Monitoring(and(evaluating(progress(towards(universal(health(coverage(in(

Brazil!!

!!

Mauricio!L.!Barreto!1,!Davide!Rasella!1,!Daiane!Machado!1,!Rosana!Aquino!1,!Diana!Lima!1,!Leila!Garcia!2,!Alexandra!Crispim!2,!Jackson!Santos!1,!Juan!Escalante!3,!Estela!Aquino!1,!Claudia!Travassos!4!!

!!

1.  Instituto de Saúde Coletiva, Federal University of Bahia, Salvador, Brazil 2.  National Institute in Science, Technology and Innovation in Health (CITECS), Salvador,

Brazil 3.  Instituto de Pesquisa Econômica Aplicada, Brasília, Brazil 4.  Federal University of Santa Catarina, Floranopólis, Brazil 5.  Secretaria de Vigilância a Saúde, Ministry of Health, Brasília, Brazil 6.  Instituto de Comunicação e Informação Científica e Tecnológica em Saúde (ICICT) /

FIOCRUZ, Rio de Janeiro, Brazil

! 1

•  Since! 1988,! Brazil! has! developed! a! dynamic,! complex! ! health!system!(the!Unified!Health!System;!SUS),!which!is!based!on!the!principles!of!health!as!a!ci*zen’s!right!and!the!state’s!duty.!!

•  The!SUS!aims!to!provide!comprehensive,!universal,!preven*ve!and! cura*ve! care! through! decentralized! management! and!provision! of! health! services,! and! promotes! community!parUcipaUon!at!all!administraUve!levels.!!

•  The!Brazilian!Health!Sector!Reform!occurred!at!the!same!*me!as! democra*za*on,! and! was! spearheaded! by! health!professionals! and! individuals! in! civil! society! movements! and!organisaUons.!!

Introduc*on!

4

Federal!Cons*tu*on,!art.!196!(1988)!

!  “health( is( a( right(of( all( citizens( and(a(duty(of(the( state,( granted( by( social( and( economic(policies( aimed( to( reduce( the( risk( of( diseases(and( the( universal( and( equitable( access( to(actions( and( services( to( its( promotion,(protection(and(recovery”.(

GINI Index – Social Inequalities

The Gini index is a measure of statistical dispersion and is used as a measure of inequality of wealth (eg. income) distribution. It varies from 0 to 1, where a value of 0 corresponds to perfect equality and a value of 1 corresponds to perfect inequality

!!!!!!!!Recent!Trends!in!Gini!Index!in!Brazil ! !!!

0.538

0.544

0.551

0.558

0.565 0.568

0.580

0.586

0.592

0.591

0.597 0.599

0.599 0.597

0.52

0.54

0.56

0.58

0.60

1994 1998 2002 2006 2010

Coe

ficie

nte

de G

ini

Ano

0,7 %/year 30

34

38

42

46

50

1900 1920 1940 1960 1980

Coe

ficie

nte

de G

ini

Ano

0.2 ponto/ano 27 anos

0.5%/year

16 ys.

30

34

38

42

46

50

1900 1920 1940 1960 1980

Coe

ficie

nte

de G

ini

Ano

0.6 %/ year 15 ys

UK!

USA!

Brazil

How!long!will!take!to!reach!the!level!of!other!large!federa*ve!countries?!!

30

34

38

42

46

50

54

58

62

1976 1980 1984 1988 1992 1996 2000 2004 2008

Gin

i Coe

ficie

nt

Year

Brasil

Mexico

EUA

Canada

hiperinflação

0,7 pontos Gini/ ano

4 anos

22 anos

10 anos

USA

Canada

Brazil

Mexico

Infant!Mortality!Rates!

Prevalence(of(undernutrition((<5(years)(by(family(income(and(year(of(survey,(1974/5((J((2006/7(

Lancet, 2011

!  To!explore!how!far!has!Brazil!advanced!in!terms!of!Universal!Health! Coverage! (UHC)! and! equity! regarding:! health!determinants,!primary,!secondary!and!terUary!care,!and!costs!for!individual!and!families.!

