Claudia Travassos

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.

Uma revisão sobre os conceitos de acesso e utilização de serviços de saúde

The purposes of this article are to review the concepts of health services access and utilization and to analyze how these concepts interrelate. Access is a complex concept (often used inaccurately) which changes over time and according to the context. Health services utilization is at the core of health systems functioning. Despite some disagreement, according to this review the prevailing perspective is that access is related to characteristics of services supply. Health care services utilization can be applied as a measure of access, but use of services depends on other factors. Individual and contextual factors influence the use of services. The article shows that the concept of access is becoming more comprehensive and is changing its focus from entry into the health system to outcome of care. Access is valued in relation to its impact on health and depends on the effectiveness of care delivered. As an outcome measure, access becomes multidimensional and difficult to operationalize. Finally, the article discusses how health determinants differ from those of health services utilization, which impacts directly on illness, but only indirectly on health.

Gênero, morbidade, acesso e utilização de serviços de saúde no Brasil

O objetivo deste trabalho e analisar o perfil de morbidade referida, acesso e uso de servicos de saude em homens e mulheres no Brasil, segundo idade e regiao urbana e rural. Os dados da PNAD/98 mostram que as diferencas de genero na morbidade variam com a idade: desfavoraveis aos meninos ate os 10 anos e desfavoraveis as mulheres a partir dos 15 anos, aumentando ate os 64 anos e reduzindo apos esta idade. A alta prevalencia de atendimento indica que as barreiras de acesso dos que procuram servicos de saude sao pequenas. No entanto, o elevado percentual de nao procura face as necessidades percebidas sugere que as barreiras de acesso sao anteriores e dependem da oferta. A cobertura por planos de saude e bem maior na regiao urbana, mas nao ha diferencas de genero significantes nas regioes. As diferencas entre homens e mulheres nas taxas de uso curativo sao pequenas, se comparadas com as de uso preventivo, maiores para as mulheres, assim como as taxas de internacao, mesmo excluindo os partos. O financiamento das internacoes nao foi diferente entre homens e mulheres, ao contrario do financiamento de outros tipos de atendimento: maior cobertura por planos para mulheres na regiao urbana; na regiao rural, maior uso do SUS para as mulheres e maior desembolso de recursos proprios para os homens.

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.

Utilização dos serviços de saúde no Brasil: gênero, características familiares e condição social

Estudo financiado pela Organizacao Pan-Americana da Saude atraves do Concurso Regional de Investigacion 1999 sobre “Genero y equidad en el acceso a la atencion de la salud en las reformas de los sistemas de salud y seguridad social”. HDP/HDR/RGP/81/5.3.

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.

Desigualdades geográficas e sociais no acesso aos serviços de saúde no Brasil: 1998 e 2003

Este estudo objetivou avaliar o padrao das desigualdades geograficas e sociais no acesso aos servicos de saude em 2003 e compara-lo com o padrao existente em 1998, usando os dados da Pesquisa Nacional por Amostra de Domicilios (PNAD). A populacao estudada foi de criancas e adultos residentes em areas urbanas que referiram restricao de atividades nos ultimos 15 dias nas duas pesquisas. A variavel dependente foi o uso de servicos de saude nos 15 dias que antecederam a entrevista. Os modelos de uso de servicos de saude testados foram controlados por idade e sexo, e incluiram renda familiar per capita, escolaridade, grande regiao e alguns estados da federacao. O estudo reafirmou o padrao de que no Brasil o acesso e fortemente influenciado pela condicao social das pessoas e pelo local onde residem. Este padrao existe tanto para os adultos como para as criancas. Houve alguma diminuicao das desigualdades sociais no acesso, mas as desigualdades geograficas no acesso aumentaram no periodo de estudo. Na regiao Sul, uma das mais desenvolvidas do pais, persiste um padrao de forte desigualdade social e o estado do Rio Grande do Sul destaca-se pela magnitude das desigualdades sociais no acesso. A amostra da PNAD apresenta limitacoes para estudos de equidade na utilizacao de servicos de saude no âmbito estadual.

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

The concept and measurement of race and their relationship to public health: a review focused on Brazil and the United States

Race has been widely used in studies on health and healthcare inequalities, especially in the United States. Validity and reliability problems with race measurement are of concern in public health. This article reviews the literature on the concept and measurement of race and compares how the findings apply to the United States and Brazil. We discuss in detail the data quality issues related to the measurement of race and the problems raised by measuring race in multiracial societies like Brazil. We discuss how these issues and problems apply to public health and make recommendations about the measurement of race in medical records and public health research.

The assessment of adverse events in hospitals in Brazil

OBJECTIVE To evaluate the incidence of adverse events in Brazilian hospitals. DESIGN Retrospective cohort study based on patient record review. SETTING Three teaching hospitals in the State of Rio de Janeiro, Brazil. PARTICIPANTS Random sample (1103) of 27 350 adult patients admitted in 2003. Patients under 18 years old, psychiatric patients and patients whose length of stay was less than 24 hr were excluded, and obstetric cases were included. MAIN OUTCOME MEASURE(S) Incidence of patients with adverse events; proportion of preventable adverse events; number of adverse events per 100 patients and incidence density of adverse events per 100 patient-days. RESULTS The incidence of patients with adverse events was 7.6% (84 of 1103 patients). The overall proportion of preventable adverse events was 66.7% (56 of 84 patients). The incidence density was 0.8 adverse events per 100 patient-days (103 of 13,563 patient-days). The patients ward was the most frequent location of adverse events (48.5%). In regard to classification, surgical adverse events were the most frequent ones (35.2%). CONCLUSIONS The incidence of patients with adverse events at the three hospitals was similar to that in international studies. However, the proportion of preventable adverse events was much higher in the Brazilian hospitals.