Pan American Health Organization

Brazil

  • Overall Context
  • Leading Health Challenges
  • Health Situation and Trends
  • Prospects
  • References
  • Full Article
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Overall Context

Flag of BrazilThe Federative Republic of Brazil is one of the five largest countries in the world (with a territory of more than 8.5 million km2, with an estimated 204.4 million inhabitants. The country is structured into 26 states and a Federal District—where the capital, Brasilia, is located—in addition to 5,570 municipalities. The states are organized according to five geographical regions (North, Northeast, Southeast, South, and Central-West), with major economic, cultural, and demographic differences.

Demographics

In recent years, the age distribution of Brazil’s population has changed rapidly, with a growing and aging population and a steadily declining fertility rate (number of children per woman of childbearing age). The Brazilian Institute of Geography and Statistics (IBGE) estimated that the population in 2013 was 0.9% larger than in the previous year. The country has experienced not only a reduction in the fertility rate in recent decades, but also a decline in premature mortality and an increase in life expectancy at birth. The fertility rate, which was 2.39 children per woman of childbearing age in 2000, had dropped to a mere 1.77 by 2013—a rate lower than that required to replenish the population. This is due primarily to factors such as expanding urbanization, the use of contraception, sex education, family planning, and the share of women in the labor market, as well as the high cost of child-rearing. Between 2000 and 2013, life expectancy at birth increased from 69.8 to 74.8 years. In 2013, women lived nearly seven years longer than men (78.5 versus 71.3 years) (). Figure 1 shows the change in Brazil’s population structure between 1990 and 2015.

Figure 1. Population structure, by age and sex, Brazil, 1990 and 2015

Source: Pan American Health Organization, based on data from the United Nations Department of Economic and Social Affairs. Population Division. New York; 2015.

According to data from the 2010 Demographic Census, the indigenous population numbered 896,900 people in 305 ethnic groups. The largest ethnic group are the Ticuna people, accounting for 6.8% of the indigenous population. Indigenous populations are present in all five regions of the country, but are most numerous in the North, with an indigenous population of 342,800, and least numerous in the South, where the figure is only 78,800. Rural areas have 502,783 indigenous inhabitants, while urban areas have 315,180 ().

The Economy

In 2000–2013, the Brazilian economy saw significant economic growth and improved distribution of wealth. The per capita gross domestic product (GDP) increased by 34%, a significant portion of which represented increased income in the poorest population groups. This phenomenon contributed to reduced inequality in the distribution of wealth (with the Gini coefficient declining from 0.553 in 2001 to 0.497 in 2013). These outcomes reflect progress in reducing poverty, creating jobs, and fostering formal employment, as well as in improving access to education and health services ().

Between 2001 and 2012, the income of the poorest 20% of the population increased three times as much as that of the wealthiest 20% (6.2% versus 2.0%), while the unemployment rate fell from 10.2% to 7.1% between 2000 and 2013 ().

Nevertheless, in recent years—and since 2014 in particular—the economic situation has shown signs of exhaustion. In 2014, real GDP growth slowed substantially (to 0.1%), followed by a 3.8% decline in 2015—a recessionary cycle that continued in 2016 for the third consecutive year ().

Fueled by increases in public utility rates and currency devaluation, inflation finished 2015 at 10.48%, failing to meet the inflation goal (4.5%) for the second year in a row; and in 2016 it remained above the target (8.97% as of August). The labor market also reflected the impact of the crisis, with an increase in unemployment, which rose from 6.8% in the second quarter of 2014 to 11.3% in 2016, accompanied by a reduction in income levels. In addition, the public sector registered a primary deficit of R$ 111.2 billion in 2015 (R$ 3.33/US$ 1.00), or 1.88% of GDP. In light of that unpromising scenario for the public accounts, the government adopted various measures to reduce spending and increase tax collections in 2015, which affected various sectors, including the health sector. Fiscal adjustment led to a cut of R$69.9 billion in the 2015 budget, of which R$ 10 billion was for health programs, services, and initiatives. Despite this, the health sector received R$ 110.2 billion in 2017 (R$ 3.18/US$ 1.00), or 7.2% more than in 2016 ().