!!!  To!contribute!to!the!defini*on!a!set!of!indicators!to!monitor!health!coverage!and!equity!at!an!internaUonal!level.!

Objec*ves!

12

13

(!  Data!at!the!aggregate!level:!!

!!!!!!!!Health!StaUsUcs!made!available!by!the!Brazilian!Ministry!of!Health!(Datasus)!from!!!!!!!!!!!rouUnely!collected!data:!!!!!!!!!!!!W!Mortality!InformaUon!System!W!SIM!!!!!!!!!!!!W!InformaUon!System!on!Live!Births!W!SINASC!!!!!!!!!!!!W!NoUfiable!Diseases!InformaUon!System–!SINAN!!!!!!!!!!!!W!Primary!Care!InformaUon!System!W!SIAB!!!!!!!!!!!!W!OutpaUent!InformaUon!System!W!SIA!!!!!!!!!!!!W!Hospital!InformaUon!System!W!SIH!!!!!!!!!!!For!socioeconomic!and!demographic!variables!data!from!the!Brazilian!InsUtute!of!!

Geography!and!StaUsUcs!and!from!the!Human!Development!Atlas!of!the!UNDP.!

!  Data!at!the!individual!level:!!

!!!!!!!W!Health!Supplement!of!NaUonal!Household!Sample!Surveys!(PNAD):!1998W2003W2008!!!!!!!!W!Family!Expenditure!Surveys!(POF):!1996W2003W2009!!!!!!!!W!Surveillance!System!of!Risk!and!ProtecUve!Factors!for!Chronic!NonWCommunicable!!!!!!!!!!!!!Diseases!!through!Telephone!Interviews!(VIGITEL)!(

Methods:!Data!Sources!

14

(((!  Data! at! the! aggregate! level:! !MunicipaliUes! have! been! straUfied! according! to! quinUles! of! their!

Human!Development! Index! (HDI)! at! the!baseline! year!of! 2000.! Indicators!under! study!have!been!calculated! for! each! quinUle! as! the! raUo! between! the! sum! of! the! outcome! in! the! municipaliUes!divided!by!the!sum!of!the!populaUon.!For!each!indicator!quinUles!trends!!have!been!represented!in!graphs.!

!  This!analysis!allow! to! show!not!only!how!the!average!poverty! level!of! the!municipality! can!affect!health! service! uUlizaUon! and! outcomes,! but! also! –! in! case! of! health! services! placed! only! in! rich!urban! municipaliUes! –! how! the! same! aspects! could! be! affected! by! other! barriers! of! access!(geografical,!cultural,!economical).!

!  Data! at! the! individual! level:! ! For! each! survey! subjects! have! been! straUfied! in! quinUles! of! their!income!or!–!if!income!was!not!available!W!schooling!level.!For!each!indicator!trends!of!the!quinUles!have!been!represented!in!graphs.!

!  This!analysis!allow!to!show!how!individual!income!or!schooling!level!could!affect!the!outcome!under!study,!indipendently!form!the!place!of!residence!of!the!subjects!(ex.!rural!or!urban).!!

Methods:!Analysis!

2000! 2010!1st$quin)le$ 15.1! 16.3!2nd$quin)le$ 18.9! 20.8!3rd$quin)le$ 19.5! 22.1!4th$quin)le$ 29.0! 33.2!5th$quin)le$ 86.9! 97.9!

Total!popula*on!!(millions)!of!each!!HDI!quin*le,!2000Z2010!

(

15

Health!Determinants!!and!Risk!Factors!

16

17

FIGURE!3:!Trends!in!percentage!of!housing!without!piped!water!according!to!quin*les!of!municipal!lDH.!

Data!Source:!IBGE!Note:!The!small!graph!refers!absolute!difference!and!rate!ra*o!between!the!richer!and!the!poorer!quin*les.!

0!

10!

20!

30!

40!

50!

60!

70!

