Social Determinants of Health Inequities in Brazil

1. Social Determinants of Health Inequities in Brazil Alberto Pellegrini Filho Researcher/ Oswaldo Cruz Foundation

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

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

4. 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)

5. Health Determinants (Dahlgren e Whitehead)

6. 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)

7. Relative risk of death by coronary disease according to occupation in UK civil servants (Rose and Marmot, 1981)

8. 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?

9. 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?.

10. Mechanisms of health inequities

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

12. 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

13. 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) WHO Commission on CSDH

14. WHO Commission on CSDH Lines of Action • Country Partners • Knowledge networks • Social Participation

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

16. 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.

17. 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 Process of creation of BNCSDH

18. 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.) Composition of BNCSDH

19. 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

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

21. Report of the BNCSDH:The Social Causes of Health Inequities in Brazil

22. Population Economically Active accordingl to economic sectorsBrazil – 1940 to 2000Source: Instituto Brasileiro de Geografia e Estatística (IBGE).

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

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

25. Fertility Rate - Brazil, France and Italy – 1900 to 2050

26. Fertility rates according to socio-demographic characteristics 1996 - 2006. 6 Brazil Residence Years of Schooling 1996 5,0 2006 4,2 4 3,6 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 1,6 1,5 1,0 0 12 or more none 5 to 8 9 to 11 Total urban rural 1 to 3 4

27. Demographic Pyramids according to familiar income Brazil – 2000

28. Illiteracy rate – Brazil – 1940 to 2000Source: Census

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

30. Infant mortality Brazil and Regions – 1960-2006Source: IBGE

31. Cause Ano North NE SE South CO Brazil Perinatal 1985-87 2003-05 42.1 61.2 42.9 62.2 48.9 61.0 46.4 58.7 48.7 57.2 46.5 60.9 Malformations 1985-87 2003-05 4.9 12.7 3.6 11.4 8.1 18.3 11.4 21.5 8.6 20.0 7.1 15.7 Respiratory Infections 1985-87 2003-05 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 1985-87 2003-05 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 1985-87 2003-05 5.3 5.2 6.1 4.2 5.3 4.2 6.0 3.1 7.1 3.8 5.7 4.2 Other causes 1985-87 2003-05 6.1 7.6 9.0 8.2 10.2 8.1 9.5 8.9 9.8 9.1 9.5 8.1 Ill-defined Causes 1985-87 2003-05 23.9 11.0 45.59.7 6.0 3.9 11.0 4.3 11.6 2.7 23.0 6.9 Causes of Infant MortalitySource: César Victora, CNDSS

32. Polio vaccine coverage Brazil and Regions – 1994 to 2006Sourc: National Program of Inmunizations- PNI.

33. % of women 25 years old or more submitted to mammography at least once in a lifetime according to years of schooling – Brazil – 2003PNAD 2003

34. % of women 25 years old or more submmitted to screening for cervix cancer at least once in a lifetime - Brazil – 2003Source: SINASC

35. % of life births by number of pre-natal consults and mother’s years of schooling – Brazil – 2005source: SINASC

37. 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 – 2003Fonte: PNAD 2003.

38. % population with Sanitation (water and sewage) and mortality due to diarrhea Brazil and regionsSource: IDB 2006

39. % 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

40. Mortality Rate and lack of “social trust” in USA (Kawachi)

41. Health status and lack of interpersonal trust in USA (Kawachi)

42. FAMILY FRIENDS NEIGHBORS COLLEAGUES MOST OF PEOPLE DO NOT TRUST 16 70 77 70 85 TRUST 84 30 23 30 15 Social Trust Brazil (% of respondents) 2007Source: PSB in Almeida AC

43. Years of Schooling TRUST IN FAMILY TRUST IN FRIENDS YES NO YES NO Illiterate 83 17 31 69 0- 4 years 82 18 23 77 5 – 8 78 22 21 79 9 - 11 86 14 30 70 12 0r more 96 4 60 40 Social trust in Brazil, according to years of schooling (% of respondents) 2007Source: PSB in Almeida AC

44. Prevalence of tobacco use (> 18 years) according to years of schooling Brazil 1989 e 2003,Source: Monteiro et al., 2007

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

46. Inter - Social Participation sectoriality Distal Intermediate Proximal SDH evidence based interventions to promote health equity

47. 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.

48. 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;

49. 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;

50. 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.