Brazil: achievements and challenges to the health system

Camila GiuglianiDenise 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 formedgroups 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 becamea statutory right to all Brazilian citizens.

• Law 8.080 –1990 - SUS

• Law 8.142 – 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)

TOTALTOTAL

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 800-1000 families (~ 4000 people)

Micro-areas of responsibility ~ 750 people

1998 1999 2000 2001

2002 2003 2004 2005

Coverage of Family Health Teams in BRAZIL, 1998/2005

Evolution of population covered by Family Health TeamsBRAZIL - 1994 – 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, 2006. Journal of Epidemiology Community Health

2006 - PACT FOR HEALTH Signed by the MoH and the State and Municipal Councils of health secretariesConsolidation 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