initiative. The problems identified by the group were discussed in meetings between June and September 2012, which focused on solving the problems and allowed the maturation of the processes, with the simplification of stages, standardization and institutionalization of communication. Deployment By January 2013, the working group begun the implementing the agreed changes. Airlines have provided institutional contact on duty with power to authorize transportation and ticket issuance. The proposed changes were linked to the employees of all those directly involved in the transport and began to integrate the training of the field teams of airlines and airports. Also in the first semester of 2013 began the drafting of the Cooperation Agreement for pro bono transport of human organs for the purpose of transplants, by the same Working Group. The document had its preliminary version finalized in December 2012, but after more detailed evaluation from the point of view of regulatory and legal impact, more time was needed for discussions. In addition, during this period, the process of hiring the employees who would work for the CNT in Rio de Janeiro began. Throughout the year 2013, there was follow-up of the process, followed by the discussion of the content of the agreement. The final version of the final document was signed in December 2013 and brought with it an improvement in the flow of communication among those involved, resulting in a significant growth in the number of transplant-related items transported per year Costs The initiative is an agreement for pro bono transport of human organs, tissues and medical teams, without disbursement of resources by the Ministry of Health. The airlines assume the cost of air transportation. Costs for boarding fees of the medical teams are assumed by the airlines and by the airport operator, depending if the last is a subscriber of the agreement. The Ministry of Health assumes the responsibility of conducting training for employees involved in transportation, both airlines and regulatory agencies, when requested by the representatives of the companies. The workstation of the CNT professionals in Rio de Janeiro, was made available by CGNA, and the team that works there is maintained and subordinated to the Ministry of Health. There was no specific budget for the Working Group, the meetings were held in Brasília-DF and the expenses of displacing servers / employees to participate in meetings held by each agency / entity. After 2016, costs for the operation of a military aircraft, used for extremely urgent cases, are carried by the Ministry of Defense.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
The initiative was implemented by a working group coordinated by the Civil Aviation Secretariat – SAC, in which took part: • Ministry of Transports Ports and Aviation Civil (represented by the Civil Aviation Secretariat – SAC) Servants: Raquel Velho, Paulo Possas, Gustavo Canuto, Marco Porto, Aline Rebouças • Ministry of Health (represented by the National Transplant System - SNT and the National Transplant Center – CNT) Servants: Heder Murari Borba, Evelyn Heinzen, Patrícia Freire • Ministry of Defense (represented by the Department of Airspace Control - DECEA) Servants: Cel Bertolino, Cel Medeiros and Cap. Arnaldo • National Civil Aviation Agency (ANAC) Servants: Herberth Guedes, Leonardo Boszczowski, Luiz Pimenta, Luiz Cavallari • Representatives of the largest domestic airlines (GOL, LATAM, AZUL, AVIANCA and PASSAREDO) Servants: Edson Pires (GOL), Tatiane Viana (LATAM), Patrizia Xavier (AZUL), Marcio Antonio Ribeiro (AVIANCA) and William Agatz (PASSAREDO) • Brazilian Airline Companies Association - ABEAR. Paulo Roberto Alonso and Victor Celestino • Representatives of the main airport operators (INFRAERO, GRUAirport, BHAirport, INFRAMERICA, RIOGaleão International Airport and Viracopos Airport) Servants: Dunia Aleixo (INFRAERO), Antonio Montano (GRUAirport), Paulo Cesar Rangel (BHAirport), Josmário Brito (INFRAMÉRICA), Herlichy Bastos (RIOGaleão Airport) and Marcelo Mota (Viracopos Airport) • National Association of Airport Administrators (ANEAA) João Tabalipa Ferreira and Douglas Rebouças de Almeida

 8. What were the most successful outputs and why was the initiative effective?
The initiative expanded and facilitated access to the pro bono flights of the participating airlines, by increasing the number of items and medical teams that have access to air transport, this helps saving and improving the lives of thousands of people every year. The list that follows contains concrete outputs to illustrate the success of the initiative: • Between 2011 and 2013, there was a 139% increase in the number of flights used by CNT; • Between 2013 and 2016, there was a 214% increase on the number of health professionals transported by the initiative. 2.781 professionals were transported in that period; • Between 2013 and 2016 over 16.000 items were transported under the cooperation agreement; • The cost of transportation of medical teams between 2013 and 2016, generated savings of approximately U$ 310.000;

