Data updated for 2001

GENERAL SITUATION AND TRENDS

Socioeconomic, Political, and Demographic Overview

Brazil has an area of 8.5 million km2 and shares borders with all the countries of South America except Ecuador and Chile. The Federative Republic of Brazil has 26 states, 5,508 municipios is and the Federal District (the seat of government). The country is divided into five major regions. The North, the largest region, occupies 45% of the national territory, but has only 7% of the population; the Southeast occupies 11% of the territory and has 43% of the population. The South is the smallest region, with 7% of the territory and 15% of the population. Each of the other two regions occupies approximately 18% of the territory, but the Northeast has 29% of the population, and the Central-West has only 6%.

The nine states in the Northeast have the lowest socioeconomic indicators in the country. Between 1960 and 1990, the share of national income of the poorest half of the population fell from 18% to 12%, and that of the richest 20 % increased from 54% to 65%. The proportion of women in the economically active population (EAP) has increased from 31 % to 35% in the past decade. Nevertheless, the median wage of women is 63% that of men. Ethnic disparities are evident in the lower wages received by blacks and pardos (other dark-skinned groups), who make up 44% of the country’s total population and in 1990 earned, on average, 68% of the amount earned by whites.

Educational levels have improved significantly in recent decades, with a reduction in illiteracy, an increase in school enrollment, and a rise in the average number of years of schooling of the population.

According to the Brazilian Geography and Statistics Institute, the unemployment rate remained at about 5% for the period 1990–1995. However, the quality of jobs has deteriorated, with a decline in industrial jobs and absorption of the unemployed into the service sector. In addition, the proportion of workers with a formal employment contract has fallen from 60% to 50%, and the proportion of "self-employed" workers who are excluded from the benefits and protections of labor legislation has increased.

During the 1980s and the early 1990s the Brazilian economy was characterized by extreme instability and inconsistent growth, with inflation rising to extremely high rates.

In 1994, the "Real Plan" (named for the country’s new currency unit, the real) was launched, ushering in a period of growth in per capita income and the beginnings of a redistribution of the wealth. The poorest half of the population saw its share of national revenues increase by 1.2%, and that of the richest 20 % decreased by 2.3%. The gross domestic product (GDP) grew 7.4 % between 1994 and 1996 (at 1996 prices), rising from US$ 662,000 million to US$ 711,000 million, with an increase in per capita GDP from US$ 4,305 to US$ 4,503. In 1996 the annual inflation rate was 9.8%, compared with rates of as much as 45% per month.

According to the national census of 1991, Brazil has a total of 146.8 million inhabitants. There are 17.2 inhabitants per km2, and 75.6% of the total population is urban. Only the state of Maranhão continues to have a predominantly rural population. Mean population growth declined from 2.4% per year during the 1970s to slightly less than 1.9% in the 1980s, and it is expected that it will fall to 1.36% by the year 2000.

The fertility rate has decreased rapidly in recent decades. The rate dropped from 2.57 children per woman in 1991 to 2.52 in 1995. The crude birth rate fell from 31.2 live births per 1,000 inhabitants in 1980 to 23.6 in 1990, and it is estimated that the rate will be 18.2 per 1,000 in the year 2000. Total mortality followed the same trend, with a rate of 7.2 deaths per 1,000 inhabitants in 1990. It is estimated that the death rate will be 6.7 per 1,000 in the year 2000. Life expectancy at birth increased 3.9 years (6.3%) between 1980 and 1990. In 1999 it is expected to be 64.8 years for males and 71.2 for females.

Between 1970 and 1991 the proportion of children under 15 years of age decreased from 42% to 35% of the total population, while the group aged 15–64 years increased from 54% to 60% and the group aged 65 and over grew from 3 % to 5%.

Around 1970 the economically dependent population (persons under 15 or over 64 years of age) made up almost 50% of the total population, and of every 20 dependents, fewer than 2 were elderly. By the turn of the century, it is estimated that dependents will make up only 33% of the total population and that of every 20 dependents, 3 will be elderly.

