Elsevier

The Lancet

Volume 377, Issue 9782, 11–17 June 2011, Pages 2042-2053
The Lancet

Series
Health conditions and health-policy innovations in Brazil: the way forward

https://doi.org/10.1016/S0140-6736(11)60055-XGet rights and content

Summary

Brazil is a large complex country that is undergoing rapid economic, social, and environmental change. In this Series of six articles, we have reported important improvements in health status and life expectancy, which can be ascribed largely to progress in social determinants of health and to implementation of a comprehensive national health system with strong social participation. Many challenges remain, however. Socioeconomic and regional disparities are still unacceptably large, reflecting the fact that much progress is still needed to improve basic living conditions for a large proportion of the population. New health problems arise as a result of urbanisation and social and environmental change, and some old health issues remain unabated. Administration of a complex, decentralised public-health system, in which a large share of services is contracted out to the private sector, together with many private insurance providers, inevitably causes conflict and contradiction. The challenge is ultimately political, and we conclude with a call for action that requires continuous engagement by Brazilian society as a whole in securing the right to health for all Brazilian people.

Introduction

“Brazil is not for beginners”, said Tom Jobim, one of the world's greatest popular composers of the 20th century. Throughout this Series of articles,1, 2, 3, 4, 5 we have shown that this statement indeed seems to be the case. We have reported remarkable progress in some aspects of health and health care, in sharp contrast with stagnation or even deterioration in other indicators. One of the ten largest economies globally, Brazil still has a long way to go before reaching current levels of health in the world's most affluent nations.

Large countries tend to be complex and difficult to administrate. With nearly 200 million inhabitants, striking regional differences exist in Brazil, from the rich southeast and south (where life expectancy approaches that of rich countries),1 to the poorer north and northeast, and to the rapidly expanding frontier of the centre-west. In this Series of articles we have shown that, despite these deep divisions, the health of Brazilian people is improving.1, 2, 3, 4, 5 Over the past four decades, life expectancy at birth increased by more than 6 months per calendar year.1 Likewise, good progress is being made towards most of the Millennium Development Goals (MDGs; table 1). Indicators for MDG 1 (poverty and child undernutrition) and MDG 4 (child survival) will most probably be met.2 Maternal mortality trends (MDG 5) have proven difficult to measure with precision because of enhanced reporting; modelled estimates show an annual rate of decline of around 4%,7, 8 which will be insufficient to reach the goal.2 With respect to infectious diseases (MDG 6), Brazil excels in control of vaccine-preventable diseases and HIV/AIDS, but other diseases—particularly dengue fever—have been unaffected by control efforts.3

Neither chronic diseases nor violence and injuries are part of the MDGs, although some researchers argue they should have been included.9, 10 Brazil is making some progress in these areas. Mortality rates of non-communicable diseases declined 20% between 1996 and 2007, mainly due to reductions in cardiovascular and chronic respiratory diseases, in parallel with falling smoking rates. By contrast, hypertension, obesity, and diabetes have risen, and neuropsychiatric disorders are currently the major contributor to disease burden.4 Both homicide and traffic-related death rates started to fall slowly after reaching peak levels in the 1990s, but much still needs to be done to control these two epidemics;5 for example, homicide rates in Brazil remain several fold higher than in neighbouring countries such as Argentina, Chile, or Uruguay.11

Social, ethnic, and regional inequalities have plagued Brazilian society for centuries, which is not surprising since Brazil is one of the world's leaders in terms of income inequalities. Nevertheless, in this Series we have provided evidence that socioeconomic and regional gaps in several health indicators are being narrowed progressively.

To place Brazil in perspective, table 2 shows time trends in key socioeconomic and health indicators in the seven Latin American countries with a population greater than 15 million inhabitants. In 1960, Brazil was ranked first or second in terms of poverty, income concentration, rural population, illiteracy, and mortality. Income concentration in Brazil is especially high, with the Gini coefficient reaching a peak of 0·64 in the late 1980s, when Brazil was the world's most unequal country. Unlike any other country in table 2, Brazil has a huge land area and a major tropical disease burden at baseline. All countries showed progress in all indicators. Absolute and relative gaps between Brazil and the average value of the other six countries were reduced for all indicators, and for some of these (fertility and urbanisation) reversals took place. Gaps in terms of life expectancy and under-5 mortality were small, except for a large reduction in the absolute gap in under-5 mortality, from 43·2 to 4·4 deaths per 1000 livebirths between 1960 and 2009.

