Brazil

Overall Context

The 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) (1). 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 (2).

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 (3).

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 (4).

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 (3).

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 (5).

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 LGBT¹ 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% (6), 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) (7). At the municipal level, nearly 80% of the population was living in municipalities with low² or very low³ HDIs in 1991; by 2010, however, that proportion had dropped to 11% (8).

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 (6).

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 (9).

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 (10). 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 (11).

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.

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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 (12).

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 (13).

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,⁴ 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 (14).

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 (15).

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) (13).

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) (16).

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 (17).

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 (18).

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% (19). 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 (14).

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 (16).

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 (16).

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 (10), 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 (20).

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 (21).

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• This entry is also available in Português

Health Situation and Trends

Health of Population Groups

Maternal and Reproductive Health

Between 2000 and 2014, the maternal mortality ratio (MMR) declined from 73.3 to 58.2 deaths per 100,000 live births, due to a marked reduction in deaths from direct obstetric causes such as miscarriages, hemorrhage, gestational hypertension, and puerperal infection (22). Since 2010, there has been an increase in late maternal deaths, likely reflecting improved recording of deaths, with strengthened surveillance of maternal mortality and better medical care (23). Despite these improvements, significant regional differences in the MMR pose a major challenge that needs to be addressed by public policy, focusing on the special characteristics of each state. In this connection, the federal government decided in 2015 to introduce a “zero maternal deaths due to hemorrhage” strategy, incorporating new technologies to prevent and address postpartum hemorrhage. The policy was initiated with pilots in eight priority states.

Between 2000 and 2014, the annual number of births fell from 3,210,000 to 2,980,000, while the percentage of live births in which mothers had seven or more prenatal checkups increased from 43.7% to 64.6%, and births in institutional settings increased (from 96.6% to 98.4%), covering nearly all deliveries. However, there was a significant rise in births by cesarean section, from 38.0% to 57.1% (Figure 2) (24). These variations may be associated with the growth of the urban population, economic improvement, and various social and cultural changes in the population. The progress that has been achieved, however, does not uniformly reach all population groups: black and indigenous women, for example, continue to have less access to prenatal services, and higher maternal mortality rates.

In 2015, circulation of the Zika virus in states of the Northeast region was associated with an increase in microcephaly cases, with the greatest concentration in Pernambuco, Rio Grande do Norte, Bahia, and Paraíba. Other types of congenital malformation associated with this infection, such as arthrogryposis and auditory and ocular alterations, are currently being identified and studied. This situation has created fear among pregnant women, producing an increase in the demand for abortion drugs (25), and has highlighted deficiencies in public policy with regard to guidance on and use of long-acting reversible contraceptive methods.

Child Health

Between 2000 and 2014, the infant mortality rate in children under 1 year of age declined from 16.0 deaths to 14.1 deaths per 1,000 live births, and from 32.0 deaths to 16.3 deaths per 1,000 live births in children under age 5. The Millennium Development Goal of 17.9 deaths per 1,000 live births was reached in 2012 (22).

Brazil promotes increased basic health care through its family health strategy, expansion of the National Immunization Program, promotion of breastfeeding, and the Stork Network program. The Bolsa Família (Family Package) program⁵ and the Integrated Management of Childhood Illness (IMCI) strategy have also helped to sharply reduce infant mortality.

Between 2013 and 2014, there was a measles outbreak in the states of Pernambuco and Ceará, but only in 2015 did public interventions succeed in interrupting the circulation of the virus (26).

In 2015, the Ministry of Health provided 43 immunobiological products, including vaccines, serum, and immunoglobulins. The child vaccination schedule included 15 vaccines distributed to some 35,000 vaccination sites.

Between 2008 and 2012, coverage of the vaccination schedule for children exceeded the goal established by the National Immunization Program, for every vaccine except rotavirus and the decavalent pneumococcal vaccine, for which coverage remained between 80% and 90%. For the BCG vaccine, coverage levels above 100% have been reported (109.4% in 2008 and 105.6% in 2012).

The human papillomavirus vaccine (HPV) has been in the national vaccination program since 2014.

