The Lancet Series On Brazil

Academic Journal
Main Category: Infectious Diseases / Bacteria / Viruses
Also Included In: Pediatrics / Children's Health;  Public Health
Article Date: 09 May 2011 - 14:00 PDT


The Lancet today launches its Series on Health in Brazil, with six papers outlining the inspiring progress the country has made in introducing healthcare for all, including a reduction in mortality from chronic diseases that most high-income countries would be proud of. The nation has also made huge inroads into improving maternal and child health and reducing the burden of infectious diseases that were at one time rampant. But the news is not all good. Rising obesity and sedentary lifestyles threaten Brazil's progress in tackling chronic diseases, and some infectious diseases, such as dengue and leishmaniasis, remain major problems. The country continues to have a huge burden of injury mortality that is different from other countries due to the large number of murders, especially those involving guns. Across the whole health system, inequities remain, both between and with regions.

Link to Series page

THE LAUNCH EVENT

WHERE: Auditorium, Pan American Health Organization, Brasilia. Setor de Embaixadas Norte, Lote 19, 70800-400 Brasilia, DF, Brazil

WHEN: 2PM-6PM Brasilia local time, Monday 9 May
The launch will include a presentation from Brazil's minister of health, and journalists will be given an extended opportunity to meet the authors of the Series and ask any questions. This is an open event and any journalist wishing to attend is free to do so.

PAPER 1: The Brazilian Health System: history, advances, and challenges

The first paper (Professor Jairnilson Pain, Instituto de Saúde Coletiva, Salvador, Brazil, and colleagues) analyses the history of Brazilian health. By far the most important development in terms of improving access has been the creation of the Unified Health System (Sistema Único de Saúde /SUS), created in 1988. In addition, the country has a thriving private health system. In tandem with SUS, key improvements in infrastructure have been made over the past few decades. For example, in 1970 only a third of homes had indoor water; by 2007, this had risen to 93%.

Other improvements, such as increased connection to sewerage, more homes with electricity and a better social security system have led to marked improvements in a wide range of Brazilian health indicators, including life expectancy (now 72 years), and large reductions in child mortality. Smoking rates in 2007 (17%) were half what they were in 1989 (34%).Yet as everywhere else, Brazil's population is aging, and by 2020 there are expected to be 68 adults over aged over 60 years to every 100 children and adolescents. The country is also getting fatter, with obesity levels rising (almost half of men in state capitals report being overweight). 40% to 50% of Brazilians aged over 40 years have high blood pressure, and 6 million of the country's 191 million inhabitants are known to be diabetic. Yet encouragingly, the gap between the country's richest and poorest is narrowing.

Some of the factors that have been big success stories for Brazil, including improved tobacco control, and the world's largest free HIV/AIDS drug distribution system, are discussed more fully in later papers.

Around a quarter of all Brazilians have some form of private health insurance, with some two thirds of these policies concentrated in the relatively affluent Southeast region. The private sector in Brazil is well supported by government, and frequently provides services contracted by the SUS. Yet the Series authors are concerned that costs associated with subsidising the private sector are threatening to undermine efforts at universal health provision via SUS. As in the US, Brazil has a system that encourages intense use of diagnostic and therapeutic procedures, when in many cases they are not appropriate. The authors believe political will is the only way to bring the private health sector back under manageable constraints.

Despite these limitations, the SUS has managed to vastly improve access to primary and emergency care, reach universal coverage of vaccination and prenatal care, and invest heavily in the expansion of human resources and technology, including major efforts to produce the country's most essential pharmaceutical needs. Health-care service use has increased 174% from 1981 to 2008. However, the proportion of the population that consulted a doctor in 2008 was 68%, lower than the 80% or more seen in many high-income countries. And at 1.9 public hospital beds per 1000 population, Brazil has fewer beds per head than any other OECD country apart from Mexico. So work still needs to be done.

The authors conclude: "Ultimately, to overcome the challenges that Brazil's health system faces, a revised financial structure and a thorough reassessment of public-private relations will be needed. Therefore, the greatest challenge facing the SUS is political."

Paper 2: Maternal and child health in Brazil: progress and challenges

Improvements in child survival interventions (including vaccinations), nutrition, and health system access are all believed to have contributed to huge reductions in under-5 child mortality in Brazil, that has declined by around 5% a year in the 1980s and 1990s and by 4% per year since 2000, to a rate of 20 child deaths per 1000 population, of which two thirds die before age 28 days. In this second paper, the authors (Professor Cesar G Victora, Universidade Federal de Pelotas, Brazil, and colleagues) say improved education of women and population urbanisation have also contributed to this great progress. Stunting prevalence nationwide has decreased from 37% in 1975 to 7% in 2007, with differences between regions also decreasing. Median breastfeeding time has increased from around 3 months in the 1970s to 14 months in 2007.