Social Determinants of Health

Since the decade of the 2000s, the country has progressively reduced health-related gaps by implementing policies for social inclusion, thus helping to reduce poverty and improve most health indicators.

These policies and programs focus on social determinants, especially the racial, ethnic, and gender dimensions that can produce inequalities, aggravate discrimination, increase health risks, and affect access to resources. Examples of such policies and programs include: those that have made universality, equity, and the comprehensiveness of health services a part of the National Policy of Comprehensive Health Care for Women (2004); the Comprehensive Plan to Combat the Feminization of the AIDS Epidemic and other Sexually Transmitted Diseases (STDs) (2007); the National Policy of Comprehensive Health Care for Men (2008); the Policy on Comprehensive Health Care for the LGBT Population (2008); and the National Policy on Comprehensive Health Care for the Afro-descendant Population (2009). Also worth noting is the creation of the Secretariat of Policies for Women (OTC) and the Secretariat of Policies to Promote Racial Equality, as well as the promulgation in 2006 of the María da Penha Law (Law 11.340) to eliminate domestic and family violence against women, and the amendment of the Penal Code in 2015 to include femicide in the group of heinous crimes (Law 13.104).

Between 2000 and 2013, public spending on education as a percentage of GDP increased from 4.7% to 6.3% (), aimed principally at public schools and universities, funding (i.e., subsidies) for students, and other educational programs, such as “Science without Borders” and “University for All” (ProUni).

While employment and income have improved in Brazil, poverty and social inequality remain major public policy challenges. In 2010, the states of the Southeast, South, and Center-West regions had high or very high (above 0.699) human development indices (HDIs), while the Northeast and North had medium-level indices (0.600 and 0.699, respectively). The country as a whole had a high HDI (between 0.700 and 0.7999) (). At the municipal level, nearly 80% of the population was living in municipalities with low or very low HDIs in 1991; by 2010, however, that proportion had dropped to 11% ().

Average years of schooling for individuals over the age of 25 increased in all age groups, with the average for the 25- to 30-year-old age group rising from 7.4 years of schooling in 2001 to 9.9 years in 2012. Moreover, the illiteracy rate in the over-15 population dropped from 13.6% to 8.3% between 2000 and 2013 ().

The Ministry of Education uses the Basic Education Development Index (IDEB) to evaluate the quality of education. In the initial years of primary education, the IDEB increased from 3.8 to 5.2 between 2005 and 2013. The proposed target for 2021 is 6.0 ().

The Health System

Brazil’s Unified Health System (UHS or SUS, for its Portuguese acronym) was created almost 30 years ago in the Federal Constitution of 1988. Based on recognition of the right to health as a civil right, the principles that define the policies of the UHS consist of: universal and comprehensive access to health services (which are organized regionally and hierarchically); promotion of equity; decentralized management; and social participation. Management of the system is shared by the three levels of government: the Ministry of Health at the federal level, and the state health secretariats and municipal health secretariats at the lower levels. The system is funded by taxes and contributions at the federal, state, and municipal levels. The network of services provided by the UHS includes its own public facilities and outsourced private services, with nonprofit sources being preferred in the latter case. According to the Brazilian Institute of Geography and Statistics, total health spending in 2013 amounted to 8.0% of the country’s GDP, with 3.6% public spending (). Social participation is promoted through health conferences and councils that operate continuously at the three levels of government, and through other mechanisms such as the Office of the Public Prosecutor, which fields citizen complaints.

The legal framework of the UHS allows for private enterprise to provide health care, either directly (direct payment) or through health plans and insurance. The complementary health care subsystem has nearly 50 million beneficiaries––almost 25% of the Brazilian population. It is regulated and overseen by the National Complementary Care Agency (ANS), primarily with regard to contractual matters, guaranteed coverage of the portfolio of services, quality of care, price adjustments, and financial sustainability ().

In 2016 the federal government launched a new National Health Plan for 2016-2019, whose central objective is the “timely expansion and improved quality of universal access, aimed at improving health conditions, promoting equity, and improving the quality of life of Brazilians.”

