Social Determinants of Health in Brazil

Alberto Pellegrini FilhoCenter for Studies, Policies and Information in

Social Determinants of Health ENSP/FIOCRUZ

(CEPI-DSS)

• Brazilian Commission on SDH

• Center for Studies, Policies and Information on SDH (CEPI-DSS/ENSP/FIOCRUZ)

• Post BNCSDH Initiatives

Brazilian Commission on SDH

1978

1993

2000

1982

SDH in WHO Constitution (1948)

Social dimension lost relevance in the era of campaigns (1950s).

SDH reappear in the health for All agenda (1978)

1990s: health as a private good

2000s: new opportunities for action on SDH

SDH in the global agenda (Tim Evans modified)

1948

WHO Commission

on SDH

World Conference on SDH

WHO

PHC-U

PHC-S

Health Reforms M

DG

CSDH

WCSDH

2005

2011

Process of creation of BNCSDH• Commission was created in March, 2006 with

sixteen personalities of social, economic, cultural and scientific life

• This diversity is an expression of the

recognition that health is a public good, constructed with the participation of all segments of the society

Composition of BNCSDH• Adib Jatene• Aloísio Teixeira• César Victora• Dalmo Dallari• Eduardo E. G. Vieira• Elza Berquó• Jaguar• Jairnilson Paim

• Lucélia Santos• Moacyr Scliar• Roberto Smeraldi• Rubem C. Fernandes• Sandra de Sá• Sônia Fleury• Zilda Arns• Paulo Buss (coord.)• A. Pellegrini (tech.

secretary)

Population Economically Active accordingly to economic sectorsBrazil – 1940 to 2000

Source: Instituto Brasileiro de Geografia e Estatística (IBGE).

61

55

46

31

25

1922

29

20 212022

32

40

55

60

67

171713

27

0

10

20

30

40

50

60

70

80

1940 1950 1960 1970 1980 1996 2000

Anos

%

Primário Secundário Terciário

Distribution of population (%) - Brazil – 1940 a 2000 Source: Instituto Brasileiro de Geografia e Estatística (IBGE).

3136

45

56

68

7681

6964

55

44

32

2419

0

10

20

30

40

50

60

70

80

90

100

1940 1950 1960 1970 1980 1991 2000

Anos

%

Urbana Rural

Fertility rate – Brazil – 1940 a 2000 Source: Census (1940-2000). IBGE

Fertility rates according to socio-demographic characteristics 1996 - 2006.

2,5 2,3

3,5

5,0

3,6

3,0

2,4

1,71,51,8 1,8 2,0

4,2

2,8 2,8

2,11,6

1,0

0

2

4

6

Total urban rural none 1 to 3 4 5 to 8 9 to 11 12 or more

1996

2006

Brazil Residence Years of Schooling

Tot

al F

erti

lty

Rat

e

Life expectancy - Brazil and Regions – 1960-2006Source: IBGE e Simões

41,0

72,4 71,369,4

73,8 74,4 73,5

51,6 53,4

57,2 60,3 56,7

66,0 66,0

59,6

71,0 71,071,5

0

10

20

30

40

50

60

70

80

Brasil Norte Nordeste Sudeste Sul Centro- Oeste

Evo

luçã

o d

a e

sp

era

nça

de

vid

a a

o n

asce

r

1960 1990 2006

BNCSDH recommendations• To establish an ‘ SDH Observatory’ for monitoring health

inequities and evaluation of policies and interventions on SDH; • To develop training courses on SDH approach for managers,

health professionals and other social workers; • To develop studies and research projects on SDH;

• To develop communication strategies about SDH to diverse social sectors

• To create a mechanism in the Presidential Cabinet to coordinate intersectorial SDH actions (MoH acting as technical secretariat)

• To create a high level Office in the Ministry of Health to promote SDH actions

Center for Studies, Policies and Information on SDH

(CEPI-DSS/ENSP/FIOCRUZ)

Center for Studies, Policies and Information on SDH (CEPI-DSS)