Mortality Profile

Given the difference between the number of deaths estimated on the basis of population projections of the Brazilian Geography and Statistics Institute and the number of deaths registered by the mortality information system of the Ministry of Health, it is estimated that the mean number of unreported deaths for the country as a whole in the period 1990–1994 was approximately 20% of the total number. The figure exceeded 50% in some parts of the North and the Northeast. In most of the South and the Southeast, underreporting was less than 10%, and it was close to 0% in urban areas. Among the reported deaths, ill-defined causes accounted for 17.8% in the period 1990–1994. The North and the Northeast have the highest proportion of deaths due to ill-defined causes (28.6% and 42.1%, respectively, in 1990), which calls for caution in analyzing the distribution of deaths due to defined causes in these regions.

Demographic data indicate that mortality levels in the Brazilian population have declined significantly in recent decades. This reduction has resulted mainly from the decline in mortality in the population under 5 years of age; deaths in that age group as a proportion of total mortality between 1980 and 1994 decreased from 24.0% to 9.8% for the subgroup of children aged under 1 year and from 4.6% to 1.7% in the group aged 1–4 years. Consequently, proportional mortality in the group aged 50 and over rose from 48.4% to 62.4% during the same period.

Analysis by cause of death according to the categories used by PAHO shows that in the period 1990–1994, excluding ill-defined causes, diseases of the circulatory system constitute the leading cause of death, accounting for 33.9 % of the total. The second leading cause of death is composed of external causes, which includes injuries and poisoning. The third leading cause of death is malignant neoplasms, which between 1990 and 1994 accounted for 13.0% of all deaths from defined causes. The most common malignant neoplasms among males are stomach cancer and lung cancer. Among females, breast cancer is most frequent, followed by cervical cancer.

The maternal mortality rate dropped during the 1982–1991 period from 156.0 to 114.2 deaths per 100,000 live births. Abortions cause 12% of all maternal deaths; the remaining 25 % are due to other causes.

Infant mortality rates tend to decline as the educational level of the mother rises, with rates of 93, 42, 38, 28, and 9 deaths per 1,000 live births in groups of mothers with less than 1 year, 4 years, 5–8 years, 9–11 years, and 12 or more years of schooling, respectively. In urban areas, postneonatal mortality is declining significantly, while in rural areas it continues to account for two-thirds of infant mortality.

SPECIFIC HEALTH PROBLEMS

Analysis by Population Group

Of all deaths of children under age 1, half occur in the Northeast, where 29% of the country’s population resides. In that same region, 39% of the reported deaths of children under the age of 1 year in 1993 were attributed to ill-defined causes, whereas in the Southeast the proportion was only 6%. With regard to morbidity, 22% of hospital discharges in the public health care system in 1995 were of children under the age of 1 year; and the principal causes of hospitalization were pneumonia (30%), diarrheal diseases (25%), and conditions originating in the perinatal period (13%). Of the hospital deaths occurring in this age group, 32% were due to conditions originating in the perinatal period, 11% were due to pneumonia, and 8% were due to diarrheal diseases. Prematurity and low birthweight accounted for 69% of all perinatal deaths.

Only 0.7% of the deaths reported in the country in 1994 occurred in the 5–9-year age group. External causes were responsible for 45% of the deaths in this group, followed by malignant neoplasms (12%) and diseases of the respiratory system (10%). External causes are responsible for the largest proportion of deaths in the group aged 10–19 years. Homicide and injury from traffic accidents accounted for a total of 63% of the deaths due to external causes in the group aged 15–19; the vast majority occurred among males.

Surveys conducted in 1987, 1989, and 1993 in primary and secondary schools in 10 capital cities showed that the six most frequently used drugs are alcohol, tobacco, solvents, tranquilizers, amphetamines, and marijuana.

Unintentional injuries and violence constitute the leading cause of death in the group aged 15–60 years. This cause accounted for 30% of all deaths from defined causes in this age group in 1994. The next most frequent causes of death are diseases of the circulatory system (24%) and malignant neoplasms (13%).

Data from a national study conducted in 1996 show that 96% of births in urban areas took place in health care institutions (78% in rural areas) and 86% of the mothers had received prenatal care. The percentage of cesarean births remains quite high, having increased from 32% in 1986 to 36% in 1996 for the country as a whole. By region, the highest rate of cesarean deliveries (52%) occurs in the state of São Paulo. Of the women of childbearing age living with a male partner, 79% of those in urban areas use some method of contraception (69% in rural areas).