The UHS is regulated by a legal framework that is constantly expanding, thus making for considerable complexity. This framework serves to standardize the various Health Regions, shape health planning, create governance instruments—such as the National Health Actions and Services List, the “Health Map”, and the Organizational Contract for Public Action in Health, while strengthening others, such as the National Essential Medicines List. Legislation also formalizes linkages among the federative entities, with an emphasis on the roles of the tripartite inter-management commissions at the national level, and the corresponding bipartite entities in the states and regions. These entities bring together federal, state, and municipal managers to determine organization, financing, operation, and shared management of the UHS networks.

Leading Health Challenges

Critical Health Problems

Communicable Diseases

In recent decades, mortality from vaccine-preventable diseases and infectious diseases has been reduced, as has maternal and child mortality, though the latter remains high in the most vulnerable populations.

With regard to emerging and reemerging diseases, it should be noted that the prevalence of diseases transmitted through the Aedes aegypti mosquito, which is present in all Brazilian states, has remained stable; dengue continues to follow an upward trend; there are signs that the sylvatic transmission cycle of yellow fever will continue during 2016; the number of malaria cases continues to gradually decrease; outbreaks of Chagas disease with cases in the acute stage have been reported; and visceral leishmaniasis continues to be present in 21 states ().

Moreover, cases of chikungunya were reported in 2014; Zika virus cases were reported in 2015; and, as of September 2016, nearly 2,000 cases of microcephaly or neurological conditions had been confirmed. The incidence of tuberculosis has remained high (33.5 cases per 100,000 population), making Brazil one of the priority countries for action by the World Health Organization. Since 2004, the prevalence of HIV/AIDS in the population between the ages of 15 and 49 (0.6%) has not changed significantly.

With respect to neglected diseases it is noteworthy that the goal of leprosy elimination has not yet been reached; in nine states, schistosomiasis is endemic; the prevalence of active transmission of lymphatic filariasis continues in metropolitan Recife; active transmission of onchocerciasis continues in one part of the Yanomami area; and trachoma is endemic in 486 municipalities.

Chronic Conditions

Noncommunicable chronic diseases have increased, owing to factors related to the demographic transition and to epidemiological and nutritional realities, with the greatest impact on the poorest and most vulnerable population groups. Significant downward trends in certain risk factors, such as the prevalence of tobacco use, have been confirmed for noncommunicable chronic diseases ().

Human Resources

Despite the collective efforts of national, state, and municipal governments to implement policies for planning and regulating the work force, there remain certain limitations in the area of health care. This can be seen primarily in the inequitable distribution of health professionals and in the gap between the needs of the UHS and the professional training provided.

The Mais Médicos (“More Physicians”) program, created by Law 12.871 of 2013, represents a strategy to address these challenges. The law has three parts—emergency services, medical education, and infrastructure—and calls for short-, medium- and long-term actions. The program is involved in the education of physicians and medical specialists in the context of the country’s new national curricular guidelines aimed at reorienting training to the needs of the UHS and creating additional capacity for medical students and residents. In 2015, 18,240 physicians participated in the program as members of family health teams, an effort that reached 4,058 of the country’s 5,557 municipalities ().

At the national level, it is expected that investments will continue in strategies for the provision, placement, and certification of health professionals, while implementing ongoing educational initiatives.

Health Knowledge, Technology, and Information

The principal public policy strategy for making the country less dependent on foreign sources for health technologies, thus reducing the sector’s trade deficit (US$11.6 billion in 2013), is based on promoting and strengthening research and innovation in health, and fostering the generation of knowledge and the production of medications, pharmaceutical products, blood derivatives, vaccines, reagents for diagnostic purposes, and medical devices. These policies are intended to address recognized barriers, such as those created by commercial patents.

The Ministry of Health established a development policy for the Brazilian health industry (PROCIS) to foster the modernization and restructuring of production and management among public producers, to support high-quality production, and to continue issuing the certificate of good manufacturing practices (CBPF) issued by the National Health Surveillance Agency. Between 2012 and 2014, US$177.6 million was invested in this effort.

In 2011, the federal government passed Law 12.401, providing for the incorporation of health technologies by the UHS; to this end, the National Commission for Technology Incorporation (CONITEC) was created. Its functions are to recommend the inclusion, exclusion, or modification of health technologies, as well as the creation or modification of clinical protocols and therapeutic guidelines. The law sets a time-line for decision-making and calls for evidence-based analysis—which takes account of factors such as the efficacy, accuracy, effectiveness, and safety of technologies—as well as cost-benefit analysis of existing technologies and their budgetary impact.

