PPP de Diagnóstico por Imagem
Rede Brasileira de Diagnóstico

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Located in the northeast region of Brazil, the state of Bahia has 564,000 km² of territory and more than 15 million inhabitants. According to a demographic research by the Federal Medicine Council, around 75% of this population depend on the public healthcare system (SUS). In this context, it was constant for patients to wait for vacancies to undergo diagnostic examinations. Moreover, critical patients had prolonged hospitalization in healthcare units – which, in consequence, increased the operational costs of these units – without starting the proper treatment for illnesses, due to the lack of examinations that support assertive medical diagnosis. Since the hospital network managed by the direct administration is wide and spread across the whole territory of Bahia, the state’s capacity to meet the demand for imaging examinations was insufficient, despite of the investments made. It was latent how difficult the maintenance of machines such as tomographs and MRI scanners was. And especially how difficult it was to operate these equipments at full capacity. From 2007 to 2014, for example, the state of Bahia acquired seven tomographs, but their use rate in healthcare units was between 20% and 25%, due to lack of maintenance or qualified professionals to operate the equipments. According to the Ministry of Health database, just one third of all high complexity bioimaging machines – such as tomographs and MRI scanners – serves the public healthcare system (SUS). In proportion to demand, there are more equipments allocated on private facilities than on public ones. On SUS, in July 2013, 22 states still didn’t have enough tomographs to reach the rate recommended by the World Health Organization (WHO) and used by the Ministry of Health, which is one tomograph for each 100,000 inhabitants. Out of those states, 15 were from the North and Northeast regions. On the private system — which offers equipments for private health insurance users, for patients redirected by SUS upon payment and for those who pay directly to the facility —, 10 states didn’t have the recommended rate, all of them in the North and Northeast. The information is from the National Registry of Health Facilities (CNES), filled in by managers all over the country and used by the Ministry of Health. In Bahia, where per capita income is around R$736 (USD233.08), according to a calculation by the Brazilian Institute of Geography and Statistics (IBGE), in 2015, imaging diagnostic examinations varied from R$ 400 to R$ 1500 (USD126,67 to USD475,02) making it almost impossible for a large share of the population to access these procedures through the private system.

B. Strategic Approach

 2. What was the solution?
The State of Bahia made sure to meet the needs of the population structuring the first Public-Private Partnership (PPP) in Imaging Diagnosis in the country, that will allocate about R$1 billion (nearly USD317 million) in resources over the 11.5 years of partnership to invest in public health, in hospitals of the capital and the countryside. It is a pioneer action in this sector, since it offers the population bioimaging services such as radiography, mammography, tomography and MRI, once restricted to a few health centers. Those services were granted to Rede Brasileira de Diagnóstico (RBD), the concessionaire that won the public bid and is responsible for making the investments in acquiring equipments, remodeling and building the bioimaging area in each hospital unit involved in the PPP. It is also responsible for maintaining and guaranteeing the availability of the infrastructure and the diagnostic medicine services for the population, in a partnership with the public sector, employing highly specialized professionals and doctors and state-of-the-art equipment.