80!

90!

100!

1991! 2000! 2010!

1st!quinUl!

2nd!quinUl!

3rd!quinUl!

4th!quinUl!

5th!quinUl!

Overall!

0!

10!

20!

0!

50!

100!

1991! 2000! 2010!

Ra*o

!

Diffe

rence!

diff! raUo!

18

Absence!of!Piped!Water!

Absence!of!Electricity!FIGURE!4!:!Trends!in!percentage!of!housing!without!electricity!according!to!quin*les!of!municipal!lDH.!

Source:!IBGE!Note:!The!small!graph!refers!absolute!difference!and!rate!ra*o!between!the!richer!and!the!poorer!quin*les.!

0!

10!

20!

30!

40!

50!

60!

70!

80!

90!

100!

1991! 2000! 2010!

%!

1st!quinUl!

2nd!quinUl!

3rd!quinUl!

4th!quinUl!

5th!quinUl!

Overall!

0!

20!

40!

60!

80!

0!

20!

40!

60!

1991! 2000! 2010!

Ra*o

!

Diffe

rence!

diff! raUo!

19

20

Primary!Health!Care!

21

22

FIGURE!7:!!!Vaccina*on!coverage!according!to!quin*les!of!municipal!HDI.!!

Data!Source:!Na*onal!Immuniza*on!Program!(PNI)!!

0.0!10.0!20.0!30.0!40.0!50.0!60.0!70.0!80.0!90.0!100.0!

2003! 2004! 2005! 2006! 2007! 2008! 2009! 2010! 2011!

1st!quintil!

2nd!quintil!

3rd!quintil!

4th!quintil!

5th!quintil!

Series6!

0.0!

10.0!

20.0!

30.0!

40.0!

50.0!

60.0!

70.0!

80.0!

90.0!

100.0!

2003! 2004! 2005! 2006! 2007! 2008! 2009! 2010! 2011!

1st!quintil!

2nd!quintil!

3rd!quintil!

4th!quintil!

5th!quintil!

Total!

DPT!(Tetravalent)!!

Measles!(SRC)!!

23

Vaccina*on!Coverage!

FIGURE!8:!Trends!in!percentage!of!pregnant!women!without!any!prenatal!visit!at!the!moment!of!delivery!according!to!quin*les!of!municipal!HDI.!

Data!Source:!MS/SVS/DASIS!Z!Sistema!de!Informações!sobre!Nascidos!Vivos!Z!SINASC!Note:!The!small!graph!refers!absolute!difference!and!rate!ra*o!between!the!PNV!of!the!richer!and!the!poorer!quin*les.!

0!

5!

10!

15!

20!

25!

30!

2000! 2001! 2002! 2003! 2004! 2005! 2006! 2007! 2008! 2009! 2010!

%!

1st!quinUl!

2nd!quinUl!

3rd!quinUl!

4th!quinUl!

5th!quinUl!

Overall!

0!1!2!3!4!5!6!

0!2!4!6!8!

10!12!

2000! 2005! 2010!

Ra*o

!

Diffe

rence!

diff! raUon!

24

Prenatal!visits!

25

Secondary!Health!Care!

26

!FIGURE!14:!Trends!in!percentage!of!delivery!at!the!hospital!according!to!quin*les!of!municipal!HDI.!!

Data!Source:!Sistema!de!Informações!sobre!Nascidos!Vivos!Z!SINASC!Note:!The!small!graph!refers!absolute!difference!and!rate!ra*o!between!the!!the!richer!and!the!poorer!quin*les.!

0!

10!

20!

30!

40!

50!

60!

70!

80!

90!

100!

2000! 2001! 2002! 2003! 2004! 2005! 2006! 2007! 2008! 2009! 2010! 2011!

%!

1st!quinUl!

2nd!quinUl!

3rd!quinUl!

4th!quinUl!

5th!quinUl!

Overall!

0.0!

0.2!

0.4!

0.6!

0.8!

1.0!

1.2!

0!

2!

4!