Data is not so clear on maternal mortality, with some studies suggesting no change in the past 10 years while others show a 4% annual decline, with a current maternal mortality ratio estimated at between 50 and 60 per 100,000 population: some 5 times or more that of high-income countries. A major challenge is bringing the caesarean section rate down: Brazil has the highest rate of caesarean section in the world, and almost half of all deliveries (47%) are by this method (80% in private sector vs 35% in SUS). This is three times the rate recommended by WHO (15%) and puts mothers and babies and increased risk of complications and death. Half of the caesarean sections that take place are planned in advance. And at 10 stillbirths per 1000 total births, Brazil's stillbirth rate is more than double that of most high-income countries.

Since induced abortions are illegal in Brazil (except in case of rape or medical danger to the mother), many abortions that do take place are illegal. An estimated 1 million induced abortions take place each year, and unsafe/illegal abortion complications cause 215000 admissions to the SUS system, which only carried out 3230 legal abortions.

While appreciating that there is more work to be done to bring the rates of all the above in line with high-income nations, the authors conclude: "The rate of reductions in stunting, infant mortality, and fertility are among the fastest ever recorded worldwide...an overarching challenge is how to reach those that are hardest to reach, such as rural populations in the Amazon Rainforest and northeast regions, including those living in the 10% of Brazilian municipalities that do not have access to a doctor."

Paper 3: Successes and failures in the control of infectious diseases in Brazil

The various investments in the healthcare system since SUS was formed, plus better access to clean water and sewerage systems, have fuelled major progress in reducing the burden of infectious diseases. In the third paper, Professor Mauricio L Barreto, Instituto de Saúde Coletiva and Federal University of Bahia, Salvador-Bahia, Brazil, and colleagues look at why some programmes have worked and others have not.

Control of diseases such as cholera, diarrhoea, Chagas disease, and those preventable by vaccination such as tetanus and polio have all been successful, having each provided universal treatment free at the point of vaccination. These policies need to be reinforced due to challenges such as increasing prevalence and transmission of drug resistance.

A partly successful programme is the HIV/AIDS plan, which is the largest distributor of free antiretrovirals in the world. Many feared drug resistance would emerge rapidly but it has only done so at the rate common in high-income countries. Some 600,000 people have HIV, with a population prevalence of less than 0.6%: estimates that have been stable since the beginning of the Millennium. Men who have sex with men, sex workers and injecting drug users (IDUs) are at the highest risk. Despite this, infection prevalence in IDUs has come down to 8% from its level of 25% in the mid-1990s. Programmes aiming to prevent mother-to-child transmission, and public health campaigns highlighting safe sex messages and the need to seek prompt treatment if infection is suspected have contributed to Brazil's overall good record in HIV/AIDS. Tuberculosis control has also improved, partly due to increased HIV control and also specific roll out of antibiotic programmes and those offering directly supervised treatment.

Failures are few but need to be noted. Dengue fever is a major public health problem, with some 3.5 million cases reported in the past decade, with 12000 leading to the more serious dengue haemorrhagic fever, and some 900 deaths. Rates of the most serious disease are six times what they were in the 1990s. No safe vaccine is available and none is likely to emerge for years. Dengue has a changing epidemiological profile and treatment is unavailable. Even with half a billion US dollars invested in vector control to combat the A aegypti mosquitoes that carry the disease, few inroads have been made. Visceral leishmaniasis control is also poor, with current efforts focusing on vector control of the sandfly carriers and removing domestic animals that can act as reservoirs. Treatment is highly toxic and while accessible and suitable in urban areas with medical support, this toxicity makes treatment in remote rural areas inappropriate.

The authors conclude: "A pressing need exists to develop new treatments and vaccines for those diseases which have proved difficult to control. In Brazil, biomedical and epidemiological research is thriving, as is public health research into infectious diseases, with much collaboration with developing and developed countries...the fast growth in medical research must be sustained-efforts must go towards identification of new treatments (eg, for leishmaniasis) new vaccines (eg, for dengue) and more effective ways to deliver specific care."