Diseases of the circulatory system caused 47% of reported deaths among Brazilians aged 60 and over in 1994. The second leading cause of death was malignant neoplasms (16%), followed by diseases of the respiratory system (14%). Of the deaths from cardiovascular disease, cerebrovascular disease accounted for 34% and ischemic heart disease accounted for 28%.

Information on accidents in the workplace comes from claims submitted to the social insurance system. The system does not provide the type of data necessary for constructing an epidemiologic profile that shows the distribution of these accidents. In 1994 a total of 338,304 work-related accidents were reported in the country.

There are no data at the national level to indicate the magnitude of the problem of disability. Between 1993 and 1996 studies of the prevalence of disability were carried out in various cities and states utilizing a research protocol developed by PAHO. The findings indicated rates ranging from 2.8% in Brasília to 9.6% in Feira de Santana, Bahía.

The indigenous population has been reduced to about 300,000 persons (0.2% of the Brazilian population), grouped in 206 ethnic groups, which occupy 554 "indigenous territories" distributed across 24 states. Approximately 50% of the indigenous population lives in the North region.

In the absence of a national policy that would ensure comprehensive care for the indigenous population, the information available is disparate and does not lend itself to comparison or provide a complete picture of the health of these population groups. Among the most common problems detected in 1996 were acute respiratory infections and diarrheal diseases. Malnutrition, parasitic diseases, anemia, tuberculosis, and skin disorders, especially scabies, are also common.

In 1993, the black or pardo population was estimated at 66.7 million, or 45% of the total population. Among the genetic diseases that affect the black population, the most prominent is sickle cell anemia. Other common diseases, such as high blood pressure, diabetes mellitus, and glucose-6-phosphate dehydrogenase deficiency, are aggravated by the poor socioeconomic conditions in which most of the black population lives.

Analysis by Type of Disease

Communicable Diseases

More than 99% of the 444,049 cases of malaria reported in 1996 occurred in the Amazon region; 128,418 (29%) were caused by P. falciparum. Between 1993 and 1996 a total of 102 cases of yellow fever were reported in the states of Amazonas, Goiás, Maranhão, Minas Gerais, Mato Grosso do Sul, Pará, and Roraima.

The incidence of dengue is increasing in the country. More than 175,000 cases were reported in 1996. Despite the high number of cases reported annually, which exceeds the number reported in any other country on the continent, there are few cases of hemorrhagic dengue. In the past four years 127 cases have been reported, with 14 deaths, and in 1996 there were only 6 cases and 1 death.

Regarding Chagas disease, in 1996 almost 2 million blood samples were processed in blood banks, yielding a seropositivity rate of 0.8%. The continuity of the activities and the attainment of the eradication goals makes it possible to anticipate that transmission of the disease by T. infestans will have been stopped by the year 2000. Schistosomiasis is endemic in almost all the states of the Northeast and in two states in the Southeast (Minas Gerais and Espírito Santo). Generally speaking, however, the trend is toward reduction of the prevalence and clinical severity of the disease.

Visceral leishmaniasis (kala-azar) is concentrated in the Northeast region, which accounts for more than 90% of the 2,000 cases reported annually.

The principal site of lymphatic filariasis is in the metropolitan area of Recife, Pernambuco, where more than 1,500 cases were reported in 1995.

Onchocerciasis affects mainly the indigenous Yanomami population living along the border with Venezuela. Cases have been reported in nearby tribes and also in white individuals who were visiting the region, which poses a potential risk for spread of the endemic to other parts of the country.

The last cases of poliomyelitis in Brazil were reported in 1989. The incidence of measles has declined dramatically throughout the country since 1992, when measles vaccine was administered to more than 90% of the under-16 population. No measles deaths were reported in the country in 1995 and 1996. Two outbreaks in 1996, in the states of Santa Catarina and São Paulo, represented a setback in the plan to eliminate the illness. In June 1997, the São Paulo outbreak continued to worsen, with 383 laboratory-confirmed cases since the beginning of the year, more than half of which were in persons aged 20–29 years. Neonatal tetanus continues to occur sporadically in Brazil. More than half the cases are concentrated in small municipalities in the North and the Northeast; in 1995, 127 cases were reported. The incidence of diphtheria has declined steadily. The highest rates occur in the South and in the 1–4-year age group. Whooping cough was the reported cause of 124 deaths during the 1992–1994 period, and almost all (118) were infants.