6!

8!

10!

2000! 2005! 2010!

Ra*o

!

Diffe

rence!

diff! raUo!

27

Delivery!at!the!Hospital!

Data!Source:!Sistema!de!Informações!sobre!Nascidos!Vivos!Z!SINASC!Note:!The!small!graph!refers!absolute!difference!and!rate!ra*o!between!!the!richer!and!the!poorer!quin*les.!

!FIGURE!15:!Trends!in!percentage!of!cesarean!delivery!according!to!IDH!quin*les!of!municipali*es!.!

0!

10!

20!

30!

40!

50!

60!

70!

80!

2000! 2001! 2002! 2003! 2004! 2005! 2006! 2007! 2008! 2009! 2010! 2011!

%!

1st!quinUl!

2nd!quinUl!

3rd!quinUl!

4th!quinUl!

5th!quinUl!

Overall!

0.0!

0.2!

0.4!

0.6!

0.8!

0!

10!

20!

30!

40!

2000! 2005! 2010!

Ra*o

!

Diffe

rence!

diff!! raUo!

28

Cesarean!Delivery!

Ter*ary!Health!Care!

29

30

Hospitaliza*on!for!Cardiovascular!Surgery!!FIGURE!17:!Trends!in!hospitaliza*on!rates!(per!100,000!inhab)!for!cardiovascular!surgery!according!to!quin*les!of!municipal!HDI.!

Data!Source:!!SIH!Note:!The!small!graph!refers!absolute!difference!and!rate!ra*o!between!!the!richer!and!the!poorer.!

0!

10!

20!

30!

40!

50!

60!

70!

80!

90!

100!

2008! 2009! 2010! 2011!

1st!quinUl!

2nd!quinUl!

3rd!quinUl!

4th!quinUl!

5th!quinUl!

Overall!

0.00!

0.10!

0.20!

0.30!

0.40!

0!

10!

20!

30!

40!

2008! 2009! 2010! 2011!

Ra*o

!

Diffe

rence!

diff! raUo!

31

0!

10!

20!

30!

40!

50!

60!

70!

80!

90!

100!

2008! 2009! 2010! 2011!

1st!quinUl!

2nd!quinUl!

3rd!quinUl!

4th!quinUl!

5th!quinUl!

Overall!

!FIGURE!29:!Trends!in!number!of!hemodialysis!!per!1,000!inhabitants!per!year!according!!to!quin*les!of!municipal!HDI.!

Data!Source:!SIA!Note:!The!small!graph!refers!absolute!difference!and!rate!ra*o!between!!the!richer!and!the!poorer!quin*les.!

0.00!0.10!0.20!0.30!0.40!0.50!

0!10!20!30!40!50!

2008! 2009! 2010! 2011!

Ra*o

!

Diffe

rence!

diff! raUo!

32

Hemodialysis!

!FIGURE!30:!Trends!in!number!of!kidney!transplanta*ons!per!100,000!inhabitants!per!year!according!to!quin*les!of!municipal!HDI.!

Data!Source:!!SIH!Note:!The!small!graph!refers!absolute!difference!and!rate!ra*o!between!!the!richer!and!the!poorer.!

Kidney!Transplanta*on!

0!

1!

2!

3!

4!

5!

6!

7!

8!

9!

10!

2000! 2001! 2002! 2003! 2004! 2005! 2006! 2007! 2008! 2009! 2010! 2011!

1st!quinUl!

2nd!quinUl!

3rd!quinUl!

4th!quinUl!

5th!quinUl!

Overall!

0.00!

0.04!

0.08!

0.12!

0.16!

0.20!

0.0!

0.5!

1.0!

1.5!

2.0!

2.5!

3.0!

2000! 2005! 2010!

Ra*o

!

Diffe

rence!

diff! raUo!

33

34

!FIGURE!16:!Trends!in!rate!of!admissions!to!hospital!!(per!100!inhabitants)!in!individuals!30Z59!years!old!in!the!past!12!months!according!to!income!classes!in!minimum!wages.!!