Paper 4: Chronic diseases in Brazil: burden and current challenges

The fourth paper (by Professor Maria Inês Schmidt, Federal University of Rio Grande do Sul, Brazil, and colleagues) discusses the progress made by Brazil in combating chronic/non-communicable diseases (NCDs). While, like all other countries, the proportion of NCD deaths out of total deaths in Brazil continues to rise (72% in 2007), the country has implemented a number of policies that have seen age-standardised mortality rates fall by 1.8% per year since 1996, which is within the range of 1-3% observed from 1970 to 2000 in committed high-income countries such as Australia, Canada, Japan, the UK and the USA. Better access to primary care and much-improved tobacco control are credited as being the major causes of this improvement, composed principally of declining rates of cardiovascular and chronic respiratory disease. Yet this progress is threatened by increasing prevalence of risk factors such as obesity, hypertension and diabetes.

Neuropsychiatric disorders are the single largest contributor to the chronic disease burden in Brazil, with an estimated 10 to 20% of people having had depression at some stage. Research in ten developed and 8 developing countries revealed metropolitan Sao Paulo to have the highest levels of depression of all the locations studied. Due to the ageing population, dementia is rapidly becoming a major health problem, with estimates of prevalence similar to those in developing countries (5 to 9%) among those 65 and older.

Around a quarter of Brazilian men and one in six Brazilian women aged 20 years or over suffer high blood pressure, rising to half of men and over half of women aged 60 years or over. Despite the decline of 31% in cardiovascular disease mortality from 1996 to 2007, Brazil's cardiovascular mortality remains high, with Suriname and Guyana the only countries in South America with higher rates. Increasing obesity levels and better diagnosis are thought to be behind much of the increasing diabetes prevalence in adults, from 3% of Brazilians in 1996 to 5% in 2007.

In men, mortality rates from lung, prostate and colorectal cancer are increasing, while that of gastric cancer is decreasing. In women, rates of breast, lung, and colorectal cancers have risen, while those of cervical and gastric cancer have declined. Smoking rate variations could explain why rates of lung cancer in men younger than 60 years are now declining, yet those of younger women are increasing. Cervical cancer incidence in Brazil, although falling, is still among the highest in the world, probably due to the fact that many high risk women are still being inadequately screened. 5-year survival rates for cancers such as breast and prostate are low compared with high-income countries, suggesting difficulties and inequalities in access to services.

The authors say that to maintain progress, more action is necessary. Strategies involving augmented intersectoral discussion and planning are needed to implement and scale-up cost-effective interventions-for example, those reducing the salt content of foods and restricting advertisement of unhealthy foods to children-that can help to produce an environment conducive to healthy lifestyle choices.

Other major challenges must also be faced: resolving long hospital waiting lists for in-patient hospital care and diagnostic services, transferring most care for chronic conditions to primary care settings using a chronic care model, and amplifying access to cost-effective medications.

The authors conclude: "NCDs are quickly becoming the main public health priority in Brazil, and policies for their prevention and control have been implemented. Although formal assessment is lacking, the SUS has made major strides, among them the implementation of very cost-effective interventions such as tobacco control and the widespread delivery of drugs to those at high risk of cardiovascular diseases. However, much more can be done...A concomitant shift of resources, in relative terms, from hospital and high technology end-stage care to health promotion and prevention is needed to augment budgetary support and central coordination for chronic disease prevention and care."

Paper 5: Violence and injuries in Brazil: their effects, progress made, and challenges ahead

In the fifth paper, Dr Michael E Reichenheim, (Institute of Social Medicine, Rio de Janeiro State University, Brazil) and colleagues look at Brazil's heavy toll of traffic and violent injuries. One in 8 deaths in Brazil is caused by external causes, and, although there are signs of decline, murders and traffic-related related injuries together make up two thirds of all deaths from external causes in Brazil. This injury mortality pattern is different from most WHO member states, where half of all deaths from external causes are due to suicide. But other South American countries have patterns not that different from Brazil.

In 2007, there were around 48 000 murders and 38 000 traffic-related deaths in the country. Domestic violence is another major concern that, although it does not cause many deaths, is responsible for many injuries.

Young, black, and poor men are the main victims and perpetrators of community violence, whereas poor black women are the main victims of domestic violence. There is also a geographical distribution of domestic violence, with the poorer, less developed north having higher rates than the more economically developed southern regions.

