Social Determinants of Health Inequities in Brazil

1
Social Determinants of Health Inequities in
Brazil

• Alberto Pellegrini Filho
• Researcher/ Oswaldo Cruz Foundation

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Outline of the presentation

• Some conceptual aspects
• WHO and Brazilian Commissions on SDH
• Health and Health Care in Brazil
• Recommendations of the BNCSDH

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Outline of the presentation

• Some conceptual aspects
• WHO and Brazilian Commissions on SDH
• Health and Health Care in Brazil
• Recommendations of the BNCSDH

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Social Determinants of Health (SDH)

• SDH are social, economic, cultural,
  ethnic/racial, psychological and behavioral
  factors that have an effect on the occurrence and
  distribution of health problems and their risk
  factors in populations
• Factors and mechanisms through which social
  conditions affect health and that can be modified
  by informed action (N. Krieger)
• Social conditions in which people live and work
  (CSDH)
• Social characteristics within which living takes
  place (Tarlov,1996)

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Health Determinants (Dahlgren e Whitehead)
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Definitions

• Inequalities sistematic differences in health
  situation of individuals or population groups
• Inequities health inequalities that in addition
  to be systematic and relevant are also avoidable,
  unjust and unnecessary (Whitehead, 1992)

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Relative risk of death by coronary disease
according to occupation in UK civil servants
(Rose and Marmot, 1981)
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Research on Health Inequalities(Nancy Adler)

• First generation Poverty and Health
• Second generation Health Gradients according SES
• Third generation Mechanisms How does SES get
  into the body?

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Research Questions

• Where health inequities among social groups
  originate?
• What are the pathways from root causes to health
  inequities?
• Where and how should we intervene to reduce
  health inequities?.

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Mechanisms of health inequities
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Outline of the presentation

• Some conceptual aspects
• WHO and Brazilian Commissions on SDH
• Health and Health Care in Brazil
• Recommendations of the BNCSDH

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WHO Commission on CSDH

• 20 internationally recognized personalities from
  governments, civil society and academy
• Put in motion a global initiative to promote SDH
  approach on public policies

• Created by WHA in 2004
• Established in March 2005.
• Final Report in September 2008

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WHO Commission on CSDH

• Michael Marmot (Chair) (UK)
• Frances Baum (Austrália)
• Monique Bégin (Canadá)
• Giovanni Berlinguer (UE)
• Mirai Chatterjee (Índia)
• William Foege (US)
• Yan Guo (China)
• Kivoshi Kurokawa (Japão)
• Pres. Ricardo Lagos (Chile)
• Stephen Lewis (UN, África)
• Alireza Marandi (Iran)

• Pascoal Mocumbi (Moçambique)
• Ndioro Ndiave (UM, IOM)
• Charity Ngilu (Quênia)
• Hoda Rashad (Egito)
• Amartya Sem (US)
• David Satcher (US)
• Anna Tibaijuka (HABITAT, UN)
• Denny Vagerö (Suécia)
• Gail Wilensky (US)

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WHO Commission on CSDH

• Lines of Action
• Country Partners
• Knowledge networks
• Social Participation

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Brazilian National Commission on Social
Determinants of Health (BNCSDH)
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Brazilian National Commission on Social
Determinants of Health

• To generate information and knowledge on social
  determinants of health in Brazil.
• To contribute for the formulation and evaluation
  of public policies aimed to promote health equity
  
• To mobilize different sectors of government and
  civil society to address the social determinants
  of health in the country.

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Process of creation of BNCSDH

• Presidential Act creates the Commission on March
  13, 2006 integrated by sixteen personalities of
  social, economic, cultural and scientific life to
  integrate the Commission
• The diversity in the composition of the
  Commission is an expression of the recognition
  that health is a public good, constructed with
  the participation of all segments of the society

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Composition of BNCSDH

• Adib Jatene
• Aloísio Teixeira
• César Victora
• Dalmo Dallari
• Eduardo E. Gouvêa 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.)

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LINES OF ACTION

• Production and Dissemination of information and
  knowledge on SDH in Brazil
• Evaluation of public policies aimed to promote
  health equity
• Mobilization of different sectors of government
  and civil society to address SDH.
• International Cooperation

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Outline of the presentation

• Some conceptual aspects
• WHO and Brazilian Commissions on SDH
• Health and Health Care in Brazil
• Recommendations of the BNCSDH

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Report of the BNCSDH The Social Causes of
Health Inequities in Brazil
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Population Economically Active accordingl to
economic sectorsBrazil 1940 to 2000Source
Instituto Brasileiro de Geografia e Estatística
(IBGE).
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Distribution of population () - Brazil 1940 a
2000 Source Instituto Brasileiro de Geografia e
Estatística (IBGE).
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Fertility rate Brazil 1940 a 2000 Source
Census (1940-2000). IBGE
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Fertility Rate - Brazil, France and Italy 1900
to 2050
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Fertility rates according to socio-demographic
characteristics 1996 - 2006.
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Brazil
Residence
1996
Years of Schooling
5,0
2006
4,2
3,6
4
3,5
3,0
Total Fertilty Rate
2,8
2,8
2,5
2,4
2,3
2,1
2,0
1,7
1,8
1,8
2
1,5
1,6
1,0
0
12 or more
none
5 to 8
9 to 11
Total
urban
rural
1 to 3
4
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Demographic Pyramids according to familiar income
Brazil 2000
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Illiteracy rate Brazil 1940 to 2000Source
Census
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Life expectancy - Brazil and Regions
1960-2006Source IBGE e Simões
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Infant mortality Brazil and Regions 1960-2006
Source IBGE
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Causes of Infant MortalitySource César Victora,
CNDSS
 