Health of the Disabled

According to data from the 2013 National Health Survey, 6.2% of the population over 18 years of age had some type of disability. Visual⁶ impairment was most common, affecting approximately 7.2 million people (3.6% of the population); 2.6 million had a physical disability such as paralysis, amputation, deformity, or dwarfism (1.3%); 2.2 million had auditory disabilities (1.1%); and 1.6 million had cognitive disabilities (0.8%). In the case of cognitive disabilities, the condition existed from birth for approximately one million individuals (0.5%), while the remainder of the cases (0.3%) stemmed from accident or disease (27).

Actions to provide care for people with disabilities are conducted through the Care Network for People with Disabilities, within the UHS; to accommodate this need, health care facilities were created, expanded, and interlinked for all people with disabilities, regardless of the nature of the disability (temporary/permanent, progressive/regressive/stable, intermittent/continuous).

Mortality

In 2006-2014, mortality in the general population decreased from 6.1 to 5.3 deaths [TN: Spanish text has these numbers reversed] per 1,000 population. In 2014, the most frequent causes of death were cerebrovascular diseases (46.2 deaths per 100,000 population), acute myocardial infarction (39.7), pneumonias (31.8), diabetes mellitus (26.7), and homicide (28.1). Among men in the 5 to 14 year age bracket, the leading cause of death was traffic accidents; in the 15 to 59 group, homicide; and in the over-60 group, ischemic heart diseases. Among women in the 5 to 29 year age backet, the most frequent causes were traffic accidents, while in the 30 to 59 and the over-60 age brackets, cerebrovascular disease was the most frequent cause of death (Table 1) (28).

Morbidity

Communicable Diseases

The International Health Regulations (IHR) are a key tool for communication, monitoring, and control of public health problems. As of 2009, the country had developed the basic skills—as required by the IHR—for warning and response at maritime ports, airports and land border crossings, and it has been collaborating with countries of the Region and with other Portuguese-speaking countries, focusing on the preparations needed to address public health events of national or international significance, particularly in the last five years.

The Aedes aegypti mosquito is present in all of Brazil’s states. The four dengue viral serotypes are in circulation, and since its reintroduction in 1981, dengue has shown an upward trend, with some 1.4 million probable cases in 2013.

Introduction of the chikungunya virus was detected in 2014, and Zika virus in 2015, both arboviral diseases transmitted by Aedes aegypti. An integrated vector management strategy was implemented to deal with the vector. In the wake of the introduction of the Zika virus, there has been major concern about Guillan-Barré syndrome and microcephaly associated with Zika infection. The federal government declared microcephaly a public health event of national or international significance, and created a health emergency operations center (HEOC), with input from a range of institutions in the country, in an attempt to coordinate, conduct, and monitor actions to combat this virus. In 2015, the government spent R$649 million (US$200 million) to combat Aedes aegypti and the diseases it transmits. These resources were focused on five priority areas: diagnosis, vector control, studies on the Zika virus and its relation to other diseases and disorders, vaccines and treatments, and innovative health services management (29). The government is also supporting poor families with children who suffer from microcephaly, by offering a subsidy equivalent to one minimum wage per month. Up to September 2016, 1,949 confirmed cases of microcephaly or alterations of the central nervous system had been reported, along with 3,030 suspected cases that remained under observation. The Northeast region of the country had the greatest number of confirmed cases (1,583) (30).

No cases of urban yellow fever have been recorded since 1942. However, sylvatic cycle transmission of yellow fever persists, causing isolated cases and sporadic outbreaks, with a case fatality rate of approximately 50% as of the end of 2016.

Although malaria continued a downward trend, new challenges have surfaced, such as the appearance of strains resistant to antimalarial drugs, and the present goal is to eliminate plasmodium falciparum malaria. In 2013, states within the Amazônia Legal region registered an annual parasite index of 6.3. The highest incidence of malaria occurred in the indigenous population (the only group classified as high-risk), with approximately 64 cases per 1,000 population, while the incidence in the Afro-descendant population was 6.2 per 100,000 population.