Trends in the health status of the Brazilian population over the past 50 years must be interpreted in terms of social determinants of health. Military dictatorship from 1964 to the late 1980s was characterised by rapid economic growth and increased income concentration, inadequate social protection with a fragmented health system, and little social participation in all sectors, including health. This situation did not preclude growth of a strong social movement advocating for reform of the health sector in the 1970s and 1980s. The return to democracy allowed creation of the Unified Health System (SUS) in the new 1988 constitution, with strong popular participation at all levels.1 Throughout this period, changes were seen in other determinants of health, including urbanisation (more than four in every five Brazilian people now live in cities), fertility (which dropped from more than six to fewer than two children per woman in 40 years), and education (primary education now being nearly universal).

From the mid-1990s, other major changes started to happen. Hyperinflation was controlled and economic stability—followed by moderate economic growth—was established. The Family Health Strategy (formerly called the Family Health Programme) expanded primary health care and used geographic targeting to reach the poorest areas of the country, particularly the rural northeast and north, small cities, and periurban neighbourhoods in metropolitan areas. Conditional cash transfer programmes evolved into the current social protection system (the Bolsa Familia), which now benefits a quarter of the population. The minimum wage increased from US$50 (about R$83 at the 1990 exchange rate) a month in the 1980s to $300 at present (almost R$500), and after a long period of income concentration, the Gini coefficient started to decline from around the year 2000.

In addition to positive changes in social determinants of health, Brazil has also profited from a strong and committed health-sector reform movement, including not only academics, policy makers, and managers but also health workers from all levels (eg, auxillary staff, nurses, and doctors), trade unionists, and the general population. This social movement was at the forefront of resistance to the post-welfare neoliberal agenda that swept through the world in the 1980s and 1990s.1 Even when national governments included coalitions led by centrist or right-centrist parties, progressive health policies continued to be pursued. A comprehensive tax-based universal health system was created at the same time that basic packages and user fees were implemented in the public sector in most low-income and middle-income countries.

Internationally, Brazil adopted an independent and outspoken stance in forums such as the World Trade Organization, at which unfair drug patent laws were challenged.12 At WHO, Brazil expressed strong opposition to the year 2000 World Health Report on health systems performance. Some people might argue that Brazil's reaction was attributable to its poor ranking among the world's countries, but the critique to that report was scientifically based, published in a high-impact journal,13 and later endorsed by the World Health Assembly.14

Nevertheless, progress has been uneven. Here, we address some of the main achievements and remaining challenges for the health of Brazilian people.

Section snippets

The Unified Health System

Since 1989, all Brazilian people have been entitled to free health care at primary, secondary, and tertiary level through a national health system that is unique in Latin America, being funded by taxes and social contributions, such as social security payments.1 As described in the first report of this Series,1 implementation of the SUS was accompanied by strong decentralisation and resulted in increased access to primary health care through the Family Health Strategy. This change has led to

Major challenges remain

In a large and complex country such as Brazil, to lay out a comprehensive list of challenges to population health—and in particular, to provision of health care—would be overambitious. Nevertheless, some of the most important issues that need to be tackled in the near future are discussed below. These challenges are by no means the only ones. A major need exists to improve coordination between the public and private sectors, between different government sectors, and between diverse levels of

Concluding remarks

On the basis of present analyses and the preceding articles in this Series,1, 2, 3, 4, 5 we conclude with a call for action (panel), in which we specify challenges directed to the government, private sector, academics, health workers, and civil society as a whole. We stress, however, that the actions recommended and the respective actors involved are deeply interconnected, and coordinated action is required by all.

Here, we have recorded important improvements in health status. The core message

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