Celia Almeida

The Brazilian health system: history, advances, and challenges

Brazil is a country of continental dimensions with widespread regional and social inequalities. In this report, we examine the historical development and components of the Brazilian health system, focusing on the reform process during the past 40 years, including the creation of the Unified Health System. A defining characteristic of the contemporary health sector reform in Brazil is that it was driven by civil society rather than by governments, political parties, or international organisations. The advent of the Unified Health System increased access to health care for a substantial proportion of the Brazilian population, at a time when the system was becoming increasingly privatised. Much is still to be done if universal health care is to be achieved. Over the past 20 years, there have been other advances, including investments in human resources, science and technology, and primary care, and a substantial decentralisation process, widespread social participation, and growing public awareness of a right to health care. If the Brazilian health system is to overcome the challenges with which it is presently faced, strengthened political support is needed so that financing can be restructured and the roles of both the public and private sector can be redefined.

Health conditions and health-policy innovations in Brazil: the way forward.

Brazil is a large complex country that is undergoing rapid economic, social, and environmental change. In this Series of six articles, we have reported important improvements in health status and life expectancy, which can be ascribed largely to progress in social determinants of health and to implementation of a comprehensive national health system with strong social participation. Many challenges remain, however. Socioeconomic and regional disparities are still unacceptably large, reflecting the fact that much progress is still needed to improve basic living conditions for a large proportion of the population. New health problems arise as a result of urbanisation and social and environmental change, and some old health issues remain unabated. Administration of a complex, decentralised public-health system, in which a large share of services is contracted out to the private sector, together with many private insurance providers, inevitably causes conflict and contradiction. The challenge is ultimately political, and we conclude with a call for action that requires continuous engagement by Brazilian society as a whole in securing the right to health for all Brazilian people.

Desigualdades geográficas e sociais na utilização de serviços de saúde no Brasil

O consumo de servicos de saude e funcao das necessidades e do comportamento dos individuos em relacao a seus problemas de saude, bem como das formas de financiamento e dos servicos e recursos disponiveis para a populacao. A Constituicao brasileira de 1988 estabelece o Sistema Unico de Saude (SUS) com base na institucionalizacao da universalidade da cobertura e do atendimento. O sistema foi implementado em 1990 e pode ser traduzido como igualdade de oportunidade de acesso aos servicos de saude para necessidades iguais. Este trabalho estuda a equidade no uso de servicos de saude a partir de duas dimensoes: a geografica e a social. Os dados utilizados sao de pesquisas realizadas em 1989 e 1996-1997, pelo IBGE. Para avaliar as desigualdades geograficas no consumo de servicos de saude foram calculadas taxas padronizadas de utilizacao de servicos. Comparou-se tambem a dimensao do gasto privado domiciliar com medicamentos e com planos de saude. Para avaliar as desigualdades sociais, estimou-se a razao de odds para tres grupos de renda e para as pessoas com e sem cobertura de plano de saude. Observou-se pequena reducao dos niveis de desigualdades no periodo analisado (1989-1996/1997), com o sistema de saude atual mantendo-se caracterizado por marcadas iniquidades.

Methodological concerns and recommendations on policy consequences of the World Health Report 2000

Celia Almeida MDa, Paula Braveman MDc, Marthe R Gold MDd, Celia L Szwarcwald DrPhb, Jose Mendes Ribeiro MDa, Americo Miglionico MSe, John S Millar MDf, Silvia Porto PhDa, Nilson do Rosario Costa PhDa, Vincente Ortun Rubio PhDg, Malcolm Segall MRCPh, Barbara Starfield MDi, Claudia Travessos MDb, Alicia Uga PhDa, Joaquim Valente MDa and DrFrancisco Viacava MDb/ a National School of Public Health, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil/ b Health Information Department, Center for Scientific and Technological Information, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil/c Department of Family and Community Medicine, University of California, San Francisco, USA/d Department of Community Health and Social Medicine, City University of New York Medical School, New York, USA/e Consultant to Ministry of Health, Montevideo, Uruguay/ f Canadian Institute for Health Information, Ottawa, Canada/ g Department of Economics, Universitat Pompeu Fabra, Barcelona, Spain/h Health Unit, Institute of Development Studies, Sussex, UK/ i Johns Hopkins Medical Institutions, Baltimore, USA