Since 2012, there has been study and discussion of the proposal to certify the interruption of transmission of Chagas disease by secondary vectors in Brazil, given the continued outbreaks of acute Chagas disease associated with contaminated foods (guarapo, or sugarcane juice, açaí, and bacaba, among others), as well as isolated cases caused by vector-borne transmission, outside the Amazônia Legal region (31).

Visceral leishmaniasis is present in 21 states, particularly in the periphery of large urban centers. In 2014, 3,453 new cases of the disease were reported, and the incidence rate was 1.7 cases per 100,000 population. That same year, 20,296 new cases of American cutaneous leishmaniasis were reported, with no differences in the behavior of the two forms of the disease over the previous five years.

In 2014, the prevalence of leprosy (Hansen’s disease) was 1.27 cases per 10,000 population; 31,064 new cases were detected, while the overall detection rate was 15.3 cases per 100,000 population. That same year, 7.5% of new cases were in children, and 6.6% involved second-degree disability. Brazil continues to be the only country of the Americas that has not yet reached the goal of eliminating this disease as a public health problem.

In 2013, the rate of detection of new cases in the black and brown population was 20.6 cases per 100,000 population, compared to 17.8 in the non-black population (white, amarelo [“yellow”], and indigenous). That year, the North, Midwest, and Northeast regions had the highest detection rates in the country (36.3, 39.6, and 24.3, respectively), while the states of Tocantins, Mato Grosso, Maranhão, and Rondônia were considered hyperendemic.

Schistosomiasis is endemic in nine states. Between 2004 and 2013, 511 severe cases and 500 deaths were recorded.

Metropolitan Recife, in the state of Pernambuco, is the only area in the country with active transmission of lymphatic filariasis; the total at-risk population numbers approximately 244,000.

The Yanomami area has a persisting known focus of onchocerciasis with active transmission, and the population at risk numbers nearly 22,000.⁷

The Ministry of Health has identified 486 municipalities nationwide with endemic trachoma, i.e., where there is a prevalence of inflammatory trachoma higher than 5% in the 1 to 14 year age group, based on data from the active search conducted in the schools of each municipality. Between 2005 and 2014, an annual average of 73,000 new cases were reported, with an incidence rate of 33.5 cases per 100,000 population in 2013. Between 2001 and 2013, the incidence rate declined by 16.7%.

Of multidrug-resistant tuberculosis patients who initiated treatment in 2012, 58% were cured or completed treatment, 6.3% had interrupted treatment, 17.7% abandoned treatment, 10.6% died, 6.1% were continuing treatment, and 1.2% had other outcomes. In 2001-2013, the incidence rate in the indigenous population grew steadily. A comparison between black and white populations shows that the incidence rate has remained higher among blacks. Operational indicators of tuberculosis control (except for directly observed treatment) were more favorable in the white population. Between 2004 and 2013, there were approximately 4,700 deaths annually from tuberculosis. In 2013, the highest mortality figures were in the indigenous population (5.5 deaths per 100,000 population), while the corresponding figures for the black and white populations were 3.8 and 1.6 deaths per 100,000 population, respectively.

An estimated 734,000 people are living with HIV/AIDS in Brazil. Since 2004, the prevalence of HIV infection in the 15 to 49 year age group has remained stable at 0.6% (0.4% of women and 0.7% of men). Recent years have seen a sharp decline in the proportion of AIDS cases among injecting drug users, in the incidence of AIDS in children under 5, and in the rate of vertical transmission of HIV. Between 1996 and 2013, mortality from AIDS declined from 9.6 to 5.7 deaths per 100,000 population. These rates are higher in the black population, associated with lower diagnostic coverage and greater problems of access to specialized services for timely and adequate treatment.

The number of people who received antiretroviral (ARV) therapy increased between 1999 and 2014, from 85,000 to 398,000. Starting in 2013, the State offered ARV treatment for all people living with HIV, regardless of the level of CD4 T lymphocytes (32). In 2016, the Ministry of Health approved the use of the ARV drug Dolutegravir. The incorporation of this drug did not affect the ARV procurement budget of the Ministry of Health, which is R$1.1 billion.