 3. How did the initiative solve the problem and improve people’s lives?
Through the implementation of the Imaging Diagnosis PPP, the state of Bahia was able to make the use of the bioimaging equipments already acquired more efficient, besides reducing hospitalization time for the patients who are waiting to have diagnostic examinations. Eleven urgency and emergency hospitals across the capital and the countryside were awarded with the PPP services. The units are integrated to a 24-hour Report Central that allows the emission of medical report in up to two hours in urgent cases, for the hospital units contemplated by the project. The operation of the PPP, carried out by Rede Brasileira de Diagnóstico, the concessionaire that is responsible for managing the services, has increased the offer of examinations, modernizing the healthcare system by incorporating new technologies and more appropriate facilities, offering services with excellence and quality and promoting ethical and humane professional attention. Based on contractual mechanisms, Rede Brasileira de Diagnóstico has its performance audited by three instances: the Health Secretariat itself, an audit from SUS and an independent verifier. Patients that would wait months to be able to undergo high complexity examinations in the public service now have free and fast access to high technology equipments, aided by highly qualified radiology professionals.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
Since it can't afford the whole amount of investment needed to fund the imaging examination demand on the public system, the state of Bahia granted the private initiative, through a Public-Private Partnership, the responsibility to manage and inject resources in this area, offering the users of the public health system (SUS) an efficient and adequate service, just like the one offered by private clinics. That initiative represents an innovation for the imaging diagnosis sector. The current PPP, under the management of RBD, is the pioneer in this segment.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
Rede Brasileira de Diagnóstico (RBD), the concessionaire originated by the PPP signed with the state of Bahia, was created to meet SUS patients’ needs for diagnostic medical examinations and is composed of three companies (Alliar, FIDI and Philips) with wide know-how and proved capacity in the country’s health area. Eleven urgency and emergency hospitals across the capital and the countryside were awarded with the PPP services. RBD makes its services available for a population of more than 5 million people across seven cities: Salvador, Lauro de Freitas, Camaçari, Vitória da Conquista, Guanambi, Jequié and Ilhéus, and also neighboring cities, that also use the facilities that were created. More than 400,000 examinations have been performed since the beginning of the project. Alliar, one of the shareholders at RBD, is one of the biggest diagnostic medicine companies in the country, with about 5,000 employees and 1,000 doctors. It offers imaging diagnostic examinations, clinical analysis and nuclear medicine in 35 cities at 100 ambulatory and hospital units. Alliar was the first diagnosis company in Brazil to obtain the ONA 3 certification. FIDI (Fundação Instituto de Pesquisa e Estudo de Diagnóstico por Imagem) is the biggest imaging diagnosis service provider for SUS. Currently, FIDI performs around 5 million imaging diagnostic examinations a year and counts on the work of more than 1,500 professionals. FIDI is integrated to the state of São Paulo public service and serves more than 40 million SUS users through 46 units in public hospitals. Philips is a diversified technology company focused on offering technologically advanced products and solutions to help doctors diagnose, treat and manage many of the most prevalent illnesses nowadays. Philips works in close collaboration with healthcare systems to improve quality, costs and patient care.
 6. How was the strategy implemented and what resources were mobilized?
Facing the challenge, RBD started planning the necessary actions to implement the services that are part of the scope of the PPP. Considering the two main phases planned for the project (transition and full operation), the efforts were specifically designed for each of the phases, according to the peculiar characteristics of each one. During the transition phase, the concessionaire is responsible for providing the services that so far had been offered by the state in the respective hospital unit. It is also responsible for the construction work to restructure and adjust the imaging diagnostic area of the hospitals included in the PPP, contemplating spaces for reception, preparation, examination and support. It also has to provide medical equipment such as CT and MRI scanners, mammographs (including the digital mammograph), X-ray machines, cassette recorders, in addition to installing computers in key areas of the hospitals so that assistant doctors have access to the examination images as soon as they are taken and are able to see the results without the need to print them. It is also their responsibility to create and keep a communication network with a report central where radiologists work 24 hours a day receiving images from all hospital units and writing up the reports. On the full operation phase, after concluding all the actions from the transition phase, the concessionaire is responsible for continuing the operation, then offering services that were not available in some units before, monitoring the performance indicators established for the PPP. Investments in construction, equipments and information technology structure are over R$100 million (near USD32 million), involving the acquisition of 42 imaging diagnostic equipments. To perform those services, around 580 professionals were directly involved, such as doctors, nurses, radiology technicians, technologists, biomedical scientists, as well as administrative workers.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
To conceive the initiative, the state of Bahia, based on studies developed jointly by the Health and Treasury Secretariats, signed an agreement with the International Finance Corporation (IFC) and the Brazilian Development Bank (BNDES) to conduct studies aimed at demonstrating the economic, technical and legal viability of the project and structuring its elements, especially the technical area. The implementation was assigned to the granted concessionaire – RBD, that was responsible for implementing all the necessary steps for the full operation of the units.

