Jairnilson Silva Paim

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.

Violência e desigualdade social: mortalidade por homicídios e condições de vida em Salvador, Brasil

INTRODUCTION Some studies have been questioning the association between poverty and violence. This studys purpose is to assess the distribution of homicide indicators associated with living conditions in Salvador, Brazil. METHODS A cluster study for the years 1991 to 1994 was carried out including the 75 data centers of the city of Salvador, BA, Brazil. Using death certificates for the study period, yearly mortality rates and mortality ratios were estimated. The 1991 census data of monthly wages and years of education for all family providers were used to define a four-category variable related to living conditions. Mortality rates due to homicide and the relative risk regarding the lowest living condition area were calculated for each social stratum. The 95% confidence intervals were calculated using the Confidence Interval Analysis software. RESULTS The highest mortality rates due to homicide were seen in the poorest areas. The relative risk due to homicide for the lowest and the highest living condition areas was statistically significant at 5% level and ranged from 2.9 to 5.1. CONCLUSIONS The data show a strong association between social inequalities and homicide in this urban area, emphasizing the importance of crime reduction programs.

Política, planejamento e gestão em saúde: balanço do estado da arte

This work provides a literature review of Policy, Planning and Health Management between 1974 and 2005. Information is presented from previous research and publications, incorporating the production contained within the LILACS database from the last five years. The emergence of studies in these sub-themes is described in an attempt to associate them with political circumstances, with particular emphasis on: the Sanitary Reform Process, the construction of the National Health System and the reorientation of health practices. The particularities of the production in this field are discussed and the need for historical and epistemological work in Brazil is emphasized. The practical challenges impose techno-scientific expertise and, primarily, socio-political militancy on individual and collective subjects.

Infant mortality in Brazil during recent periods of economic crisis

OBJECTIVE To analyze time trends in infant mortality in Brazil during a recent period of economic crisis (1980-1998). METHODS Time-series study based on the Ministry of Healths Mortality Information System, IBGE Foundation and Funda o Nacional de Sa de (National Health Institute database. Serial parameters were described using autoregressive integrated moving average (ARIMA) models, and the association between infant mortality rates and a number of determinants was evaluated using Spearman correlation coefficients. RESULTS Infant mortality showed a declining trend (-59.3%) and a strong correlation with most of the indicators analyzed. However, only correlations between infant mortality rate and total pregnancy and birth rates presented a significant difference between the two decades. CONCLUSIONS Variations in pregnancy rate were the main cause for the persistent decline in infant mortality in the 1980s. In the subsequent period, causes related to living conditions, especially healthcare, may have been more important.

A Constituição Cidadã e os 25 anos do Sistema Único de Saúde (SUS)

This article, celebrating the 25th anniversary of Brazils 1988 Constitution, aims to review the countrys social policy development, discuss political projects, and analyze challenges for the sustainability of the Unified National Health System (SUS). Based on public policymaking studies, the article revisits the origins of liberal social policy, focused on social assistance, and analyzes the hegemony of U.S. policies targeting poverty and their repercussions for universal policies. After identifying the formulation of political projects in Brazils democratic transition, it discusses their implications during the various Administrations since 1988, along with the difficulties faced by the National Health System. The article concludes that the political forces occupying government in the last two decades have failed to present a project for the country on the same level as those who drafted the Citizen Constitution.Este artigo, comemorando 25 anos da Constituicao Federal de 1988, teve como objetivos resenhar o desenvolvimento das politicas sociais, discutir projetos politicos e analisar desafios para a sustentabilidade do Sistema Unico de Saude (SUS). Apoiando-se em estudos sobre politicas publicas que privilegiam a genese, revisita as origens da politica social liberal, centrada na assistencia social, e analisa a hegemonia das politicas americanas voltadas para a pobreza e suas repercussoes nas politicas universais. Apos identificar a formulacao de projetos politicos na transicao democratica brasileira, discute seus desdobramentos nos governos seguintes, juntamente com as dificuldades enfrentadas pelo SUS. Conclui que as forcas politicas que alcancaram o poder nas duas ultimas decadas nao apresentaram um projeto para a Nacao a altura daqueles que geraram a Constituicao Cidada.