The Unified Health System guarantees the entire population free access to the various ARV regimes being used in the country. Eleven of the 22 drugs that currently make up the clinical protocol for treating HIV infection are produced domestically, and a strong negotiation strategy is employed to obtain lower prices in the pharmaceutical market.

Chronic, Noncommunicable Diseases

This group of diseases affects primarily the poorest population and the most vulnerable groups.

In 2013, the National Health Survey estimated that 57.4 million people suffer from at least one noncommunicable chronic disease (39.3% of the adult population—44.5% of women and 33.4% of men). The study found hypertension to be the most frequently mentioned illness (prevalence: 21.4%), followed by chronic spinal column problems (18.5%), depression (7.6%), arthritis (6.4%), and diabetes (6.2%). The prevalence of other diseases was below 5% (Table 2) (27).

In 2012, mortality from diabetes in the white and black populations was comparable to the national average. In the amarelo and brown populations, the rate was lower, while the indigenous population had the lowest rate of all of these population groups. That same year, the risk of death from hypertensive disease was higher than the average in the black population, while the risk among the white population was lower than the average.

Nutritional Diseases

In 2011, the country’s authorities reached an agreement with the productive sector on a goal to reduce the amount of sodium in processed food, by eliminating 28,500 tons of this mineral in food produced until 2020. It is calculated that 5,230 tons of sodium were eliminated in 2012, and 7,652 tons in 2014. Regulatory initiatives are included in the Conduct Adjustment Agreement (Término de Ajuste de Conducta [TAC])—a civil action by the State aimed at disseminating nutritional information in products marketed through fast food networks (33).

In spite of the progress achieved, sharp inequalities persist between population groups. There are high rates of chronic malnutrition in vulnerable groups, such as indigenous children, quilombolas, residents of the North region, and members of families that are beneficiaries of income transfer programs, with children and women living in pockets of poverty being particularly affected.

Improved access to health and an increase in the population’s income should have favorably affected the indicators of micronutrient deficiencies; however, studies indicate that iron and vitamin A deficiencies persist. There is also a resurgence of beriberi (deficiency of vitamin B1/thiamine) in some states, as well as unbalanced consumption of iodine by a portion of the adult population.

Accidents and Violence

In 2013, there were over a million hospitalizations due to external causes, paid for by the UHS, most (70%) involving men, of whom 36.2% were in the 20 to 39 age bracket. That year, the overall hospitalization rate for the population was 52.6 per 10,000 (31.2 for women and 74.56 for men). There were 151,000 deaths from accidents and violence, or 75.5 deaths per 100,000 population (26.4 for women and 125.5 for men) (28, 13). Young men were more likely to die or be injured due to an external cause, a fact attributable to the higher-risk work they perform, as well as alcoholic use, aggressive behavior, and dangerous operation of motor vehicles.

In 2013, there were 42,266 deaths due to traffic accidents, mostly involving men (82%). This is the leading cause of death in the 10-14 and 40-59 age brackets. Since 2000, mortality among motorcyclists involved in traffic crashes increased steadily in all regions of the country, especially in municipalities with smaller populations, becoming the most frequent form of fatal traffic collision. Between 2000 and 2013, mortality among motorcyclists increased from 1.5 to 6.0 deaths per 100,000 population (13).

Among the policies implemented to reduce the prevalence of traffic accidents are the new Brazilian Traffic Code (1988), the “Dry Law” (Law 11.705/2008), legislation making car seats compulsory for infants in motor vehicles (Law 12.760/2012), the “Life in Traffic” program, and the Rodovida program (focused on improving road safety on federal roads).

In 2013, there were 57,396 deaths due to homicide—most of them (92%) men between the ages of 20 and 39, and most due to gunshots. Between 2000 and 2013, the homicide rate among men increased from 47.9 to 51.7 deaths per 100,000 population (13). Noteworthy among the measures and initiatives implemented in this connection is the implementation, in 2003, of the Disarmament Statute (34).