 8. What were the most successful outputs and why was the initiative effective?
Installation of a 16-channel computed tomograph at Hospital Otávio Mangabeira (HEOM), specialized in lung disease and reference in tuberculosis that, despite of that, worked for 75 years without a tomograph, which is fundamental for the diagnosis and treatment of such illnesses. Implementation of the mammography guided stereotactic biopsy service at Centro Estadual de Oncologia (CICAN), allowing early breast cancer diagnosis. Installation of a 64-channel computed tomograph in Vitória da Conquista, third biggest city in the state, with 350,000 permanent residents and floating population of 1 million people. The previous tomograph, with just one channel, was out of order for long periods. Before the concessionaire started operating, it hadn’t been working for six months. The main emergency hospital in the state, Hospital Geral do Estado (HGE), that also had just one 1-channel tomograph, had less than 10% of performed examinations with reports, handwritten and done on handbooks. Examinations were evaluated in film, developed through a chemical process. After RBD started operating, a multislice tomograph was installed, enabling fundamental examinations for emergency assistance, research about pulmonary embolism, angiotomography and multiple rapid examinations in cases of polytrauma. Moreover, examinations started to be evaluated in workstations, enabling multiplanar and 3D reconstruction. Also, from then 100% of examinations had a report. Before the operation by RBD, the hospital with the highest complexity in the state of Bahia, Hospital Geral Roberto Santos (HGRS), with more than 600 beds, used to perform examinations according to the availability of doctors. Examinations that needed a specialist to make a report, such as angiotomographies, were performed only on the days the professional was available. Also, no more than 25% of all examinations had a report, making it difficult for assistant doctors, who don't have experience in evaluating imaging examinations, especially in more complex clinical conditions. After the operation started, with doctors available 24 hours a day at the report central, they were able to multiply by 6 the number of requests, reaching 100% of examinations reported.

 9. What were the main obstacles encountered and how were they overcome?
The main obstacle definitely was the remodeling and expansion construction work carried out inside the hospital units while they were functioning, without interrupting the service. During the whole transition phase, when construction was carried out, many risk situations were identified, demanding from the concessionaire a constant search for solutions to guarantee the execution of the work without risk for the patients, especially the hospitalized ones. Among these situations, for example, when starting the excavations or demolitions in some units, were identified medicinal gases pipelines and power grids that were not registered in the as-built projects, which made the concessionaire use complex strategies to eliminate interferences without interrupting the services or posing risk to the patients. Another challenge was to establish planning criteria that guaranteed the correct operational flow inside the units, so as not to break any regulatory standard while keeping the operation with minimum impact for the patients and employees at the units. At some moments, examinations needed to be performed out of the units. In these occasions, the concessionaire provided transportation for the patient in specialized ambulances.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
The need for an efficient healthcare system is a reality in Brazil, especially regarding diagnostic examinations that are essential for preventing and treating illnesses. They are precautions that contribute for a healthier life. Rede Brasileira de Diagnóstico – RBD was created with the goal of meeting the need of SUS patients for diagnostic medical examinations and the mission of providing the best possible imaging diagnosis service in the public area, with excellence and quality, promoting professional, ethical and humane attention. RBD aims to be the best imaging diagnosis company serving the public sector in Brazil, valuing ethics, commitment and respect for life, ongoing employee development, quality, integrated teamwork and technological availability at the service of human beings. Those pillars have enabled an improvement on imaging diagnosis on the public sector. This allowed a 40% increase in the number of examinations only in the first two years of operation by the concessionaire, due to the availability of imaging equipment and qualified professionals to offer excellent services and humane attention. Besides that, the offer of examination vacancies allows more and more people to access the service, improving the overall public health in the country.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)

 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)
Rede Brasileira de Diagnóstico intensifies women awareness campaigns during the months of March and October, focusing on mammogram examinations. Just in October 2016, they achieved an increase of 63% in the number of examinations, compared to the average of the previous months. In March 2017, the number of appointments was increased by 2,770 examinations. Since the service is aimed at users of the public healthcare system (SUS), the operation by RBD has a strong connection to the users/patients in higher social vulnerability who don’t have access to the private healthcare services. Therefore, with the investment in state-of-the-art equipment, supported by professionals with a high degree of technical capacity, these people can receive quality attention that used to be reserved for users of the private healthcare system. This ends up influencing directly the quality of life for those served by the project.

Contact Information

Institution Name:   Rede Brasileira de Diagnóstico
Institution Type:   Local Government  
Contact Person:   Gustavo Carvalho
Title:   Chief Medical Officer  
Telephone/ Fax:   +55(71)30215340
Institution's / Project's Website:  
E-mail:   gustavo.balthazar@rbdimagem.com.br  
Address:   Av. Luiz Viana Filho, 6462 - Torre West, 6º Andar, Sala 611
Postal Code:   41730-101
City:   Salvador
State/Province:   Bahia

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