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Naomar de Almeida FilhoInstituto de Sade Coletiva

Universidade Federal da Bahia

Social structure,health of vulnerablepopulations and the

equity-promotion roleof health systems

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1964-1985 Military dictatorship

US dependent foreign policy External debt (economic miracle) Political repression National security ideology

Economic & political background

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1986-2002 1988 New Constitution

Hyperinflation Economic crisis External debt explosion Political freedom Neoliberal ideology

Economic & political background

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Economic & political background

2003-present Reconstruction of the State

Sustained economic growth Technological dependency Independent foreign policy Expanded social policies

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Economic developmentPoverty reduction

Environmental challengesDilemas in the labor contextViolence and intoleranceReduction of social inequalities

Social Context

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Evolution of Social Class Profile.Brasil: 1992-2009

Fonte: FGV A Nova Classe mdia: O lado brilhante dos pobresFonte: FGV A Nova Classe mdia: O lado brilhante dos pobres

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Percentage change in Gini coefficient by country.Latin America, 2000-2006

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11/23Source: Brazil - IPEA; other countries - Central Intelligence Agency's World Factbook

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Reconstruction of the State:Debate public vs. private

Rhetorical intersectorialityLate expansion of public policiesFight against corruption

Reforms com-promisedIdeological regression

Political Context

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Health inequalities (update)

The life expectancy of Brazilian citizens reached73.5 years in 2010, up 8.5 percent from 67 yearsin 1991, according to the Brazilian Institute of

Geography and Statistics (IBGE) Among women, life expectancy reached 77.4 years

in 2007, from 70.9 years in 1991 life expectancy of Brazilian men increased from

63.2 to 69.8 years in the same period

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Brazil's infant mortality rate dropped to 21.6 deathsfor every 1,000 live births in 2010, a 46 %decrease from the 45.1 deaths per 1,000 births

in 1991. Regional differences in infant mortality rates

remain high. The northeastern region, thepoorest in Brazil, registered an infant mortalityrate of 35.6 deaths per 1,000 living births; in thesouthern region, the rate was 16.1/1,000 births.

Health inequalities (update)

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Brief History of Brazils HealthReform (1988-2009)

1986 8th National Health Conference 1988 The New Constitution

1990 The SUS Law (Unified Health System) 1992 Community Health Agents Program 1996-2000 The Family Health Program 2000-2007 Budget increase (CPMF) 2008-present: Overcoming inequities

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Thesis 1 about responsibility of theState regarding public policies

The Brazilian Statedoes not comply with the

responsibility of providingpublic services with quality,universal access and equity

to its population

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Corollaries of Thesis 1

1.Despite advances, the persistence of socialinequalities is a serious problem thatdeserves special attention not only from

governments at all levels, but also fromthe entire society .2.Expansion of funding, participatory

governance, efficient management andaffirmative action policies can correcthistorical inequities .

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In the fields of health andeducation, in addition to not

guaranteeing high-qualitypublic services (Thesis 1),

the Brazilian state is apromoter of inequality

Thesis 2 about responsibility of theState regarding public policies

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1.In principle universalist, the public healthsystem is underfinanced, withrecognized deficiencies

2.The private sector provides care to thosewho have income big enough topurchase health plans, benefitting fromstrong tax exemptions

3.Private health plans are subsidized by theSUS in higher cost and high-complexityprocedures (not-profitable)

Corollaries of Thesis 2 for Health

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The vicious impact of social inequality onthe Brazilian National Health System

-i gh c om pl ex it y i gh c om pl ex it y ublic services of ublic services of et ter quali tyet ter quali ty ;

-or freeor free

ore access ore accessEff iciencyff iciency

oli t ical oli t icalcapi talapi tal

ocial Valueocial Value

oor majori ty oor majori ty inances the inances the

Statetate ublic ublic

ervices of ervices of ower ower

quali tyual i ty-e tt er q ua li ty e tt er q ua li ty

ervices ervices -ut -ut-f reachf reach

recarious recarious ealth Less ealth Less

accessccess ocial ocial

xclusion xclusion

Reproductionof Submission

aid private aid private ervices of ervices of

et ter qual ity et ter qual ity i th i th

ax exemptionax exemption

ich minority ich minority as as iscal iscal

incentivesncentives

Reproduction of Domination

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RegressiveRegressiveTaxTax

SystemSystem

Political modelPolitical modelreproducesreproducesdominationdomination

State of Social Iniquity

Inequalities inInequalities inHealthHealth

SocialSocialperversion inperversion inEducationEducation

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Health Policy in Brazilopen questions, open choices

Health: human right or commodity? individual health or collective health? health care or health situation? health inequalities or health inequities? social policy or public policy? health policy or health politics ? Politics of Disease or Politics for Health?