Principal investigator: Viviane Pires Ribeiro
Article title: HEALTH CONDITIONS AND HEALTH-POLICY INNOVATIONS IN BRAZIL: THE WAY FORWARD
Article authors: Cesar G Victora, Mauricio L Barreto, Maria do Carmo Leal, Carlos A Monteiro, Maria Ines Schmidt, Jairnilson Paim, Francisco I Bastos, Celia Almeida, Ligia Bahia, Claudia Travassos, Michael Reichenheim and Fernando C Barros
Location of the Intervention: Brazil
Sample Size: The entire Brazilian territory
Sector: Health Insurance
Type of Intervention: Actions to improve health conditions and service provision.
Main Variable of Interest: Improvement of health conditions
Evaluation method: Other
Evaluation Context
In recent years, Brazil has faced several economic, social, and environmental transformations. Previous studies show considerable progress in some aspects of the health conditions of the Brazilian population and the country's health system, in stark contrast to the stagnation or even deterioration of other indicators. Socioeconomic and regional disparities are enormous, signaling that much more progress is needed to improve the living conditions of a large part of the population.
With approximately 200 million inhabitants, Brazil has striking regional differences. Wealthier regions, such as the South and Southeast, coexist with poorer regions, such as the North, Northeast, and the border region of the Central-West. Despite these profound differences, research indicates that the health of Brazilians has improved. Life expectancy at birth has increased by more than six months each year over the last four decades. Regarding infectious diseases, the country stands out in the control of vaccine-preventable diseases and HIV/AIDS, but other illnesses, such as dengue fever, have been little affected by control efforts.
Intervention Details
According to Victora et al. (2011), the trends observed in the health conditions of the Brazilian population over the last fifty years should be interpreted in terms of the social determinants of health. The military dictatorship was characterized by rapid economic growth, increased income concentration, a fragmented health system, and scarce social participation in all sectors. This scenario stimulated a strong social movement that advocated for health sector reform. Thus, the return to democracy enabled the creation of the Unified Health System (SUS), within the context of the new 1988 Constitution. Throughout this period, changes occurred in other determinants of health, including urbanization, fertility, and education.
In the 1990s, important changes occurred, such as the Family Health Strategy, which expanded primary health care in specific geographic areas, reaching the poorest regions of the country. Conditional cash transfer programs, such as Bolsa Família, were developed to complement the social protection system.
In addition to positive changes in the area of social determinants of health, Brazil has advanced with a vigorous reform movement in the health sector, including not only academics, policymakers, and managers, but also professionals at all levels, trade unionists, and organized society. However, progress in the country has been uneven. In this sense, Victora et al. (2011) discuss some of the main achievements and some of the biggest challenges to improving the health of Brazilians.
Methodology Details
The analysis carried out by Victora et al. (2011) is based on a discussion of the main achievements and the greatest challenges in improving the health of the Brazilian population. The authors analyzed the Unified Health System, social participation, human resources in health, the public-private partnership, private health insurance, the development of capacities for health research, mass media and health promotion, regulation and medicines, etc.
Based on the analyses and the series of five previous articles, Victora et al. (2011) developed a “call to action” (Panel).
Results
Based on the analyses carried out – on the Unified Health System, social participation, human resources in health, private health insurance, etc. – and on previous studies, Victora et al. (2011) developed a “call to action” (Panel). According to the authors, in a large and complex country with so many changes underway, a call to action in pursuit of improved health conditions and service provision must necessarily be lengthy. To this end, the recommendations were divided into categories directed at the Brazilian government, the private sector, academics, health workers, and civil society as a whole.
The recommendation to the government is that it should reaffirm its commitment to improving the health of the Brazilian population, particularly with regard to the principles of the 1988 Constitution and the SUS (Unified Health System), with actions in the following areas: Health conditions; Financing of health care; Primary health care; Regulation, accountability and quality of care; Human resources in health; Health research; and Intersectoral actions.
Although the government plays a central role in the sector, other actors – health workers, the private sector, universities, training institutions, health councils, researchers, and civil society – should be equally involved in order to achieve better health levels for the Brazilian population. That is, the recommended actions and their respective actors are deeply interconnected, and coordinated action on the part of society is necessary.
Lessons in Public Policy
The central message of the study conducted by Victora et al. (2011) is that improvements in health conditions can be attributed both to favorable changes in the social determinants of health and to the dynamics of a vigorous sectoral reform movement, initiated in the 1970s, which led Brazil to adopt a unique approach, in relation to Latin America, by creating a national health service with the main objective of reducing inequalities. The health reform and the creation of the SUS (Unified Health System) were part of a broad movement aimed at mitigating social exclusion, integrating initiatives from different sectors.
Despite overall progress, Victora et al. (2011) emphasize that social and economic disparities remain unacceptably high, noting that much effort will be needed to improve the basic living conditions of a significant portion of the population. New issues emerge as a result of urbanization and social and environmental changes, and some long-standing health problems persist without significant improvement. The administration of a complex and decentralized public health system, and the vigorous activity of various private health insurance companies, inevitably lead to conflicts and contradictions. The challenge is ultimately political and requires the active and continuous engagement of society, with a view to ensuring the right to health for the entire Brazilian population.
Reference
VICTORA, Cesar G. et al. Health conditions and health-policy innovations in Brazil: the way forward. The Lancet, v. 377, no. 9782, p. 2042-2053, 2011.