General Objective

To support activities developed by government and civil society for the promotion of health equity through the production and dissemination of knowledge and information, training of personnel and evaluation of policies and programs on SDH

Center for Studies, Policies and Information on SDH (CEPI-DSS)

• Observatory on Health Inequities: monitoring health inequities, follow-up and evaluation of interventions on SDH

• Training activities for managers in the diverse spheres of public administration;

• Studies and Research on SDH;• Promotion and participation on collaborative networks

of researchers and managers; • Information and communication about SDH to

government, professionals and general public: Portal SDH (www.dssbr.org) and VHL SDH (http://bvsdss.icict.fiocruz.br)

Mortality by diabetes mellitus in people with 15 years or older according to years of schooling

Women between 50 and 69 years old that never did mamography according to years of schooling

Mortality by homicide in people with 15 years or older according to years of schooling

Mortality by homicide in people with 15 years or older according to years of schooling

Distribution of people (15 years or older) according to region and years of schooling

Northeast Southeast

Child Mortality (less than 5 years) and illiteracy in Brazilian municipalities

source: Celso Simões

Northeast South

Special Issue on SDH of REPORTS IN PUBLIC HEALTH

Portal on SDHwww.dssbr.org

• Observatory: Indicators and analysis• News of interest on SDH• Summaries and analysis of articles on SDH• Basic and reference documents • Opinions• Interviews• Bank of Experiences• Blog; Twitter; Selected Links

Post BNCSDH Initiatives

Participation in Global and Regional Initiatives

• Global: WCSDH, Rio +20, SDG and post-2015 development agenda

• Region of Americas: OPS, UNASUR and MERCOSUR

Rio Declaration

1. Governance to tackle the root causes of health inequities:implementing action on social determinants of health;2. Promoting participation: community leadership for actionon social determinants;3. The role of the health sector, including public healthprograms, in reducing health inequities;4. Global action on social determinants: aligning priorities and stakeholders;5. Monitoring progress: measurement and analysis to informpolicies and build accountability on social determinants.

National Initiatives: Definition of strategies to implement WCSDH recommendations

Regional Conferences on SDH

Objectives• To perform regional health situation analysis with

SDH approach• To review on going policies and programs on

SDH in the Region• To discuss implementation of WCSDH

recommendations in the regional context• To make recommendations for actions in the

Region with respective follow-up and evaluation mechanisms

Participants

• Representatives of different sectors of the three spheres of government;

• Representatives of civil society active in the Region;

• Regional and national specialists;

• Regional Institutions of education, research and administration;

• CONASS, CONASEMS, ABRASCO.

Activities

• Definition of regional institution: Aggeu Magalhães Institute/FIOCRUZ for the first Conference in Northeast

• Publication of documents, news, opinions, interviews, experiences and other source of information about the Region in www.dssbr.org;

• Elaboration of working documents:- description and analysis of regional health situation with SDH approach;- on going policies and programs including recommendations to overcome identified problems;

• Regional Conference with 400 invited participants and Web broadcasting

Regional Conference on SDH Northeast, september 2013:

Why Northeast?• Region with the biggest social and health inequities

in the country

• Presence o research centers to analyze different aspects of regional situation

• Important economic, political and social changes with impact on SDH

• Good representation of government, civil society and academic leadership

• FIOCRUZ NE

Regional Conference on SDHNortheast

• Plenary Sessions: “Northeast: recent development, challenges ahead”, “SDH and Health situation in NE” and “Polices and Programs in NE related to SDH”;

• Parallel sessions: “Water and Sanitation”, “Big projects and their impact in Health”, “Access and quality of health services”, “Violence and drugs” and “Food and nutrition security”.

Thank you!