0.0!

0.2!

0.4!

0.6!

0.8!

1.0!

0.0!

0.5!

1.0!

1.5!

2.0!

2.5!

3.0!

3.5!

1998! 2003! 2008!

Ra*o

!

ifferen

ce!

diff! raUo!

0!

2!

4!

6!

8!

10!

12!

14!

16!

18!

20!

1998! 2003! 2008!

<!1!Minimum!wage!

!1!W!2!Minimum!wages!

!2!W!3!Minimum!wages!

3!W!5!Minimum!wages!

>!!5!!Minimum!wages!

Overall!

Data!Source:!PNAD!Note:!The!small!graph!refers!absolute!difference!and!rate!ra*o!!between!!the!richer!and!the!poorer.!

35

Reported!Hospitaliza*on!

Health!Outcomes!

36

!FIGURE!31:!!Trends!in!underZfive!mortality!rates!according!to!HDI!quin*les!of!municipali*es!selected!for!the!quality!of!vital!informa*on.!

Data!Source:!SIM!Note:!The!small!graph!refers!absolute!difference!and!rate!ra*o!between!!the!U5MR!of!the!richer!and!the!poorer!quin*les.!

0!

10!

20!

30!

40!

50!

60!

70!

80!

2000! 2001! 2002! 2003! 2004! 2005! 2006! 2007! 2008! 2009! 2010! 2011!

Mortality!rate!(x10

3 )!!

1st!quinUl!

2nd!quinUl!

3rd!quinUl!

4th!quinUl!

5th!quinUl!

Overall!

0.0!

0.5!

1.0!

1.5!

2.0!

2.5!

0!

5!

10!

15!

20!

25!

2000! 2005! 2010!

Ra*o

!

Diffe

rence!

diff! raUo!

37

UnderZfive!Mortality!

FIGURE!32:!Trends!in!underZfive!mortality!rates!from!diarrhoea!according!to!IDH!quin*les!of!municipali*es!selected!for!the!quality!of!vital!informa*on.!

0!

1!

2!

3!

4!

5!

6!

7!

8!

9!

10!

2000! 2001! 2002! 2003! 2004! 2005! 2006! 2007! 2008! 2009! 2010! 2011!

Mortality!rate!(!x103)!!

1st!quinUl!

2nd!quinUl!

3rd!quinUl!

4th!quinUl!

5th!quinUl!

Overall!

0!

1!

2!

3!

4!

5!

6!

0!2!4!6!8!

10!12!14!16!

2000! 2005! 2010!

Ra*o

!

Diffe

rence!

raUo! diff!

UnderZfive!Mortality!From!Diarrhoea!

Data!Source:!SIM!Note:!The!small!graph!refers!absolute!difference!and!rate!ra*o!between!!the!U5MR!of!the!richer!and!the!poorer!quin*les.! 38

39

Data!Source:!PNAD!Note:!The!small!graph!refers!absolute!difference!and!rate!ra*o!!between!!the!richer!and!the!poorer.!

0.0!

0.2!

0.4!

0.6!

0.8!

1.0!

0.0!

1.0!

2.0!

3.0!

4.0!

5.0!

1998! 2003! 2008!

Ra*o

!

Diffe

rence!

diff! raUo!

!FIGURE!34:!Trends!in!percentage!of!individuals!from!30!to!59!years!who!reported!physicianZdiagnosed!hypertension!according!to!income!classes!in!minimum!wages.!

0!

5!

10!

15!

20!

25!

30!

1998! 2003! 2008!

%!

<!1!Minimum!wage!

!1!W!2!Minimum!wages!

!2!W!3!Minimum!wages!

3!W!5!Minimum!wages!

>!!5!!Minimum!wages!

Overall!

40

SelfZReported!Hypertension!

SelfZreported!Diabetes!

Data!Source:!PNAD!Note:!The!small!graph!refers!absolute!difference!and!rate!ra*o!!between!!the!richer!and!the!poorer.!!