From the beginning of the cholera epidemic in 1991 up to 1994, a total of 150,000 cases were reported nationwide, with 1,700 deaths. In 1996, there were only about 900 confirmed cases.

In 1995, a total of 91,013 cases of all clinical forms of tuberculosis were reported, making the incidence 29 per 100,000 inhabitants. Tuberculosis occurs as an opportunistic infection in 15% of AIDS cases.

As of late 1996 there were 105,744 known leprosy cases, which makes the prevalence 6.8 per 10,000. In the same year, 39,792 new cases were diagnosed.

The incidence of human and canine rabies has been reduced enormously since the national control program was instituted in the 1970s. In 1995, 31 human cases and 712 canine cases were reported. In 1996 there were 25 human cases. Human leptospirosis is endemic in the principal urban centers and seasonal outbreaks occur during periods of flooding. Human hydatidosis continues to be an important problem, mainly in the southernmost region of the country.

As of February 1997, 103,262 AIDS cases had been reported, and 74% of them were in the Southeast region. For the entire period, the mean cumulative incidence for the country as a whole was 74 cases per 100,000 inhabitants. By region, incidence ranges from 125 per 100,000 in the Southeast to only 21 in the Northeast. Preliminary estimates indicate that between 338,000 and 448,000 adults aged 15–49 years may be infected with HIV. There has been a steady decline in the excess incidence of the disease among males. The male-to-female ratio decreased from 28:1 in 1985 to 3:1 in 1993, which may indicate an increase in heterosexual transmission by bisexual males and heterosexual drug users. Among women, 27% of the cases reported up to 1995 occurred among drug users and 12% occurred among partners of bisexual men.

Between 1987 and 1996, a total of 504,219 cases of sexually transmitted disease (STD) were reported in Brazil. In descending order of magnitude they were distributed among the following categories: nongonococcal urethritis (28.5%), venereal syphilis (28.3%), gonorrhea (27.7%), condyloma acuminata (11.3%), chancroid (1.8%), lymphogranuloma venereum (1.0%), congenital syphilis (0.9%), granuloma inguinale (0.3%), and gonococcal conjunctivitis (0.2%). Since 1985 Neisseria meningitidis serogroup B has been the most common causal agent, although since 1987 a progressive increase in the frequency of serogroup C has been observed, especially in the South and the Southeast, where in some states these two serogroups occur with about the same frequency. Other important causes of meningitis are pneumococcal infections (responsible for 6% of all meningitis cases), Haemophilus influenzae type B (5%), Mycobacterium tuberculosis (2%), and viral infections (30%). Of the 1,500 cases of H. influenzae meningitis reported annually, more than 90% occur in children under 5 years old.

Viral hepatitis is very common in Brazil and in 1995 and was responsible for 16,851 hospitalizations and close to 800 deaths. Various studies have demonstrated the enormous impact that hepatitis B and hepatitis delta have on the population of the western Amazon region.

During the 1970s, the Rocio virus, a new arbovirus, caused about a thousand cases of encephalitis in the state of São Paulo. In the 1980s, Brazilian purpuric fever caused by Haemophilus aegypti led to outbreaks of septicemia among children in the states of São Paulo and Paraná. In 1993 a family outbreak of Hanta virus infection was detected serologically.

Noncommunicable Diseases and Other Health-Related Problems

During the past two decades, a steady decline in malnutrition has been registered among children under 5 years old (malnutrition is defined as weight-for-age two standard deviations or more below the expected mean value), with a reduction of 60% between 1975 and 1989 and 20% between 1989 and 1996. The mean height of Brazilian children born during the 5-year period 1980–1984 is significantly greater (3.3–4.6 cm) than during the 1960s, with a larger increase among girls. The reduction in malnutrition during the period 1975–1989 has changed the ratio between malnutrition and obesity, which was more than four malnourished children for each obese child and is now two malnourished children for each obese child. During the same period, the proportion of obese adults almost doubled, rising from 5.7% to 9.6%. In 1989 the proportion of obese women exceeded the proportion of malnourished women in all income groups; among men, this occurred only in the middle- and high-income groups.

