Social structure, health of vulnerable populations and the equity-promotion role of health systems

Naomar de Almeida Filho
Instituto de Saúde Coletiva
Universidade Federal da Bahia

Economic & political background 1964-1985 • Military dictatorship • US dependent foreign policy • External debt (economic miracle) • Political repression • National security ideology

Economic & political background 1986-2002 • 1988 New Constitution • Hyperinflation • Economic crisis • External debt explosion • Political freedom • Neoliberal ideology

Economic & political background 2003-present • Reconstruction of the State • Sustained economic growth • Technological dependency • Independent foreign policy • Expanded social policies

Social Context
—Economic development —Poverty reduction —Environmental challenges —Dilemas in the labor context —Violence and intolerance —Reduction of social inequalities

Evolution of Social Class Profile. Brasil: 1992-2009

Fonte: FGV – A Nova Classe média: O lado brilhante dos pobres

Percentage change in Gini coefficient by country. Latin America, 2000-2006

Gini coefficient trend. Brazil, 1995-2006-2011

Source: Brazil - IPEA; other countries - Central Intelligence Agency's World Factbook

Political Context

Reconstruction of the State:

—Debate public vs. private —Rhetorical intersectoriality —Late expansion of public policies —Fight against corruption —Reforms com-promised —Ideological regression

Health inequalities (update)
• The life expectancy of Brazilian citizens reached 73.5 years in 2010, up 8.5 percent from 67 years in 1991, according to the Brazilian Institute of Geography and Statistics (IBGE) • Among women, life expectancy reached 77.4 years in 2007, from 70.9 years in 1991 • life expectancy of Brazilian men increased from 63.2 to 69.8 years in the same period

Health inequalities (update)
• Brazil's infant mortality rate dropped to 21.6 deaths for every 1,000 live births in 2010, a 46 % decrease from the 45.1 deaths per 1,000 births in 1991. • Regional differences in infant mortality rates remain high. The northeastern region, the poorest in Brazil, registered an infant mortality rate of 35.6 deaths per 1,000 living births; in the southern region, the rate was 16.1/1,000 births.

Brief History of Brazil’s Health Reform (1988-2009)
Ú 1986 8th National Health Conference Ú 1988 The New Constitution Ú 1990 The SUS Law (Unified Health System) Ú 1992 Community Health Agents Program Ú 1996-2000 The Family Health Program Ú 2000-2007 Budget increase (CPMF) Ú 2008-present: Overcoming Ú Ú


Thesis 1 about responsibility of the State regarding public policies

The Brazilian State does not comply with the responsibility of providing public services with quality, universal access and equity to its population

Corollaries of Thesis 1
1.Despite advances, the persistence of social inequalities is a serious problem that deserves special attention not only from governments at all levels, but also from the entire society. 2.Expansion of funding, participatory governance, efficient management and affirmative action policies can correct historical inequities.

Thesis 2 about responsibility of the State regarding public policies

In the fields of health and education, in addition to not guaranteeing high-quality public services (Thesis 1), the Brazilian state is a promoter of inequality

Corollaries of Thesis 2 for Health
1.In principle universalist, the public health system is underfinanced, with recognized deficiencies 2.The private sector provides care to those who have income big enough to purchase health plans, benefitting from strong tax exemptions 3.Private health plans are subsidized by the SUS in higher cost and high-complexity procedures (not-profitable)

The vicious impact of social inequality on the Brazilian National Health System
Rich minority has fiscal
Reproduction of Domination


Poor majority finances the State
Reproduction of Submission

Paid private services of better quality with

Public services of

tax exemption

lower quality

Precarious health Less access Social exclusion More access Efficiency Political capital Social Value

Better - quality services out -

of - reach

High - complexity public services of better quality ;

for - free

State of Social Iniquity
Regressive Tax System Social perversion in Education Inequalities in Health

Political model reproduces domination

Health Policy in Brazil open questions, open choices
Ú Health: human right or commodity? Ú individual health or collective health? Ú health care or health situation? Ú health inequalities or health inequities? Ú social policy or public policy? Ú health policy or health politics? Ú Politics of Disease or Politics for Health? Ú

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