The National Pharmaceutical Care Policy (2004) seeks to guarantee universal access to medicines in the National Essential Medicines List, and to encourage the formulation of strategies to promote rational drug use. In 2003-2014, spending on drugs, vaccines, and blood derivatives rose from R$1.9 million to R$12.7 million. During that period, two programs were created: the People’s Pharmacy of Brazil, which facilitates access to drugs through its own network and through agreements with private networks of pharmacies and drugstores; and the National Program for Pharmaceutical Services Qualification within the UHS, which is designed to help improve, apply, and systemically integrate pharmaceutical care with health initiatives and services, in order to ensure uninterrupted, comprehensive, safe, responsible, and humane care.

The government has invested heavily in health information systems. These systems cover information on mortality (SIM), live births (SINASC), hospitalizations (SIH), and reportable diseases (SINAN), as well as the National Register of Health Facilities (CNES).

In 2000-2014, SIM increased its coverage from 91% to 95%, while SINAC’s coverage grew from 92% to 96%. Among the most important public policies implemented are: surveillance of mortality for ill-defined underlying causes (2004), maternal mortality (2008), and fetal and infant mortality (2010). As a result of these major advances, the percentage of deaths due to ill-defined underlying causes dropped from 14.3% to 5.8%. Furthermore, the percentage of infant and fetal deaths that were investigated rose from 47.2% (33,450 of 70,799 deaths) to 73.4% (51,832 of 70,577 deaths), while the percentage of investigated maternal deaths rose from 73% (1,266 of 1,719 deaths) to 93% (1,628 of 1,739 deaths), and the percentage of investigated deaths of women of childbearing age increased from 76.5% (49,590 of 64,782 deaths) to 89% (56,949 of 63,977 deaths).

The SIH system incorporates approximately 12 million records a year, covering approximately 70% of the population served by the public and private hospitals within the UHS.

The Center for Strategic Information on Health Surveillance (CIEVS) was created to monitor outbreaks, epidemics, and other public health emergencies, in accordance with International Health Regulations (IHR). At present, Brazil’s 26 states and the Federal District have Centers for Strategic Information on Health Surveillance, which make up the National Public Health Emergencies Warning and Response Network.

The Environment and Human Security

Brazil has experienced natural disasters in the last few years, notably tornados and floods in Santa Catarina, the water crisis in São Paulo, and the landslide in Rio de Janeiro. In 2012, there were 2,342 declarations of public emergency or calamity, though the figure was lower in 2014 (1,886). The Fundão dam landslide in the municipality of Mariana, in the state of Minas Gerais, created a major socio-environmental disaster, as 34 million cubic meters of tailings (mainly iron oxide) spilled and entered the Doce River estuary of the Atlantic Ocean. This affected the region’s flora and fauna and compromised the water supply of several cities in Espírito Santo and Minas Gerais ().

Brazil is the world’s second largest food producer (after the United States), and the largest user of toxic agricultural products. The 2013-2014 sugar harvest used nearly one billion liters—an average of 5.2 kg of toxic agricultural products per inhabitant—and the incidence of poisoning rose gradually between 2008 and 2013 (from 3.70 to 6.26 cases per 100,000 population), while the use of toxic agricultural products also rose (from 12.54 to 21.43 kg per planted hectare) ().

In 2007-2012, the greatest number of occupational injuries leading to hospitalization, mutilation, or disability was associated with: accidents involving biological materials (198.8 cases per 100,000 workers); severe accidents among workers over the age of 18 (183.8 per 100,000 workers); severe accidents among people under 18 (11.5 per 100,000 workers); and workplace violence (6.9 per 100,000 workers) ().

Over 17 million households gained connections to the public sanitation system between 2001 and 2012, representing major growth in the coverage of this network and in the use of septic tanks, increasing from 66.7% to 78.6% of all Brazilian households. During this period, a comparable number of households (16 million) gained access to the public drinking water system, increasing coverage from 81.1% to 86.4%. In addition, there was a reduction in hospitalizations and deaths due to diarrhea—a development that also reflected interventions such as the introduction of the rotavirus vaccine in 2006 ().