The most important micronutrient deficiencies are vitamin A, iodine, and iron deficiencies. Vitamin A deficiency is common in the Northeast, where more than 40% of children have serum retinol concentrations under 20 (µg/dl. This deficiency is also considered to be endemic in the Jequitinhonha Valley in Minas Gerais and in the Ribeira Valley in São Paulo.

Among pregnant women receiving prenatal care, the prevalence of iron deficiency anemia has been found to range from 25% to 44%, with an extremely high value of 65% in the state of Pará. Among children under 5, published studies show a prevalence that ranges from 59% in São Paulo to 70% in Pará.

Between 1989 and 1996 the mean duration of breast-feeding increased from 5 to 7.5 months, and the frequency of exclusive breast-feeding increased 11-fold in infants up to 3 months of age and 25-fold in infants 4–6 months of age.

A multicenter study on diabetes mellitus conducted in nine Brazilian capital cities between 1986 and 1988 showed a mean prevalence of 7.6% in the urban population aged 30–69 years, with higher values in São Paulo (9.7%) and Porto Alegre (8.9%).

Between 1930 and 1980 mortality due to cardiovascular causes rose from 11.8% to 30.8% in the capital cities. More recent analyses of all deaths reported in Brazil in the period 1990–1994 indicate that 33.9% were due to cardiovascular diseases, which are the leading cause of death in all regions of the country.

The overall incidence of all types of cancer is 176 cases per 100,000 females and 162 per 100,000 males, among whom lung cancer is the most frequent form, with an incidence of 20.1 per 100,000, which far exceeds the estimated rate in females (5.9 per 100,000), among whom lung cancer is the sixth most frequent malignant neoplasm.

It is estimated that in 1997 deaths from malignant neoplasms in all sites totaled 97,700. The largest number were due to lung cancer (11,950 deaths) and stomach cancer (11,150), followed by deaths due to breast cancer (6,780), cervical cancer (5,760), colon and rectal cancer (5,440), and prostate cancer (4,690). Unlike morbidity, mortality from cancer is higher among males (72.5 deaths per 100,000, compared with 60.7 per 100,000 in females).

Accidents and violence (external causes) account for close to 15% of all deaths from defined causes, with a rate of 70 deaths per 100,000 inhabitants. In the group aged 5–39 years they are the leading cause, and in the group aged 15–19 they are responsible for almost 80% of all deaths. Homicide ranks first among all external causes of death, accounting for close to 30% of deaths attributable to this group. Between 1977 and 1994 the specific death rate due to homicide increased 160% nationwide. Among all the external causes, one of the most important is traffic accidents, which increased rapidly until the mid-1980s and began to decrease slightly in 1990. According to national statistics on traffic accidents, in 1995 there were 255,000 accidents with injuries; a total of 321,000 people were injured and there were 25,513 deaths. A large proportion of the deaths were pedestrians who were struck by automobiles.

The most recent data on the distribution of mental disorders in the Brazilian population come from a study conducted in 1990–1991 in three metropolitan regions. Neurotic disorders, especially anxiety and phobia, were found to be most frequent, with prevalence rates ranging from 7.6% in São Paulo to 17.6% in Brasilia.

Drug use is a growing problem, especially among young people; illegal drugs are the most frequently used type of drug in this population group. Alcoholism and drug use together account for close to 20% of all hospitalizations for mental disorders in Brazil. The proportion is as high as 28% in the South, according to data for 1995. It is estimated that some 30 million Brazilians smoke and that 80,000 deaths each year are due to causes related to tobacco use. The prevalence of dental caries in the Brazilian has declined markedly. The index for decayed, missing, and filled teeth (DMFT) index among 12-year-olds fell from 6.67 in 1986 to 3.06 in 1996. In 1996, 42% of the population had access to fluoridated water through public water supply systems.

RESPONSE OF THE HEALTH SYSTEM

National Health Plans and Policies

The Federal Constitution of 1988 deals specifically with as a right to all and a responsibility of the State, which should fulfill through economic and social policies aimed at reducing the risks of illness and other health impairments, as well as through universal and equitable access to activities and services for the promotion, protection, and recovery of health within a Unified Health System (UHS) that is public, federal, decentralized, and participatory in nature and provides comprehensive care.

