Questions/Answers

The Couto Maia Institute (ICOM) is a public-private partnership, being the largest and most modern hospital specialized in infectious diseases in Brazil. Originated from the merger of the old Couto Maia Hospital and the Dom Rodrigo de Menezes Specialized Hospital. In July 2018, the new facilities with structure and equipment were inaugurated in accordance with the precepts that guide the assistance to patients with infectious and parasitic diseases. The State of Bahia, made up of 417 municipalities, did not have an adequate structure to provide quality assistance to people affected by infectious and parasitic diseases, as the Couto Maia and Dom Rodrigo de Menezes Specialized Hospitals were more than one hundred years old and, since the 1970s, their physical structures were not fit for expansion and technological incorporation and did not meet current health surveillance standards. On the other hand, they had highly qualified technical staff, with expertise in infectious and parasitic diseases and in dealing with the main epidemics of tropical diseases. In this context, the Couto Maia Institute Project (ICOM) was created, with the objective of providing quality care to patients with infectious and parasitic diseases. To excel at its purpose, the Couto Maia Institute: (1) provides training and resources to outpatient, hospital and pharmacological care for the target groups, especially users with HIV-AIDS, Hansen's disease and tropical diseases, within ethical standards; (2) adopts the principles of humanization and rationalization of resources of the Unified Health System (SUS); (3) Is used for teaching and research; (4) offers patients and their families an environment designed to be humanizing, comfortable and secure, in a wide area, full of natural light and natural vegetation; (5) responds to Bahian society in facing endemic crises, common in the region Northeast of Brazil.

Selected category 4: With the constant increase in the number of cases of HIV / AIDS and the growing wave of infectious contagious epidemics (such as Guillan-Barré Syndrome, Zika Virus, dengue and, recently, COVID-19) it is necessary to have a public service capable of assisting SUS users with safety, comfort and quality, using the relevant medical technology. Therefore, in July 2018, the Couto Maia Institute Project was created. ICOM was structured and designed to face health crises, guaranteeing a fast and effective service to the entire Bahian population, especially the most vulnerable. Universal and equal access to public health services is at the core of our work.

a) ICOM aligns mostly with the following 3. Health and Wellness We have 120 beds (20 in ICU), a Surgical Center for small and medium procedures, Bioimaging (Computed Tomography, Ultrasonography, High Digestive Endoscopy, Echocardiogram, Electrocardiogram and traditional X-ray), a Hansen's disease and an Infectious Diseases clinic (working especially with HIV / AIDS). With the pandemic, we expanded to 161 beds, focused on the care of COVID-19, 89 of which were in the ICU. We have a “Center for Special Immunobiologicals” (CRIE), with vaccines for specific groups, as recommended by the WHO and the dispensing of drugs for vulnerable people affected by HIV / AIDS and Hansen's disease, free of charge. 17 Partnerships and means of implementation ICOM presents an innovative management model: a public-private partnership between the Health Department of the State , responsible for patient care activities and the Couto Maia S / A concessionaire responsible for the services: food, equipment maintenance, clinical engineering, laundry, hospitality , reception, concierge, property security, fire-fighting, hygiene, landscaping, and administrative support, elaboration, construction, furniture and fundraising for its execution. Creating a hospital unit with a standard of excellence in management and assistance, with 100% records of assistance and administrative processes in a digital environment.

b) This initiative is sustainable in the social sphere because it is a reference public hospital in the State of Bahia for the treatment of infectious diseases, especially HIV-AIDS, Hansen's disease and neglected tropical diseases. We perform 2 thousand monthly visits, expanding the population's access quality public health. In the economic sphere, the public-private partnership optimizes the expenditure of public resources. In the environmental aspect, capture and reuse of rainwater; environments with natural lighting and environmental preservation area.

a) There was a large demand from patients with infectious diseases in Bahia. The former specialized hospital there were only 06 ICU beds, intended for pediatrics and adults, serving 417 municipalities; the infectious diseases and leprosy outpatient clinic operated in an improvised location, with a low capacity for daily care. The physical structure of the Couto Maia Hospital did not support the growing demand after the junction, in 2012, with the Hospital Dom Rodrigues de Menezes, specialized in Hansen's disease. In addition to that, the number of hospitalizations for AIDS surpassed those of meningitis in 2013. Nevertheless, it was not possible to expand and incorporate technological facilities in the old Couto Maia Hospital, while the health surveillance standard. With ICOM, the number of ICUs increased to 20 beds, 10 for pediatrics and 10 for the adult public, and a modern clinic was created with 10 doctors' offices, procedure room, dressing room, physiotherapy room and occupational therapy, in addition to an equipped and modernized rehabilitation gym. The new ICOM has a modernized infrastructure, fully computerized, with diagnostic support, bioimaging, satellite pharmacies and immediate technical support, in accordance with the Ministry of Health.