Between 2009 and 2014, there was an increase in reports of domestic violence. Among women, the majority of victims were adults and adolescents; among males, adults and children were the main victims. Perpetrators of violence against children were most frequently the mother or stepmother (70.9%), while among adolescents it was the father or stepfather (40.2%). In the case of violence against adults, the most frequent perpetrator was the person with whom the victim had intimate relations (85.2%). In 65.9% of cases of domestic violence against older adults, violence was committed by the victim’s son (13).

Protection and risk factors

Between 2008 and 2013, the prevalence of tobacco use declined from 18.2% to 14.7% of the population. This may be attributable to measures adopted as part of the WHO Framework Convention on Tobacco Control, such as: prohibition on smoking in public indoor locations; prohibition on tobacco advertising and on promotion and sponsorship of tobacco products; inclusion of warning images on packages; support offered for users to quit smoking; and increased taxes on tobacco products (35).

With regard to alcohol use, the 2013 National Health Survey found that 13.7% of the population over 18 years of age had consumed alcohol in excess⁸ once during the 30 days prior to the interview. This percentage was three times higher among men than among women (21.6% versus 6.6%). In terms of excessive alcohol consumption—four or more days in a week—the difference between men and women was tenfold (24.2% for men versus 2.4% for women)

The prevalence of overweight and obesity increased in 2002-2013. Data from 2013 indicate that the prevalence rates of overweight and obesity in men were 57.3% and 17.5%, respectively, as compared with 59.8% and 25.2%, respectively, in women. The highest figures were in the states of the Southeast, South, and Center-West regions, which had the highest HDI. The same study found that 46% of adults were not sufficiently active.⁹ Prevalence of insufficient activity was higher in women, with values from 50.3% (in the South region) to 56.4% (in the North), as compared with the figures for men: 37.3% (in the Northeast) to 41.0% (in the Southeast). More than half of individuals over age 60 were inactive (62.7%).

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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.

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References

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2. Brazilian Institute of Geography and Statistics – IBGE. Indígenas. Available from: http://indigenas.ibge.gov.br/graficos-e-tabelas-2.html.

3. Ministry of Planning, Budget and Management – MPOG. Institute of Applied Economic Research – IPEA. Available from: http://www.ipeadata.gov.br.

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5. Ministry of Planning, Budget and Management. PLOA 2017 Orçamento Cidadão. Available from: http://www.orcamentofederal.gov.br/clientes/portalsof/portalsof/orcamentos-anuais/orcamento-2017/ploa/ploa-2017-orcamento-cidadao/view.

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12. Ministry of Health, Secretaria de Vigilância em Saúde. Leishmaniose Visceral. Available from: http://portalsaude.saude.gov.br/index.php/o-ministerio/principal/secretarias/svs/leishmaniose-visceral-lv.

13. Ministry of Health. Saúde Brasil 2014: uma análise da situação de saúde e das causas externas. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/saude_brasil_2014_analise_situacao.pdf.

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15. Entenda o acidente de Mariana e suas consequências para o meio ambiente. Available from: http://www.brasil.gov.br/meio-ambiente/2015/12/entenda-o-acidente-de-mariana-e-suas-consequencias-para-o-meio-ambiente.

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24. Ministry of Health. Estatísticas Vitais, Nascidos Vivos. Available from: http://www2.datasus.gov.br/DATASUS/index.php?area=0205&VObj=http://tabnet.datasus.gov.br/cgi/deftohtm.exe?sinasc/cnv/nv.

25. Aiken AR, Scott JG, Gomperts R, Trussell J, Worrell M, Aiken CE. Requests for Abortion in Latin America Related to Concern about Zika Virus Exposure. N Engl J Med 2016;375:396-8.

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29. Portal Brasil. Governo vai investir R$ 649 mi no enfrentamento a zika e Aedes aegypti. [Internet] Available from: http://www.brasil.gov.br/saude/2016/03/enfrentamento-do-zika-e-do-aedes-vai-contar-com-r-649-mi-1.

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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.

33. Malta, DC et al. Avanços do Plano de Ações Estratégicas para o Enfrentamento das Doenças Crônicas não Transmissíveis no Brasil, 2011-2015. Epidemiol. Serv. Saúde, Brasília, v. 25, n. 2, p. 373-390, June 2016.

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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