Organization of the Health Sector

Institutional Organization

The public health services, complemented by private services that work under contract with the Government in the framework of the UHS, cover 75% of the population. Most inpatient hospital services are provided under a system of public reimbursement for services provided by private entities (80 % of hospitals that provide services within the UHS are private). In contrast, 75% of outpatient care within the UHS is provided by public establishments. In 1995, 20% of the Brazilian population, some 34 million persons, were covered under private health insurance plans, at a total cost of US$ 6,400 million.

Basic operational guidelines (BOG) for the UHS were approved under the organic health legislation. At present BOG 01/96 is being implemented. This BOG defined the managerial responsibility of each level of government within the UHS. In addition to strengthening managerial functions and the capacity of the municipal governments and the Federal District to deliver services to the population, BOG 01/96 promotes the process of decentralization through mechanisms for the automatic transfer of federal resources to the states and municipalities. It also strengthens processes of shared management between the Federal Government and the state and municipal governments through tripartite and bipartite joint.

The tripartite joint management commission is composed of equal numbers of representatives of the Ministry of Health, the National Council of State Secretaries of Health, and the National Council of Municipal Secretaries of Health.

Authorization to practice the various health professions is granted by the respective professional boards to candidates who hold a degree from a university or technical school. These boards are autonomous public entities created by law and entrusted with regulating and monitoring the practice of professionals in their respective areas of specialization throughout the country. The health regulations on drugs, equipment, and cosmetic and hygiene products are enforced by the Health Surveillance Secretariat within the Ministry of Health.

The National Health Quality Control Institute serves as a national reference and quality control laboratory for an integrated network of state and university institutions.

Control of agricultural toxins is regulated by intersectoral legislation and involves the Ministries of Health, Agriculture, and Environment. The health sector is responsible for toxicology assessments.

Food control is a component of the national health surveillance system. Specific legislation establishes basic regulations for the registration, control, and labeling of food products as well as product identification and quality standards, monitoring, and related administrative procedures.

Health Services and Resources

Since 1994 the Ministry of Health has been carrying out a program of family health as a strategy for reorganizing primary health care. The program seeks to incorporate health promotion into traditional medical care through reorganized health units that focus on families and their social relations within a given area. Several programs at the national level are aimed at ensuring comprehensive care for the health of women, children, and adolescents. Since 1995 the project on reduction of infant mortality has been coordinating specific maternal and child health and basic sanitation activities in the 913 municipalities with the highest levels of poverty.

Communicable disease control activities are carried out through specific programs and initiatives overseen by the National Health Foundation, with variable degrees of interinstitutional articulation and coordination. Mean annual coverage levels among children less than 1 year old for the routinely administered vaccines are approximately 95% for BCG, 75% for DTP, and 80% for the measles vaccine.

Under a national program for the control of cervical cancer launched by the National Cancer Institute in 1996, pilot projects are to be implemented in five state capitals.

Constitutional provisions specify that municipal governments are responsible for the management of basic sanitation services. Data from 1995 indicate that 76% of households nationwide are connected to a water supply system. In urban areas the proportion is 90%, and in rural areas it is about 17%. Of the households included in the national survey carried out in 1995, 60% overall were connected to a sewer system or had a septic tank, but the coverage was much higher in urban areas (71%) than in rural areas (14%). Of the total amount of wastewater collected, only 20% is treated at a water purification plant. In 1995, 72% of Brazilian municipios had regular refuse collection by public or private sanitation services. In the other municipalities (28%) refuse is burned, buried, or simply dumped in vacant lots, lakes, rivers, or the ocean.

As of 1997, all new cars are required to meet maximum emission levels similar to those in developed countries. Almost one-third of the national vehicle fleet runs on hydrated alcohol fuel, and all gasoline must be blended with alcohol.

To combat vitamin A deficiency, close to 5.8 million children received vitamin A supplements during the immunization campaigns carried out in the Northeast region between 1983 and 1991. In 1994 the program was extended to other endemic areas, and a coverage level of more than 80% was achieved.

The Ministry of Health is responsible for ensuring the supply of iodine to salt distributors. Activities at the national level aimed at controlling iron deficiency anemia are limited to ensuring the availability of ferrous sulfate supplements through health services within the health care system.