b. Sexism and misogyny are widespread in Brazil, with men occupying the highest leadership positions. Despite that, ICOM is in line with the SDG 5, of gender equality, and guarantees the full and effective participation of women in the management body. The board and leaders, at all levels of decision-making, are composed predominantly of women.

c. ICOM's target groups are patients affected by HIV / AIDS, Hansen's disease, severe acute flu syndromes (such as COVID-19) and other diseases such as visceral leishmaniasis, leptospirosis and tetanus. Increased access to care significant improved results and had a significant positive impact on patients. In 2017, there were 56 active hospital beds, generating 1,338 annual admissions. In 2019, with the implementation of the ICOM Project and the availability of 120 active beds, there was a 257% increase in the number of patients admitted to the hospital unit (3,443 admissions). The relevant role of ICOM is highlighted in this pandemic moment. From March until now ( November 12, 2020) 3,137 suspected cases of COVID-19 were admitted and 1,766 were hospitalized, with an average stay of 10.7 days. The occupancy rate was 90% for a lot of this period. In parallel, the general infectious diseases outpatient clinic was expanded, covering arboviruses, exanthematic diseases, hepatitis, flu-like syndromes, neuro infectious diseases (such as meningitis and Guillain – Barré Syndrome), HIV / AIDS and Hans disease.

The public-private partnership signed between the Health Department of the State of Bahia (responsible for patient care activities) and the concessionaire Couto Maia S / A (responsible for all other services) through Contract 035/2013, was established in April 2013 . Construction beginning in June 2013. For political reasons, the work was halted in April 2014, and resumed only in March 2017. The implementation of the Instituto Couto Maia Project took place on July 6, 2018, with the inauguration of the largest and most modern hospital specialized in infectious diseases of the Brazil.

b. Obstacles Faced: (1) Absence of a public notice for the proposed model of Mixed Public Private Partnership. This was a pioneering experience in Brazil, where the private partner would be restricted to non-assistance activities, and to build and equip the unit. A commission was formed to prepare the public notice, based on public notices from other Public Private Partnership models in the world. (2) With the change of state administration, the project budget was not updated, becoming obsolete over the years. The bidding was carried out in 2012 and the works only started in 2017, requiring adjustments to the architectural project.

ICOM is the most modern infectious diseases hospital in Brazil. The records of the assistance and administrative processes are 100% in a digital environment, which facilitates providing health care with excellence. We have 28 beds of negative pressure, intended for the isolation of patients with diseases transmitted by aerosols, in order to protect other inpatients and professionals. We also excel in the humanizing and empathic treatment we offer our patients. ICOM invested in the formation of a multidisciplinary group prepared to welcome and manage historically excluded, stigmatized and vulnerable groups such as the LGBT community, people with substance use disorders and homeless people.

b. The initiative was inspired by the model of a mixed Public Private Partnership, where the private partner was restricted to non-assistance activities, in addition to building and providing the hospital equipment unit.

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ICOM's experience of Public Private Partnership is aimed at building and privately managing support and maintenance services, such as security, cleaning, conservation, hospitality and laundry, known in the health language as 'gray coat' services. This model is currently the most widespread in the world, in relation to public-private partnership models in the health sector. The excellence of the service provided by the assistance body is a reference in Brazil. Our highly trained and qualified professionals in infectious diseases have extensive experience in intensive care in times of crisis, attested in this pandemic of COVID-19.

PPP in the form of “gray robes”, seems to be a very promising experience, in which the private operates only in the areas of support to the assistance service, and the direct assistance to the patient is performed by the State. It is an experience that can be transferred to other hospital units and depending on the political decision and the laws of each state or country.

a. The Bahia state health secretary (SESAB) is responsible for the financial resource of R$ 6,457,000.00 (six million, four hundred and fifty-seven thousand reais), divided into 11 months (February to December) and, as human resources, 380 public servants and 714 professionals the assistance area, from outsourced companies The Concessionaire was responsible for providing 115,421,214.96 (one hundred and fifteen million, four hundred and twenty one thousand, two hundred and fourteen reais, ninety-six cents), used in construction, studies and projects, installations, machinery, equipment, furniture, utensils, software, vehicles and pre-operating expenses and, as human resources, the hiring of 375 non-assistance professionals.