 9. What were the main obstacles encountered and how were they overcome?
The first obstacle encountered was the difficulty in understanding the limitations and needs of those involved while discussing complex and eminently technical issues in the health and civil aviation sectors. The solution to this problem came naturally from the exchange of knowledge and information in the discussions of the Working Group. In addition, CNT took the initiative to promote the "First Logistics Forum for Distribution of Organs for Transplantation in Brazil", in the city of Pirenópolis-GO, on October 24 and 25, 2013, which assisted in the Leveling of the knowledge of both the health professionals involved in the transplant process, and the representatives of aviation and transportation. Another obstacle faced was the difficulty of articulation among those involved, which was solved in part by the narrowing of relations, under the coordination of SAC, and partly by the transfer of CNT activities to Rio de Janeiro and the use of the Collaborative model Decision Making - CDM. Another point of attention was the need to guarantee security in the shipment of teams/material by means of the x-ray inspection. Prior to the initiative, it was not a rule to inspect through x-ray the material before entering the aircraft. The term of cooperation has established the understanding that all items and teams must undergo security inspection prior to shipment. A debate began with ANAC for the issue of regulations regulating the issue. On May 15, 2015, Portaria n. 1,155, which disposed of the subject and pacified the question, allowing safer operations and making possible to include bone marrow on the agreement by the end of 2015. The transport of human hearths and lungs were particularly difficult due to its very narrow window of opportunity (4 hours) for successful transportation and transplant. That was partially addressed by putting one military plane at CNT’s request.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
The initiative impacts the lives of thousands of people every year, as mentioned on question 8,and figure 1 below, the Brazilian health care system is available to all citizens through the Unified Heath System (SUS), a system that covers all expenses for treatment, surgery and recovery of the patients, making a huge effort to help people, regardless of age, color, gender or social class. The implementation stage of the needed measures identified in the work was carried out gradually between June 2012 and December 2013, when the term of cooperation was signed. The first results of the work could be observed even in 2012, with the implementation improvements gradually. By the end of 2012 and during 2013, although the text of the cooperation agreement was not fully pacified, practically all operational aspects were in the process of being tested and the professionals undergoing training, or in some cases the processes were already fully implemented. As can be seen in Figure 1, the number of flights used by CNT almost tripled between 2011 and 2013 NUMBER OF FLIGHTS USED BY SNT / CNT PER YEAR At the operational level, all operations are monitored from the collaborative decision room in Rio de Janeiro. The operation of the room, located in the military area of the III COMAR, at Santos Dumont Airport, allows contact with all entities involved in the process and allows access to operational information and updated weather forecasts three times a day. The on-site CNT team monitors transportation and reports to their superiors at the CNT / SNT in Brasília. At the strategic level, the SNT / CNT e-mail work group receives monthly reports on organ transports. Periodic meetings are scheduled for follow-up, in which the evolution of the indicators, number of items transported and number of flights used by each company are discussed. In addition, the participants' feedbacks are presented. The data are collected from the transportation annex, used to authorize the flight, by CNT attendees - Rio de Janeiro, forwarded by e-mail to the administrative office of CNT - Brasília, which is responsible for tabulating the data, and presenting it to the components of the work group, giving transparency to the process. The tabulated data are: date and number of the transport, origin and destination of the flights, material transported and the airline that carried out the transport.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
The initiative allowed the Ministry of Heath to access air transportation without the need to contract an airline company, that fact helps reducing corruption by removing the need to transfer funds from the government to private entities. Additionally, in 2015, new articles were added to the text of the agreement to complement transparency on the medical team being transported, to ensure there was no misuse of that tool.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
No, the initiative is universal.

Contact Information

Institution Name:   Civil Aviation Secretariat/Ministry of Transports, Ports and Civil Aviation
Institution Type:   Ministry  
Contact Person:   MARCO PORTO
Title:   Coordinator of planning of civil air navigation  
Telephone/ Fax:   55 61 33117163
Institution's / Project's Website:  
Address:   Setor Comercial Sul - B (SCS-B), Quadra 9, Lote C, TOWER C, 5TH FLOOR
Postal Code:   70308200
State/Province:   DF

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