Migration

Between 2010 and 2015, the number of immigrants doubled from 54,582 to 117,341, the majority coming from Haiti, Bolivia, Colombia, Argentina, and China. The number of refugees also doubled in that period (from 3,904 to 8,863), with individuals arriving from Syria, Angola, Colombia, the Democratic Republic of the Congo, and Palestine ().

In 2014, the number of Brazilians living abroad was estimated at 3.1 million, the majority of them in the United States, Paraguay, and Europe. Emigration is expected to increase during the coming years as a result of the economic crisis that the country has been experiencing since 2014.

Monitoring the Health System’s Organization, Provision of Care, and Performance

One of the country’s main priorities in the last 20 years has been to expand the coverage of primary health care (PHC), with a strategic focus on family health. In 2000-2015, the proportion of the population covered by family health teams rose from 17.43% to 63.72% (). Thus, more than 120 million people now benefit from such care. At present, the country has 40,162 multidisciplinary teams, each with a physician, a nurse, a nursing technician, and one or more community health workers. However, difficulties persist in attempting to expand coverage both in large urban centers (average coverage in the state capitals is 45%) and in the most remote, least accessible areas. The Mais Médicos program, implemented in 2013 with the Pan American Health Organization/World Health Organization (PAHO/WHO), has helped to expand and guarantee access to the UHS. By increasing the number of places for medical students (5,306 new places per year) and residents (4,742 places), the program has turned out 18,240 new physicians, in 4,058 municipalities. Investment was also made in building and remodeling 26,000 basic health facilities ().

Multidisciplinary care strategies were developed to strengthen the role of PHC as the network’s main mechanism for coordination and response, adding 22,227 oral health teams and 4,288 family health support centers to support the family health teams.

A 2009 study on medical health care identified 94,000 totally or partially active health facilities. Of the 52,000 public care facilities in operation, 95.6% were municipal, and of the 42,000 private units, 9.4% operated on a nonprofit basis (run by philanthropic institutions such as the Santa Casa de Misericórdia), while 90.6% operated on a for-profit basis (primarily private offices of physicians, dentists, and other professionals working independently or with private health plans).

In recent decades, success in controlling vaccine-preventable diseases has helped to substantially reduce infant mortality. The principal achievements in this regard have been the eradication of polio, elimination of the circulation of endemic measles and rubella, and a marked reduction in the incidence of vaccine-preventable diseases such as diphtheria, tetanus, whooping cough, rotavirus diarrhea, and, more recently, meningitides and pneumonias, caused by the meningococcus and pneumococcus viruses ().

The National Immunization Program, which has universal coverage, includes a large number of vaccines, and covers children, adolescents, adults, the elderly, indigenous populations, and groups with special conditions. Approximately 96% of the vaccines used are produced by Brazilian laboratories, thus making the program sustainable, preventing stock-outs, creating more balanced commercial conditions, and allowing for a high level of coverage. However, due to uneven coverage throughout the country, action should be taken to achieve more uniformity and prevent susceptibilities which, over time, could lead to the reemergence of low-incidence diseases ().

Between 2000 and 2013, total health spending as a proportion of GDP increased from 7.2% to 8.0%, rising from US$502 to US$946 per capita. This is one of the lowest percentages for countries with universal health systems, and compared to other countries in the Region. In 2013, the public portion of the country’s health spending represented 3.8% of GDP (), still far from the 6% proposed by PAHO/WHO as a reference for the countries of the Region. According to WHO data, health spending in 2014 as a proportion of total public spending was barely 6.7%. Despite the fact that private health spending has decreased, and that the Constitution mandates a public health system with universal access, private spending remains higher than public spending, accounting for 53.9% of total health spending in 2014. In that year, a quarter of health spending took the form of direct (out-of-pocket) expenditures ().

Constitutional Amendment 29 (2000), with corresponding regulations provided by Complementary Law 141 (2012) and modifications enacted by Constitutional Amendment 86 (2015), established the minimum percentage of public resources to be invested annually to finance public health initiatives and services at the state level (12% of taxes), municipal level (15%), and federal level (13.2% of net revenue in 2016, with steady increases to 15% in 2020). In addition to those changes, Law 13.097 was passed in early 2015, authorizing direct or indirect participation of foreign capital in health care, which is to be supported by greater state regulation of the sector.