B. The consortium disbursed the investment for the construction and acquisition of medical equipment. The state reimbursement after the start of operations in the hospital, and this is divided into 20 years, diluting the State's contribution to the project's financing. This partnership optimizes the expenditure of public resources, with transparency proven by independent evaluators of the Contract. It is worth mentioning that, in order to contain the crisis arising from COVID-19, SESAB hired additional 100 doctors, 50 nurses, 40 physiotherapists, 150 nursing technicians, 04 nutritionists, 05 biochemical pharmacists, 09 laboratory technicians and 03 radiology technicians contracted through outsourced companies.

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B. The project is subject to permanent evaluation by an independent verifier, represented by Accenture Brazil, through on-site visits, periodic application of questionnaires to users, staff and managers. This is done in order to assess the quality of the service provided by the Concessionaire . Internally, there is a Contract Inspection Commission with the purpose of monitoring the fulfillment of the partnership.

c. According to the public-private partnership notice of the Couto Maia Institute: Indicators: To determine the performance index and the calculation of the variation of the effective monthly consideration; Evaluate: the economic and financial balance of the contract and review the Marginal Cash Flow; operating procedure manuals; concession assets; the basic architectural projects for the construction of the Hospital Unit; the Equipment and Furniture Specification Book; Calculate the Hospital Occupancy Rate. Tools: Instrument for assessing the quality of services for monitoring the development of work; measuring quality levels and correcting directions; user satisfaction survey.

d. In the last quarterly report, referring to the 8th (eighth) quarter of Operation of ICOM (July, August and September 2020), sent by the independent verifier Accenture Brazil, we obtained the following results: The Performance Index calculated is equal to 3.77 (maximum of 4), generating a Performance Factor of 100%. The calculated Occupancy Rate is equal to 63.6%. The resulting Effective Monthly Consideration, considering the Occupancy Rate above: represents 96.36% of the Maximum Monthly Consideration. Regarding risks and problems, from the analysis of the satisfaction survey, the independent verifier sends to the Concessionaire so that corrective measures can be taken. The General Director of the Hospital Unit temporarily suspended the performance of satisfaction surveys, given the current scenario experienced by the care of COVID-19 patients. There is an internal evaluation, through a contract inspection commission, composed of a technical staff, which evaluates the indicators and the fulfilment of the Contract, legitimizing the Initiative.

ICOM is a state public hospital, linked to the State Health Secretariat of the State of Bahia. However, it must communicate well not only with several health administrative bodies of the Bahian state; but also with the Federal Government (through the Ministry of Health) and with the Mayor’s administration (through the Basic Health Units and Municipal Secretariats). The Hospital Epidemiology Centre is also in constant communication with the state’s Epidemiological Surveillance. Internally, the General, Medical, Nursing and Administrative Directorates carry out a democratic management process with the other care areas and with the Concessionaire. Management is carried out in partnership with several commissions, such as: Teaching and Research, Crisis Management, Patient Safety, Death, Medical Record Assessment, Medical Ethics, in addition to the Research Ethics Committee and Work Group in Humanization.

The implementation of the ICOM Project involved, directly and indirectly, the Federal Government, the State Government, the City Halls, private initiative and civil society. As a Specialized Hospital, Universities and Research Centers - especially the Oswaldo Cruz Foundation (FIOCRUZ) and Federal and State Public Universities - have also become interested parties and develop teaching and research activities in this hospital. During the execution and offer phases of the works, as well as during management of the non-assistance services of the ICOM Project, there was a Mediation Committee, with representatives from the Couto Maia Hospital, SESAB and Concessionaire to resolve any divergences and controversies, both technical or economic and financial.

The experience of a modern, well-equipped structure, with an articulated governing body, made ICOM one of the main institutions in responding to the COVID-19 pandemic in Brazil. The management model favoured the quick expansion of beds, including the ICU, with the expansion of the gas, electrical and hydraulic network. Being a part of the Brazilian national health service (SUS), facilitated the quick transfer of non-COVID patients to other hospitals, and in two weeks ICOM was converted into a State Reference Unit for COVID-19. We recognise the importance of having a public health system (SUS) with an integrated regulatory network, and institutions with the ICOM’s profile: organized, equipped, modernized, with incentive to research, transparent in the use of public financial resources, and in constant evaluation. We were able to rapidly expand the number of professionals and carry out in-service training activities to offer comprehensive and intensive assistance, in times of serious crisis due to this Pandemic. The existence of clear and well defined Standard Operational Protocols, built collectively, made it so it was easy and fast for these to be updated and the other protocols (aimed at biosafety and adequate assistance to patients) to be created.