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Brazil Health

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Health indicators in Brazil have shown great progress over the last 50 years. The average life expectancy of Brazilians has increased considerably. Infant mortality rates, although they are still high by both world and Latin American standards, are almost four times lower than they were at the beginning of the 1940s.

The morbidity structure and the mortality profile have undergone substantial changes. The main causes of death, earlier centred around the so-called communicable diseases are today to be found, with increased urbanization, among chronic-degenerative diseases (cardiovascular problems and tumours) and in external causes such as accidents and homicides, both resulting to a large extent from daily life in large cities.

This does not mean that communicable diseases have disappeared. They continue to exist, although concentrated in particular pockets of rural poverty and associated in large measure with migratory movements, notably in the North-east, North and Central East regions. The North-east for example still shows high infant mortality rates, especially related to the poor state of nutrition of a high proportion of children and newborn babies. The return of endemic diseases which had been eradicated such as cholera, and the emergence of new ones, such as Aids, are new characteristics of our disease profile, requiring new forms of preventive action from the government.

In spite of the progress seen, Brazil still shows regional differences in its health indicators. Regions such as the North-east have sickness patterns which are very similar to those of the most backward countries of Africa, Asia and Latin America. Whereas the states of the South, South-east and the Federal District, where, in spite of the internal dissimilarity of the indicators, health conditions are to be found that are similar to those of many developed countries.

The structure of the health system in Brazil has changed a great deal in the last 30 years. Until the 60s there was a division of labour between the Health Ministry and the former Institutes of Retirement and Pensions (AIPs). The former took care of community health, the logistics of vaccine distribution and medical but basic care for the low income population in the regions where the government was not able to offer a service of better quality. Whereas the IAPs concentrated on providing medical care to workers in certain professional categories and their families, covered by welfare protection.

After the 60s, there was a growing trend towards the expansion of the cover of the health system for the Brazilian population. In 1967, the former AIPs were brought together as the Instituto Nacional de Previdência Social (INPS) [National Social Welfare Institute], which included, for the purposes of medical care, all workers with an approved work permit, as well as the self-employed who wished to contribute to social welfare.

In 1976 the Instituto Nacional de Assistência Médica da Previdência Social (Inamps) [National Medical Care for Social Welfare Institute] was created as the body responsible for all medical care to the population dependent on workers in formal employment. Over the 70s and 80s, the non-contributing population segments incorporated into the health system, such as rural and poor people, expanded and there were also strategies for decentralization linked to the programmes for expanding the cover.

The Constitution of 1988 instituted the Sistema Único de Saúde (SUS) [Single Health System], which set as its goal universal cover of the entire Brazilian population, in the pattern of the traditional systems of social welfare existing in the European countries which took the route of setting up a welfare state.

The course taken by the Brazilian health system has however continued to reveal some basic problems which still need to be resolved. The financing of the health sector in the country has been insufficient to cover the aims of universality, completeness and fairness. In the country little is spent on health and spent badly, whilst a great deal of the financial effort of the sector has not been channelled towards the most needy segments of the population. Consequently, there exists a serious deficit and gaps in the cover of the Brazilian health system.

At the beginning of the 90s there was a serious institutional and financial crisis in the health sector in Brazil, which brought as a corollary a fall in the quality and cover of the public health system. Along with this, the trend for the SUS to become in practice a system devoted to caring for the lowest income social groups, whereas the middle and higher income classes were able to rely on the so-called private supplementary medicine systems which were expanding at a fairly rapid rate. Nowadays these systems cover around 35 million people, notably workers employed in the larger firms and middle and upper class families.

In spite of being a health system financed to a large extent by the public sector, via a system of insurance payment called AIH, the structure of supply of health services in Brazil is predominantly private. A high proportion of hospital institutions and beds belong to the private sector, with the responsibility for the health clinics (health posts and centres) remaining with the public sector, especially in the poorer regions of the country.

Brazil also has a structure of human resources in health which is growing fast. It can be said that the number of professionals of this area has grown considerably in recent years, but the composition of the health teams is still inadequate, insofar as it centres on the doctor and the nursing attendant, the latter without basic training. It is becoming necessary to increase the interdisciplinary nature of health teams and to increase, in their internal composition, the level of vital categories such as professionally trained nurses, both at higher and medium level.

In its initial years of operation the SUS did not show satisfactory results. This was for no other reason than that the system was undergoing reforms established progressively by the Health Ministry. The reforms were increasingly aimed at decentralization, with an increase in the autonomy of states and municipalities in the setting up of structures to provide health services appropriate to the circumstances of each situation.

The changes were also aimed at the need to define health priorities which would enable the major problems of the population to be balanced, alongside the provision of information systems which would make the results obtained and the expenditure required to achieve them more transparent. Many of the public and private hospitals in Brazil do not have computer systems to enable them to obtain financial and accounting data on the costs of the main procedures.

The reforms still need to be based on new mechanisms of administration and management which will allow greater autonomy for the hospitals and health service networks in personnel management and in the organisation of the supply in order to fill the needs of each region.

The Health Ministry and federal government - in partnership with the states and municipalities - are constantly in search of new definitions which will enable the Brazilian health system to achieve greater efficiency and attain the objectives of universal cover and equality. The main challenge is to administer the scant resources available appropriately so that they can fulfil needs and deficiencies, especially for the poorest sections of the population.

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