Uma metodologia de avaliação do desempenho do sistema de saúde brasileiro

Este artigo e uma sintese de alguns dos principais resultados das discussoes realizadas ao longo de 18 meses entre pesquisadores de diversas instituicoes, afiliadas a Abrasco, e procura contribuir para a formulacao de uma metodologia que permita: a) compreender quais sao e como se inter-relacionam os fatores que influenciam a eficiencia, a efetividade e a equidade no desempenho do SUS; b) melhorar a formulacao de politicas e c) monitorar as desigualdades no acesso e na qualidade dos servicos recebidos pelos diferentes grupos sociais no Brasil. A metodologia desenvolvida nutre-se de elementos utilizados nas propostas de avaliacao de desempenho dos sistemas de saude canadense, australiano, ingles e a da OPS e tem o formato de um painel de controle (dashboard), onde podem ser visualizadas simultaneamente diferentes dimensoes da avaliacao. O artigo descreve a experiencia na adaptacao e desenvolvimento da metodologia e fornece sugestoes no sentido de aplica-la para melhorar a formulacao da politica de saude no Brasil.

Self-management of fatigue in rheumatoid arthritis: a randomised controlled trial of group cognitive-behavioural therapy

Objectives To investigate the effect of group cognitive behavioural therapy (CBT) for fatigue self-management, compared with groups receiving fatigue information alone, on fatigue impact among people with rheumatoid arthritis (RA). Methods Two-arm, parallel randomised controlled trial in adults with RA, fatigue ≥6/10 (Visual Analogue Scale (VAS) 0–10, high bad) and no recent change in RA medication. Group CBT for fatigue self-management comprised six (weekly) 2 h sessions, and consolidation session (week 14). Control participants received fatigue self-management information in a 1 h didactic group session. Primary outcome at 18 weeks was the impact of fatigue measured using two methods (Multi-dimensional Assessment of Fatigue (MAF) 0–50; VAS 0–10), analysed using intention-to-treat analysis of covariance with multivariable regression models. Results Of 168 participants randomised, 41 withdrew before entry and 127 participated. There were no major baseline differences between the 65 CBT and 62 control participants. At 18 weeks CBT participants reported better scores than control participants for fatigue impact: MAF 28.99 versus 23.99 (adjusted difference −5.48, 95% CI −9.50 to −1.46, p=0.008); VAS 5.99 versus 4.26 (adjusted difference −1.95, 95% CI −2.99 to −0.90, p<0.001). Standardised effect sizes for fatigue impact were MAF 0.59 (95% CI 0.15 to 1.03) and VAS 0.77 (95% CI 0.33 to 1.21), both in favour of CBT. Secondary outcomes of perceived fatigue severity, coping, disability, depression, helplessness, self-efficacy and sleep were also better in CBT participants. Conclusions Group CBT for fatigue self-management in RA improves fatigue impact, coping and perceived severity, and well-being. Trial registration: ISRCTN 32195100

Health sector reform in Brazil: a case study of inequity

Health sector reform in Brazil built the Unified Health System according to a dense body of administrative instruments for organizing decentralized service networks and institutionalizing a complex decision-making arena. This article focuses on the equity in health care services. Equity is defined as a principle governing distributive functions designed to reduce or offset socially unjust inequalities, and it is applied to evaluate the distribution of financial resources and the use of health services. Even though in the Constitution the term “equity” refers to equal opportunity of access for equal needs, the implemented policies have not guaranteed these rights. Underfunding, fiscal stress, and lack of priorities for the sector have contributed to a progressive deterioration of health care services, with continuing regressive tax collection and unequal distribution of financial resources among regions. The data suggest that despite regulatory measures to increase efficiency and reduce inequalities, delivery of health care services remains extremely unequal across the country. People in lower income groups experience more difficulties in getting access to health services. Utilization rates vary greatly by type of service among income groups, positions in the labor market, and levels of education.

