Tackling Health Inequalities through the Brazilian public health system
Brazil saw during the last thirty years an impressive decline in its infant mortality rate as well as important gains in life expectancy. Despite these important achievements, new data, produced in the period, made clear the magnitude of health inequalities present in the country. For example, in the 1980s the mean of the infant mortality rate for the 5561 Brazilian municipalities classified by income quartiles was 134 per thousand births in the first quartile (the poorest), while in the fourth quartile (the richest), it was 55. In the 1990s, the maternal mortality for black women was 3,6 times higher than that for white women, and in the 2000s the indigenous infant mortality rate was still more than triple that of the population as a whole, as was the indigenous tuberculosis incidence.
In the 1980s, during the democratization process, the debate about how to deal with health inequalities, both in the access to health care services and in the patterns of health condition distribution between social groups, gained momentum. The creation of the SUS, the Brazilian universal public health system, in 1988, reflected the aspirations of a national and international movement advocating ‘health for all’ and was expected to help in tackling entrenched inequalities.
However, the SUS initially lacked at least two of the institutional mechanisms needed to turn these aspirations into reality:
a model of medical care that truly supported primary care;
a legal and administrative frame defining a clear governance structure among the federal, the states and the municipal governments.
These were developed mainly in the 1990s, through:
A local innovation process prompted by crises in the earlier highly centralized and hospital-centered public health system, allowing decentralized programs in, for example, primary care and HIV/AIDS prevention, to be created by civil society, municipal or state level authorities and tested before becoming national programs.
The establishment of a clear division of labor among the national Ministry of Health, states and municipalities, including signed agreements defining responsibilities and transparent financing rules for national policy implementation. In this arrangement, the federal ministry provides nearly 55% of total funding, and states and municipalities cover the remaining 45%. The Ministry sets policy, but does not directly deliver services. States are in charge of coordinating the services provided within their territories, linking basic, intermediate and high-complexity services and supporting poor municipalities. Municipalities are responsible for the provision of basic care and the referral of patients to services of higher-complexity for users living in both rural and urban areas. The proportion of municipalities taking on decentralized responsibility for expanding the coverage of primary care programs increased from 23.4% in the mid-1990s to 88.7% in 2010.
The mobilization of Brazil’s Health Reform Movement, which advocated for the effective institutionalization of citizen participation and oversight through health policy conferences, a national health council, and subnational health councils—now established in all 27 states and in nearly all municipalities. They address core issues of priority-setting and accountability, and can challenge health system managers on policy rather than merely participating in implementation. Fora for bringing municipal, state and federal authorities together to discuss policies and budget allocations have also been created. These play a decisive role in regularly engaging civil society and health authorities, and facilitating the flow of information across municipal, state and federal levels.
The early receptiveness to local innovation and clear division of labor among spheres of government contributed decisively to ensuring implementation of successful large scale changes that strengthened primary care and helped to reduce regional inequalities as can be seen in Figure 1 below.
Graph 1 – Infant mortality rate, Brazilian regions, 1980 to 2010
It shows an important reduction in inequalities in infant mortality rates in the last thirty years, between the North and Northeast, the poorest Brazilian regions, and the South and Southeast, the better off regions. This tendency is also seen when we look at the municipal level. Infant mortality rates in the first quartile of Brazilian municipalities (the poorest) are today 2,1 times higher than in the fourth quartile (the richest), while in 1980 it was 2,5 times higher. The information made available by the Indigenous Health Subsystem also shows a sharp decline in infant mortality rates and tuberculosis incidence among indigenous populations.
The cycle described above – from local innovation, to federal programs and scaling up, and back down to local implementation – helped ensure dissemination of innovative experiences through the public health system, which contributed to strengthen the primary care and tackle entrenched inequalities. Despite these gains Brazil still has a long way before achieving a truly equitable distribution of health services and indicators between poor and rich municipalities, as well as between the better and worse off social groups. It remains to be seen if the vigor of the governance mechanisms in place will endure or if new mechanisms will have to be considered in order to reduce health inequalities. From what we can see, we would suggest that it is time to reinforce the mechanisms of mutual learning between municipalities as many innovations that may help in this battle are happening at the local level.
|Author :||Vera Schattan P Coelho
Citizenship, health and Development Group
Brazilian Centre of Analysis and Planning – CEBRAP