According to the most recent data on current capacity of the health sector, in 1992 there were 49,676 health care establishments: 27,092 (55%) in the public sector and 22,584 (45%) in the private sector. There were 24,016 outpatient care facilities (65% public); 7,415 hospitals (28% public); 8,440 emergency care facilities (38% public); 16,400 specialized diagnostic centers (25% public); 1,078 blood banks (28% public); 7,050 specialized treatment centers—radiation therapy, chemotherapy, etc. (28 % public); and 429 psychiatric care facilities (20% public). Eight percent of public establishments and 24% of private establishments provide inpatient care. The country has 544,357 hospital beds, or 3.6 per 1,000 inhabitants, 25% in the public sector and 75% in the private sector. The vast majority of psychiatric hospital beds (100,749, of which 30 % are in public-sector facilities) are concentrated in the Southeast (63%), compared with the North (less than 1%), and the Northeast (18%). The Southeast and South regions of the country possessed about 60% of the total installed capacity in terms of establishments and available beds.

Brazil is one of the world’s 10 largest consumer markets for drugs, with a 1.5%–2.0% share of the world market. Gross receipts in the domestic drug market totaled US$ 9,700 million in 1995, a 15% increase with respect to the previous year. The pharmaceutical industry directly generated 47,100 jobs in 1996, with overall investments of US$ 200 million in that year. The sector comprises some 500 companies, including drug producers, chemical-pharmaceutical industries, and importers. There are 45,000 pharmacies that sell 5,200 products in 9,200 different forms.

In 1996, the national immunization program used 196 million doses of 26 different types of vaccines and sera worth a total of around US$ 84 million. Of this amount, close to 76 million doses were manufactured in the country, which was sufficient to meet the total demand for BCG, tetanus toxoid, double antigen, yellow fever, and human and canine rabies vaccines as well as antivenom, antitetanic, antipertussis, and antirabies sera.

Consumption of medical and hospital equipment and materials in Brazil in 1995 totaled close to US$ 2,000 million, which represents 1.7% of the world market for these products. Domestic industries met about 60% of internal demand, with equal participation by the public and private sectors.

Brazil has 513,338 health professionals, of which 40.1% are physicians, 26.8% are dentists, 13.2% are professional nurses, 10.1% are pharmacists, and 9.8% are veterinarians. There are 757 inhabitants per physician, 1,132 per dentist, 2,330 per nurse, and 2,981 per pharmacist. Increasing numbers of women are entering the medical profession. In 1996, 31.9 % of all practicing physicians in the country were women. The distribution of health services and health professionals in the country is characterized by a heavy concentration of human resources in the most developed regions and in the state capitals. The health sector accounts for about 8% of all jobs in the formal economy of the country. One-third of these health sector jobs are in public administration at one of the three levels of government.

In recent decades, activity in the area of health science and technology in Brazil has come to depend on extrasectoral support, mainly from federal development agencies, which have allocated 25%–35% of all the funds they invest to health. With regard to Brazilian scientific output, records from the LILACS (Latin American and Caribbean Literature on Health Sciences) database for the 1981–1992 period show that more than half the indexed publications were Brazilian. According to the database of the Institute for Scientific Information, the number of citations with one or more Brazilian authors increased from 1,317 in 1981 to 2,841 in 1992, totaling 23,975 publications for the period in 1,429 specialized journals; only nine of these journals were published in Brazil.

Public spending on health at the three levels of government, which in 1989 was US$ 13,200 (US$ 96 per capita), declined enormously in subsequent years, dropping to US$ 8,700 million (US$ 63 per capita) in 1992. This sharp reduction paralleled a reduction in federal spending, which historically has accounted for three-fourths of total public spending, and was 42% lower in 1992 than in 1989. In 1993, federal public spending began to rise again gradually, reaching US$ 14,000 million in 1996, approximately 25% more than in 1989.

Major sources of international financial cooperation in the area of health are the United Nations Population Fund, which contributes significantly to the program on women’s health, and the World Bank, which has supported large-scale projects, such as those for control of endemic diseases in the Northeast and control of malaria in the Amazon region. The REFORSUS project, as noted above, is being financed by the IDB and the World Bank. Also under way are two projects for the prevention and control of drug use, which are receiving support totaling US$ 2.4 million from the United Nations International Drug Control Program.