The National Food and Nutrition Policy of 1999 included a set of public policies on health and nutrition, such as adequate and healthy diets, food and nutrition surveillance, and prevention and comprehensive care for food- and nutrition-related diseases ().

Prospects

In recent decades, public policies have helped improve health conditions in the population, as evidenced by increased access to prenatal care, resulting from policies designed to meet the Millennium Development Goals, and due to government priorities. There have been reductions in morbidity and mortality from vaccine-preventable diseases; in mortality due to infectious diseases; in the risk of premature death, especially during the first year of life; in maternal mortality; and in certain risk factors for noncommunicable chronic diseases, such as tobacco use.

The political and economic stability of recent decades has facilitated the introduction and consolidation of programs like the Growth Acceleration Program (PAC), the Bolsa Familia program, and the National Health Plan, as well as programs in education and public safety. Notable also are the improved social determinants, such as increased coverage of drinking water, sanitation, and trash collection. However, the economic and political crisis that the country has been experiencing since 2014 and 2015 could have a negative impact on these and other health indicators, and on public policy in general. The challenge is how to continue to move forward with the abovementioned health policies in a context of economic problems and changing health policies.

In terms of communicable diseases, there have been reductions in the incidence and prevalence of vector-borne diseases, initiatives have been implemented to decrease morbidity and mortality from neglected diseases affecting the most vulnerable populations, and vaccine coverage has been increased.

In recent years, chronic noncommunicable diseases (NCDs) have received ever-growing attention from the national authorities, resulting in the creation of the Strategic Action Plan to Combat Chronic NCDs in 2011. Brazil also adopted WHO’s voluntary targets, including a 25% reduction in premature mortality (under age 70) due to NCDs.

In late 2013, the Mais Médicos program was launched, in the midst of strong opposition from the medical association. Over time, however, the program attained wide acceptance in the community. Evaluations to date indicate that the process has had positive results, although impact indicators continue to be assessed, and there is continuing concern over the continuity of the program, given the aforementioned financial problems.

Major challenges include the need to quickly move forward with environmental agreements, increase basic sanitation coverage, especially in rural areas, and reduce the burden of neglected diseases.

References

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32. Ministry of Health. Guia de consulta rápida protocolo clínico e diretrizes terapêuticas para manejo da infecção pelo HIV em adultos. Available from: http://www.aids.gov.br/sites/default/files/anexos/publicacao/2013/55308/guia_rapido_protocolo07_2015_pdf_29479.pdf.

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34. Ministry of Justice. Secretaría Nacional de Seguridad Pública. Diagnóstico dos homicídios no Brasil: subsídios para o Pacto Nacional pela Redução de Homicídios. 2015. Available from: http://www.justica.gov.br/sua-seguranca/seguranca-publica/analise-e-pesquisa/download/estudos_diversos/1diagnostico-homicidios.pdf.

35. Ministry of Health. INCA, PAHO/WHO. Pesquisa Especial de Tabagismo—PETab. 2008. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/pesquisa_especial_tabagismo_petab.pdf.

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Reference/Note:

1. Lesbian, gay, bisexual, and transgender.

2. Between 0.500 and 0.599.

3. Under 0.500.

4. The country has 1.8 physicians per 1,000 inhabitants, much fewer than countries such as Argentina (3.2), Uruguay (3.7), Portugal (3.9), and Spain (4). Moreover, medical resources are unevenly distributed and concentrated in large urban centers, leaving poor and less accessible municipalities without care.

5. The Bolsa Família program transfers funds to the poorest population and is overseen by the Ministry of Social Development.

6. This category includes blindness in both eyes, blindness in one eye with reduced vision in the other, blindness in one eye and normal vision in the other, and very limited vision in both eyes.

7. The elimination of onchocerciasis requires stronger cooperation between Brazil and Venezuela, under the 2015-2016 Binational Plan of Action for the Elimination of Onchocerciasis in the Yanomami area.

8. Five or more drinks for men and four or more for women.

9. This includes those who engaged in no physical activity or did so less than 150 minutes per week, in the form of recreation, work, or travel to work.

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