Murder mortality rose from 27 per 100000 population in 1991 to 32 in 2003, but by 2007 had decreased back to the level seen in 1991. This is much higher than in China (1.2 per 100000) and Argentina (5), but lower than in South Africa (37) and Colombia (39). Men are 10 times more likely to be murdered than women; yet one woman is murdered every 2 hours, making Brazil the 12th worst country in the world in this regard. Murders of children aged 0 to 14 years accounted for most of the rising murder mortality in the 1980s, while in the 1990s adolescents aged 15-29 saw a sharp increase. In the new Millennium, murder rates have fallen in all age groups apart from those aged over 50 years. Murder with guns is also at a very high rate in Brazil (20 per 100000 population) compared with Canada, France, the USA and the UK (all under 3 per 100000). Alcohol and drug misuse, cultural clashes, economic stagnation in the 1980s and availability of firearms are among the reasons for Brazil's high murder rate. Violence generally is thought to cost the Brazilian economy more than US$30 billion (R$ 87 billion) per year. Quality of life improvements (including access to healthcare) could be behind recent falls in violence-related mortality. Examples of projects with positive results are the First Job programme and the Family Grant Programme.

The authors say: "Despite some successful experiences in recent years, public safety largely operates by confrontation and repression rather than sharing intelligence and prevention...Widespread corruption and impunity provide a culture of permissiveness that surrounds violence and its consequences."

At 28 per 100 000 population, Brazil's traffic-death rate is higher than the world average (19) and all low-to-middle income countries combined (20), as well as being higher than in high-income countries (13). The Brazilian transport system gives priority to roads and private-car use without offering an adequate infrastructure, and is poorly equipped to deal with infringement of traffic rules. But progress is taking place, such as the 2008 law that reduced the legal limit for alcohol in drivers to zero. But some cities still lack breathalysers needed to enforce such laws. The authors say: "The high-traffic related morbidity and mortality in Brazil have been linked to the chosen model for the transport system that has given priority to roads and private car use without offering adequate infrastructure."

Thanks to growing investment from national research agencies, the number of research groups dedicated to studying violence and injuries has increased from 7 in 2000 to 80 in 2009. The authors conclude: "In response to the major problems of violence and injuries, Brazil has greatly advanced in terms of legislation and action plans. The main challenge is to assess these advances to identify, extend, integrate, and continue the successful ones."

Paper 6: The way forward

In the final paper, Series guru Professor Cesar G Victora (Universidade Federal de Pelotas, Brazil) and colleagues summarise the progress made and the challenges ahead. Improvements in the social determinants of health-such as wealth, access to healthcare, and reduced inequality -have been the main drivers of improvements in health status and life expectancy. The approach taken by Brazil-that of creating a national health service-is unique in Latin America.

The authors say: "Many challenges remain, however. Socioeconomic and regional disparities are still unacceptably large, reflecting the fact that much progress is still needed to improve basic living conditions for a large proportion of the population. New health problems arise as a result of urbanisation and social and environmental change, and some old health issues remain unabated. Administration of a complex, decentralised public-health system, in which a large share of services is contracted out to the private sector, together with many private insurance providers, inevitably causes conflict and contradiction...as does the presence of a strong private health insurance sector."

They issue a call to action* that stresses the coordinated action by the government, private sector, academics, health workers, and civil society as a whole that will be required for Brazil to continue improving on the progress already made, and address the concerns covered by the first five papers.

The authors conclude: "The challenge is ultimately political, requiring continuous engagement by Brazilian society as a whole to secure the right to health for all Brazilian people."

COMMENTS WITH THE SERIES

In a Comment introducing the Series, Lancet Senior Executive Editor Dr Sabine Kleinert and Editor-in-Chief Dr Richard Horton applaud the successes in Brazilian health , but also highlight the areas of concern that continue to impede progress.

They say: "There is still much to do. The complex mix of public and private health provision needs urgent attention. Brazil has the highest rate of caesarean sections in the world, many high-technology interventions are done for the wrong reasons, obesity is increasing at alarming rates, and alcohol consumption and violence are unacceptably high and have far-reaching consequences. What is needed now is continued political will to tackle difficult questions and make the right decisions based on the country's most important priorities."

They conclude: "A strong emphasis on health as a political right, together with a high level of engagement by civil society in that quest, might also mean that other countries can look to Brazil for inspiration (and evidence) to solve their own health predicaments...We hope this Series does show why Brazil should not only be taken more seriously by the international health and science communities, but also be admired for implementing reforms that have put health equity at the centre of national politics-an achievement many readers might wish for their own countries."

Source
The Lancet

• Additional
• References
• Citations