Mortalidade infantil e condições de vida: a reprodução das desigualdades sociais em saúde na década de 90

An ecological study was conducted to determine the infant mortality trend from 1991 to 1997 and to analyze its relationship to living conditions in Salvador, Bahia State, Brazil. Inequality patterns in infant death were analyzed by spatial distribution and a compound socioeconomic index. The data showed a decline in the infant mortality rate, with neonatal deaths and perinatal causes playing a growing role. Despite this overall trend, the infant mortality rate increased in 1992, and it was only in 1997 that it returned to the 1991 level. This fact was interpreted as related to worsening living conditions during that period. Spatial distribution highlights the persistence of health inequalities; education was the variable with the most significant correlation rate. When distributed according to the living conditions index (LCI), both the infant mortality rate and proportional infant mortality showed a linear increase from the intermediate stratum (20.4 per mil ) to the lowest (29.3 per mil ) and from the highest stratum (5.3%) to the lowest (13.3%), respectively. The authors conclude that despite the reduction in the total infant mortality rate, the persistence of social inequalities and a social process that hinders improvement of living conditions are responsible for the inequalities observed in infant mortality.

Desigualdades na mortalidade, espaço e estratos sociais

OBJETIVO: Descrever os diferenciais da mortalidade do Municipio de Salvador, Bahia, Brasil. METODOS: Foi realizado estudo de agregados a partir da divisao do municipio em 75 zonas de informacao e de sua populacao em seis estratos sociais para os quais foram estimados alguns indicadores de mortalidade. As fontes de dados foram as Declaracoes de Obito de residentes no municipio e o Censo Demografico de 1991. RESULTADOS: A diferenca entre os coeficientes de mortalidade do estrato com melhores condicoes de vida e aqueles com piores condicoes de vida variou entre 43,1% e 142,0% o que corresponde a Razoes de Desigualdades de 1,4 e 2,4. Essas diferencas atingiram percentuais de 656,3% quando a unidade de analise foi a zona de informacao. CONCLUSOES: Esses achados revelam a persistencia das desigualdades em saude no Brasil, destacando a importância desse tipo de analise diante das tendencias recentes de planificacao com base territorial bem como diante da pertinencia de intervencoes inter-setoriais voltadas para a modificacao dos fatores condicionantes da saude.OBJECTIVE A description of the mortality differentials in Salvador, Bahia, Brazil, is presented. METHODS An ecological study was carried out. The city was divided into 75 information areas and its population into six social strata. Standardized Mortality Rates, Age Specific Mortality Rates, Proportional Infant Mortality and the Proportional Mortality Ratio were calculated for each region and social strata. Data were obtained from Death Certificates and the Populational Census. RESULTS The mortality ratio difference between the strata with best living conditions and the poorer strata ranged from 43.1% to 142.0% which corresponds to an inequality ratio ranging from 1.4 to 2.4. When that analysis was carried out in smaller areas, these differences reached 656.3%. CONCLUSIONS These findings show the persistence of health inequalities in Salvador in more serious disproportion than that found in other studies. Despite the methodological problems related to the nature of the data and the study, project the authors it was highlight, the meaning of this kind of research concerned with new approaches to health planning and health promotion.

Eqüidade e reforma em sistemas de serviços de saúde: o caso do SUS

O ensaio procurou responder a seguinte pergunta: o SUS e uma politica publica de promocao da equidade? Nesse sentido, apresenta alguns delineamentos previos sobre certas nocoes presentes na pergunta, especialmente sobre as concepcoes de equidade e do SUS. Realiza uma breve revisao sobre reformas setoriais em contraponto com a Reforma Sanitaria Brasileira e um sumario do perfil de desigualdades em saude no pais. Conclui examinando alguns esforcos para a reducao dessas desigualdades levantando a hipotese de que o SUS pode promover equidade no sentido de justica sem comprometer o seu carater universal e igualitario.

Epidemiologia e planejamento: a recomposição das práticas epidemiológicas na gestão do SUS

Com os objetivos de sistematizar os esforcos para a utilizacao da epidemiologia nos servicos de saude, descrever algumas propostas construidas no Brasil e discutir obstaculos e possibilidades de recomposicao das praticas epidemiologicas no Sistema Unico de Saude (SUS), o ensaio apresenta elementos da crise da epidemiologia e analisa certos constrangimentos impostos ao desenvolvimento da racionalidade tecnico-sanitaria e a incorporacao tecnologica do saber epidemiologico na gestao em saude. Sao identificados avancos e recuos desses processos durante a implementacao do SUS e apresentadas algumas proposicoes para a construcao coletiva de uma epidemiologia contra-hegemonica que contribua na constituicao de sujeitos sociais comprometidos com uma pratica sanitaria que aposte na planificacao e gestao de um sistema de saude efetivo, democratico, humanizado e equânime.