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Polio vaccine coverage Brazil and Regions 1994
to 2006 Sourc National Program of
Inmunizations- PNI.
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of women 25 years old or more submitted to
mammography at least once in a lifetime according
to years of schooling Brazil 2003 PNAD 2003
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of women 25 years old or more submmitted to
screening for cervix cancer at least once in a
lifetime - Brazil 2003Source SINASC
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of life births by number of pre-natal consults
and mothers years of schooling Brazil
2005source SINASC
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Porcentagem de pessoas ocupadas de 10 anos e mais
que se atendem pelo SUS e/ou têm plano de saúde,
por nível de renda (salários mínimos per capita)
Brasil 2003 Fonte PNAD 2003.
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population with Sanitation (water and sewage)
and mortality due to diarrhea Brazil and regions
Source IDB 2006
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of individuals 10 or more years old that used
Internet in the last three months, according to
regions and years of schoolingBrazil
2005Source National household survey 2005
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Mortality Rate and lack of social trust in USA
(Kawachi)
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Health status and lack of interpersonal trust in
USA (Kawachi)
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Social Trust Brazil ( of respondents)
2007Source PSB in Almeida AC
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Social trust in Brazil, according to years of
schooling ( of respondents) 2007 Source PSB in
Almeida AC
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Prevalence of tobacco use (gt 18 years) according
to years of schooling Brazil 1989 e
2003,Source Monteiro et al., 2007
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Outline of the presentation

• Some conceptual aspects
• WHO and Brazilian Commissions on SDH
• Health and Health Care in Brazil
• Recommendations of the BNCSDH

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Inter
-
Social Participation
sectoriality
Distal

Intermediate
Proximal
SDH evidence based interventions
to promote health equity
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General orientations for SDH policies
Macroeconomic policies of market place,
environmental protection and promotion of a
culture of peace and solidarity to promote
sustainable development and to combat social
inequalities, violence, environmental
deterioration and their effects on society.
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General orientations for SDH policies
Policies aimed to promote better living
conditions, assuring universal access to clean
water, healthy work environments, high quality
educational and health services, overcoming
fragmented sectoral actions and promoting an
integrated approach in all levels of public
administration
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General orientations for SDH policies
 Policies aimed to strengthening community
networks of support and solidarity, specially of
vulnerable groups, to promote their participation
in collective actions for better health
conditions and well-being
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General orientations for SDH policies
Policies to promote behavioral changes to reduce
risks and to enhance quality of life, through
educational programs, social communication,
access to healthy food, creation of public spaces
for sports and physical exercises, as well as
prohibition of tobacco and alcohol publicity.
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Actions on SDH for health equity promotion
IntersectorialCoordenation
Evidences
Social Participation
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Participation () of federal government
institutions in selected actions 2004-2006
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Participation () os selected actions by theme
2007
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Total values by themes - 2006
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Implementation of SDH policies

• To create a structure or mechanism in the
  Presidential Cabinet to coordinate intersectorial
  SDH actions (MoH as technical secretariat of this
  structure)
• To create an Office in the Ministry of Health to
  promote SDH actions

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Joint Action FIOCRUZ/MoH

• To establish an SDH Observatory for monitoring
  health inequities, as well as for follow-up and
  evaluation of policies and interventions on SDH
• To develop training courses for managers, health
  professionals and other social workers
• To develop studies and research projects about
  SDH
• To develop communication processes and strategies
  about SDH to diverse social sectors

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Portal on SDH

• Information and Knowledge on SDH from information
  systems and national and international literature
• Monitoring health inequities, follow-up and
  evaluation of interventions
• Virtual courses for managers in the diverse
  spheres of public administration
• Information services to several sectors of
  society to promote wide participation in the
  definition and implantation of public policies
  related to SDH
• Spaces and opportunities of interaction for
  strategic actors such as decision makers,
  managers, researchers, health professionals and
  others.

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determinantes.saude.bvs.br
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Search with clustering of the results by SDH
categories
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News andHighlights
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2
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Intersectorial network of institutions related
to SDH
Collections of international, regional and
national information sources operated by the
portal filtering SDH related contents
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THANK YOU

• Alberto Pellegrini Filho
• Fundação Oswaldo CruzAv. Brasil 4365Mourisco
  sala 505ManguinhosCEP 21045-900
• Rio de Janeiro RJ Brazil

• Phone [phone]Fax [phone]Mobile
  55-21-9962-9606e-mail pellegrini_at_fiocruz.br 

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Modes of Production of Knowledge (Gibbons)
     
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Modes of Production of Knowledge (Gibbons)
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In a new mode of production knowledge socially
distributed the problems are formulated and
research is developed in a problem solving
context, involving a complex interaction between
specialists, users, and funders. (Gibbons et
al., 1994)