Alberto Pellegrini FilhoDirectorCenter for Studies, Policies and Information on SDH (CEPI-DSS) National School of Public Health/FIOCRUZ.phone: 55-21-2598-2894e-mail: pellegrini@fiocruz.brweb: dssbr.org and bvsdss.icict.fiocruz.br

Modes of Production of Knowledge (Gibbons)

 

  

“Traditional”(Mode 1)

Socially distributed(Mode 2)

“Locus” of production of knowledge

Institutions with walls, mainly universities and research institutions

Collaborative networks of institutions  

Research agenda

Agendas defined by researchers according to development of their disciplines 

Agendas defined in contexts of application 

Types of research

Basic (to know to understand) vs. Applied (to know to utilize) 

Problem solving 

Approach Disciplinary 

Transdisciplinary 

Modes of Production of Knowledge (Gibbons)

Relationship between producers and users of knowledge

Unidirectional and “a posteriori” transfer of knowledge 

Continuing exchange of knowledge  

Criteria for evaluation

Scientific Merit 

Scientific merit and social relevance 

Means of dissemination of results

Scientific Journal 

Several media 

Financing Public resources Diversity of public and private sources 

Management of scientific activity

Centralized planning Creation of spaces/opportunities for interaction

Disminución de la desigualdad em A. Latina por país 2000-2010 (% de cambio anual del Gini)

Fuente: Nora Lustig, Luis F. Lopez-Calva e Eduardo Ortiz-Juarez

Coeficiente de Gini en Argentina, Brasil y Mexico 1992-2010Fuente: Nora Lustig, Luis F. Lopez-Calva e Eduardo Ortiz-Juarez

Technical cooperation on capacity building to implement Rio Declaration

Institutional Development

Methodologies/Technologies

Human Resources development

Governance

Social participation

Health sector

Global action

Monitoring

Causes of Infant MortalitySource: César Victora, CNDSS

Cause Ano North NE SE South CO Brazil

Perinatal 1985-872003-05

42.1 61.2

42.962.2

48.961.0

46.458.7

48.757.2

46.560.9

Malformations 1985-872003-05

4.912.7

3.611.4

8.118.3

11.421.5

8.620.0

7.115.7

Respiratory Infections

1985-872003-05

11.5 8.2

11.4 6.9

15.7 6.6

14.2 5.9

12.9 6.8

13.9 6.9

Diarrhea 1985-872003-05

30.1 5.1

27.0 7.1

11.8 1.8

12.5 1.9

12.9 3.1

17.3 4.2

Other infections 1985-872003-05

5.35.2

6.14.2

5.34.2

6.03.1

7.13.8

5.74.2

Other causes 1985-872003-05

6.17.6

9.08.2

10.2 8.1

9.58.9

9.89.1

9.58.1

  Ill-defined Causes

1985-872003-05

23.911.0

45.59.7

6.03.9

11.0 4.3

11.6 2.7

23.0 6.9

Participation of Ministries in selected actions – 2004-2006

2,3 4,7 1,27,0

22,1

2,311,65,8

8,1

4,7

11,6

4,73,5

5,8 3,51,2

MAPA

MCID

MCID

MDA

MDS

ME

MEC

MI

MJ

MMA

MS

MTRE

PR

PR/SEDH

PR/SEPM

PR/SEPPIR

Participation in selected actions by theme – 2007

9,3

18,6

9,3

16,33,5

18,6

24,4

Agricultura

Ambiente/Habitação

Prev. e Combate a Violência e Prom. Direitos

Trabalho e Inclusão Produtiva

Alimentação

Educação, Esporte e Cultura

Proteção Social para Grupos Vulneráveis

Total values executed by theme - 2006

US$ (1.000) %

Agriculture 78,289 0,86

Nutrition 770,950 8,47

Environment/

Housing

87,377 0,96

Education, Sport and culture

42,865 0,47

Prevention of Violence

29,977 0,33

Socail Protection 8,081,656 88,75

Employment and productive inclusion

15,367 0,17

Total 9,106,481 100

Women with 25 years or older that never did screening for cervix cancer according to years of

schooling

% of live newborns in hospital births according to years of schooling

% of live newborns in hospital births according to years of schooling

% of live newborns with 7 or more pre-natal visits according to mother’s years of schooling

% of live newborns with 7 or more pre-natal visits according to mother’s years of schooling