Reforma do Estado e reforma de sistemas de saúde: experiências internacionais e tendências de mudança

Este texto discute a agenda de reforma do Estado, avaliando seus eixos centrais e dificuldades de implementacao; identifica as traducoes que adquire nos modelos que vem sendo implementados na area de saude e analisa as reformas de alguns paises (EUA, Reino Unido e Colombia). Aponta ainda as perspectivas que se desenham como tendencias nas propostas de reforma setorial no Brasil, vis a vis a experiencia internacional, onde a ideia de separacao de funcoes de financiamento e execucao tem prosperado, enquanto a de introducao de mecanismos competitivos na alocacao de recursos financeiros tem sido objeto de varias criticas. Alem disso, discute esses mecanismos em termos de eficiencia e eficacia e da capacidade regulatoria do Estado. Reflete sobre o quanto os paises latino-americanos tem sido mais radicais nos seus processos de reforma, mesmo partindo de condicoes muito precarias e estando submetidos a constrangimentos financeiros e importante subfinanciamento setorial. Aponta como tendencia, na America Latina, possibilidades de desmonte dos sistemas anteriores, sem garantia de melhoras substantivas na cobertura e na equidade, seja pelo radicalismo do processo, seja pelo alto grau de experimentalismo com que as reformas estao sendo implementadas.

Teoría y práctica de las reformas en los sistemas de salud: los casos de Brasil y México

Este trabajo se propone reflexionar sobre el lugar que la comunidad de los especialistas en salud publica esta ocupando en las reformas contemporaneas de los sistemas de salud. Discutimos la cuestion a partir de los casos de Brasil y de Mexico porque, en ambos paises, un grupo de especialistas en salud publica proyecto su participacion mas alla del ambito tecnico-cientifico y logro influir en el conflicto en torno a la reorientacion de las politicas de salud de sus paises. Una de sus acciones consistio en elaborar un marco cognoscitivo en el cual se alimentan proyectos tecnico-asistenciales de reforma entendidos como propuestas politicas con contenido tecnico. Nuestro proposito es demonstrar que estos profesionales logran influir en el debate nacional en el momento en que la discusion tecnico-cientifica rebasa el ambito de los especialistas para instalarse en el palco del debate socio-politico. En nuestra opinion, esto sucede porque el conocimiento tecnico-cientifico producido por esos grupos fue postulado, independendiente de su valor intrinseco, como plataforma ideologica alternativa, capaz de dar sustento a un proyecto tecnico-asistencial de referencia que, convertido en proyecto politico, sirvio para aglutinar a determinados sectores sociales.This study focuses on the role of public health experts in the contemporary health sector reform process. The authors discuss the issue based on the case of Brazil and Mexico, where a group of public health specialists have oriented their participation to influence the conflict concerning health policy reform in the respective countries. One approach has been to develop a new cognitive framework for technical health sector reform projects viewed as policy proposals with technical content. The purpose is to demonstrate how these specialists have managed to influence the national debate over health sector reform when the technical and scientific discussion leaves the academic sphere and reaches the social and political realm. The authors contend that this occurs because such technical and scientific knowledge has been postulated (independently of its intrinsic value) as a political and ideological alternative platform for sustaining a health sector reform proposal which, once transformed into a policy project, has served to aggregate certain political and social forces.

“They didn't tell us, they made us work it out ourselves”: Patient perspectives of a cognitive–behavioral program for rheumatoid arthritis fatigue†

Fatigue is an overwhelming rheumatoid arthritis (RA) symptom caused by interacting clinical and psychosocial factors. Cognitive–behavioral therapy (CBT) addresses links between thoughts, feelings, and behaviors and uses cognitive restructuring to facilitate behavior changes. In a randomized controlled trial, a group CBT program for RA fatigue improved fatigue impact, severity, and perceived coping, as well as mood and quality of life. The aim of this study was to explore the patient perspective of the program and the impact of behavior changes.