Brazil: achievements and challenges to the health system Camila Giugliani Denise Nascimento Porto Alegre, Brazil IPHU Short Course – Savar – November 2007

“In Brazil, the search for alternative ways of guaranteeing the health of the population took place alongside the re-introduction of the democratic process and the construction of a Public Health System for all”. National Policy on Health Promotion (Brazil, 2006).

In the second half of 1970s various conferences and meetings were organized to discuss the national health policy. The inhabitants of shantytowns supported by priests and health professional formed groups know as “Popular Health Councils” to demand better conditions and health care. In 1979, following the guidelines of Alma-Ata, the National Programme of Basic Health Services was introduced. It was an attempt to reverse the curative approach previously adopted by the National Institute of Health. In the 80s: the lobby of multinational health care companies In 1988 : New Constitution : the provision of health care became a statutory right to all Brazilian citizens. Law – SUS Law – 1990 – Social participation

Since 1988, when the current Brazilian Constitution passed, the Brazilian Public Health System, namely Unique Health System (SUS) has been in charge of providing universal, integral and equitable access for the Brazilian citizens.

Sistema Único de Saúde (National Health System) Equity Comprehensiveness Universality Descentralization Social participation (social control)

TOTAL 1,68 1,68 1,68TOTAL 1,111iiii 25% of population covered by private insurance schemes which do not not guarantee comprehensive services ANS – National Health Agency regulates the private health sector (19/11/2007)! Example: agreements on standardization of health information system 85% population dependent on Public Health Services

Community Health Workers First project – 1970s 80s Ceara (Northeast) draught – employing the women National program - PACS 1991 Workers lived in the community and were selected on a community- based process

Family Health Program 1994 – National level – Incorporated the PACS and became a full team program Based on a philosophy that “prioritises actions of promotion, protection and recovering of the health of individuals and families, from the newborn to the elderly, healthy or ill, on an integral and continuous basis”. Follows the principles stated on the SUS (NHS). In the beginning (1994), objective was to provide access to the more vulnerable, by prioritising the implementation of family health teams in vulnerable areas throughout the country. Actually, the PSF became a more comprehensive strategy, with the objective of reorganizing health practices, based on a comprehensive understanding of the health-disease process.

Family Health Strategy  “Strategy of reorientation of the assistance model,... by the implementation of multiprofessional teams in health facilities... In charge of the care of a defined number of families, in a limited geographical area. The teams perform actions of health promotion, prevention, recovering, rehabilitation of the more frequent illnesses, and in the maintenance of the health of this community....”  “Reorganize the system (SUS) towards a network with strong organisational basis oriened to primary health care….” Ministry of Health, 2005.

Family Health Strategy teams Minimal team: 1 physician 1 nurse 2 nurse assistants 4-6 community health workers every ~ 2 minimal teams – 1 oral health team (dentist and dental assistant) Catchment area  families (~ 4000 people) Micro-areas of responsibility  ~ 750 people

Coverage of Family Health Teams in BRAZIL, 1998/2005

Evolution of population covered by Family Health Teams BRAZIL – AUGUST/2006

Some supportive evidence Evaluation of the impact of the Family Health Program on infant mortality in Brazil, 1990–2002 From 1990 to 2002 IMR declined from 49.7 to 28.9 per 1000 live births. During the same period average Family Health Program coverage increased from 0% to 36%. A 10% increase in Family Health Program coverage was associated with a 4.5% decrease in IMR, controlling for all other health determinants (p<0.01). Macinko et al, Journal of Epidemiology Community Health

PACT FOR HEALTH Signed by the MoH and the State and Municipal Councils of health secretaries Consolidation of the SUS 3 PACTS PACT FOR LIFE Include strengthening of primary care PACT FOR THE DEFENSE OF THE SUS (NHS) Permanent social mobilisation to achieve right to health and budget increase and regulation PACT FOR THE MANAGEMENT Where are we going?

PACT FOR THE MANAGEMENT DEFINE INEQUIVOCALLY THE RESPONSABILITY OF EACH SPHERE: federal, state, municipal ESTABLISH THE DIRECTIVES FOR THE MANAGEMENT OF THE SUS, with emphasis in descentralisation, regionalisation, financing, pactuated and integrated program, regulation, social participation and control, planning, management of health education.

Problems, questions, challenges Implementation of law Barriers to Access in all levels Reference system (specialties) Budgets and equity in the allocation of resources