!FIGURE!35:!Trends!in!percentage!of!individuals!from!30!to!59!years!who!reported!physicianZdiagnosed!diabetes!according!to!income!classes!in!minimum!wages.!

0.0!

0.2!

0.4!

0.6!

0.8!

1.0!

1.2!

1.4!

0.00!

0.10!

0.20!

0.30!

0.40!

0.50!

1998! 2003! 2008!

Ra*o

!

Diffe

rence!

diff! raUo!

0!

1!

2!

3!

4!

5!

6!

7!

8!

9!

10!

1998! 2003! 2008!

%!

<!1!Minimum!wage!

!1!W!2!Minimum!wages!

!2!W!3!Minimum!wages!

3!W!5!Minimum!wages!

>!!5!!Minimum!wages!

Overall!

41

Health!Expenditure!

42

43

Discussion!

44

Summary!Points!!!  <!The!Brazilian!National!Health!System!(SUS)!has!guaranteed!

access!to!free!health!care!for!the!population!over!the!last!25!years,!but!one<quarter!of!Brazilians!(among!the!richest)!are!covered!by!private!health!plans.!!

!  <!The!relative!abundance!of!administrative!and!survey!data,!at!the!aggregate!and!individual!levels,!has!allowed!for!the!analysis!of!the!evolution!of!a!wide!range!of!health!determinants,!health!outcomes,!and!health!coverage!indicators!during!recent!years.!Using!an!integrated!approach!and!following!a!theoretical!framework,!recent!trends!in!several!health!outcomes!and!health!coverage!indicators!using!concentration!indices,!differences,!and!relative!inequality!measures!were!analyzed.!

!  <!Primary!health!care,!in!particular!through!the!expansion!of!the!Family!Health!Program,!succeeded!in!guaranteeing!near!universal!coverage,!in!particular!in!immunizations!and!antenatal!care.!!Secondary!and!tertiary!care!coverage!is!expanding!however,!while!large!social!and!geographical!!inequalities!still!persist.!!

45

Summary!Points!!

!  <!Health!expenditures!are!higher!but!decreasing!in!the!poorest!quintiles!of!the!population,!and!catastrophic!health!expenditures!are!minimal!but!still!present,!particularly!in!middle<income!households.!

!  <!The!overall!effect!of!the!SUS!on!the!health!outcomes!investigated!is!positive,!and!remarkable!decreases!have!been!registered!in!childhood!mortality,!particularly!that!associated!with!poverty<related!diseases.!

!  <!The!SUS!is!expanding!coverage!overall,!increasing!access!to!all!levels!of!care,!with!some!important!positive!trends!toward!equity;!however,!under<financing!and!inequalities,!in!particular!!in!secondary!and!tertiary!health!care!still!persist.!

46

Recommenda*ons!!!  To!strengthen!!monitoring!and!evaluation!Unified!Health!System!(SUS),!

defining!a!set!of!indicators!interconnected!by!a!consolidated!framework!that!must!reflect!the!several!levels,!components!and!effects!of!the!unified!heath!system,!relevant!health!determinants!and!health!outcomes,!with!greater!focus!on!equity;!!

!  Make!of!the!efforts!to!the!new!generation!of!health!information!systems!in!development,!including!the!individual!SUS!card,!to!be!integrated!in!the!monitoring!and!evaluation!efforts;!!

!  Integrate!to!SUS!health!information!systems!relevant!data!on!health!care!generated!by!private!health!plans;!

!  To!strengthen!initiatives!directed!to!expand!and!integrate!primary!health!care!(PSF)!!with!secondary!and!tertiary!care!!through!the!establishment!of!healthcare!regions,!underpinning!the!organisation!of!healthcare!networks!(hierarchy,!territorialisation!and!coordination),!making!all!the!efforts!to!decrease!social!and!geographical!inequities;!

!  Increase!funding!–!guarantee!through!law!enforcement,!cut!of!public!subsidies!and!investments!in!the!private!health!sector.!

47