Brazil

Carlos A. M. Guerreiro

Introduction

Brazil is a country of continental dimensions (8,511,965 km²), divided into 26 states and a federal district. In 2004, its population was estimated to be 178.4 million inhabitants; life expectancy at birth (male/female), 66.0/73.0 years; gross domestic product (GDP) per capita (international $, 2002), U.S. $7,762; health life expectancy at birth (male/female), 57.2/62.4; child mortality (male/female) per 1,000, 39/32; adult mortality (male/female) per 1,000, 240/129; and total health expenditure per capita (international $, 2002), 611; and total health expenditure as percentage of GDP (2002), 7.9.⁵³ In October 2005 the estimated population was 184.7 million inhabitants.

Brazil has achieved dramatic results in improving living conditions: Infant mortality declined from around 50 per 1,000 live births in 1990 to 33 per 1,000 in 2000, and net enrollment in basic education rose from 84% in 1991 to 97% in 2002. Brazilians with access to an improved water source rose from 73% of the population in 1986 to 87% in 2001.

Despite Brazil’s impressive advances, the poorest one fifth of Brazil’s 184.7 million people account for only a 2.2% share of the national income. Brazil is second only to South Africa in a world ranking of income inequality. More than one quarter of the population live on <$2 a day and 13% live on <$1 a day. Brazil’s northeast contains the single largest concentration of rural poverty in Latin America. Past development programs have failed to make a major dent in a region in which 49% of the population is classified as poor.

Crime is plaguing urban Brazil. Political corruption is also a serious problem in the country.

In global terms, Brazil rates 13th in economic strength and among the first group of countries in agricultural production.⁵⁴

Information related to demographic, socioeconomic, and health indicators of the country is listed in Tables 1 and 2.¹⁶^,⁵⁴

General Data on the Health System

Some states in the country suffer more than others, particularly from some long-standing endemic diseases such as dengue, cholera, Chagas disease, schistosomiasis, and malaria. New diseases, such as AIDS, are also a growing problem.

The rate of reported AIDS cases increased from 10.6 per 100,000 in 1992 to a high of 18.7 per 100,000 in 1998. Brazil has experienced a stabilizing trend with rates of 16.5, 16.4, and 14.8 per 100,000 in 1999, 2000, and 2001, respectively. In the last decade, heterosexual transmission of reported AIDS cases grew from 25.8% in 1991 to 56.1% in 2002. Since 1998, the death rate from AIDS has stabilized at 6.3 per 100,000. This tendency is attributed to Brazil’s guarantee of access to free antiretroviral drugs since 1996.

The country also rose to the challenge posed by the single biggest health threat in the modern world, pioneering an anti-HIV/AIDS strategy that became an international model by guaranteeing universal access to retroviral medication.¹⁵

Brazil has a constitution that states that health is the right of every citizen and the duty of the state to provide. A law was passed on September 19, 1990, creating the Unified Health System (Sistema Único de Saúde [SUS]). The SUS is composed of the health activities and services provided by municipal, state, and federal organizations and institutions. This same law assumed the coexistence of private medicine in its various forms.

Despite this legislation, a great number of problems remain. These range from the social policies practiced by the federal government to the management of responsibility at the different levels and the effective management of rendering services.

Although SUS theoretically offers total coverage to everyone, in reality, only 77% of the population is covered, according to an estimate that we have applied using data from the federal government from 1994 (from the Bulletin of Ministry of Economy, 1994). Of those not covered, 22% were unassisted, and another 55% received some assistance. The remaining 23% sought assistance from the private sector: Medical insurance, health maintenance organizations (HMOs), traditional fee-for-service providers, and others.

Large portions of citizens receiving private medical care eventually seek, or are directed to, public health services. This happens especially in cases of chronic or terminal diseases and those involving complex and costly procedures. In these cases, there is no reimbursement from the public sector.

Epilepsy Data

An epidemiologic study with a selected sample size of 17,293 individuals revealed that the cumulative prevalence of epilepsy in São José do Rio Preto, a 350,000-inhabitant city in São Paulo state, was 18.6 per 1,000 inhabitants with 8.2 being active, defined as at least one seizure within the last 2 years. The prevalence per 1,000 inhabitants for the age groups (years) was 4.9 (0 to 4), 11.7 (5 to 14), 20.3 (15 to 64), and 32.8 (65 or over).¹²

Table 1 Socioeconomic, Demographic, and Health Indicators Data about Brazil

	Most recent year	Data
Socioeconomic context
Total population (000s)	2003	176,596
GNI per capita, Atlas method (U.S.$)	2003	2,760
Expected years of schooling	2002	15
Adult literacy rate (% of population ages 15+)	2003	88
Demographic indicators
Average annual population growth rate (%)	1990–2003	1.4
Age dependency ratio (dependents as a proportion of working-age population)	2003	0.5
Total fertility rate (births per woman)	2003	2.1
Adolescent fertility rate (births per 1,000 women ages 15–19)	2003	68
Contraceptive prevalence rate (% of women ages 15–49), any method	1996	76.7
Health status indicators
Life expectancy at birth (yr)	2003	69
Infant mortality rate (per 1,000 live births)	2003	33
Under 5 yr of age mortality rate (per 1,000)	2003	35
Maternal mortality ratio (per 100,000 live births), modeled estimates	2000	260
Prevalence of child malnutrition—underweight (% of children under age 5)	1996	6
Health care indicators
Child immunization rate, measles (% of ages 12–23 months)	2003	99
Child immunization rate, DPT3 (% of ages 12–23 months)	2003	96
Births attended by skilled health staff (% of total)	1996	87.6
Physicians (per 1,000 people)	2001	2.1
Hospital beds (per 1,000 people)	1996	3.1
Tuberculosis treatment success rate (% of registered cases)	2002	75
DOTS detection rate (% of estimated cases)	2003	18
Health finance indicators
Health expenditure, total (% of GDP)	2002	7.9
Health expenditure, public (% of GDP)	2002	3.6
Health expenditure, public (% of total health expenditure)	2002	45.9
Health expenditure per capita (U.S.$)	2002	206.0
Risk factors and future challenges
Prevalence of HIV, total (% of population ages 15–49)	2003	0.70
Prevalence of HIV, female (% of population ages 15–24)	2001	0.50
Tuberculosis incidence (per 100,000 people)	2003	62
Tuberculosis death rate (per 100,000 people)	2002	8
DOTS, directly observed treatment strategy; DPT3, three doses of the combined vaccination against diphtheria, pertussis, and tetanus; GDP, gross domestic product. GNI, gross national income. From World Bank. Health Nutrition Population. Available at: http://web.worldbank.org.easyaccess1.lib.cuhk.edu.hk/WBSITE/ EXTERNAL/COUNTRIES/LACEXT/BRAZILEXTN/0, contentMDK:20189430∼pagePK: 141137∼piPK:141127∼theSitePK:322341,00.html. Accessed: August, 2005.

Very recent data from the Demonstration Project of Global Campaign Against Epilepsy, in Brazil, supported by the International League Against Epilepsy, the International Bureau for Epilepsy, and the World Health Organization, revealed that the prevalence of cumulative and active epilepsy, respectively, was 9.1 per 1,000 and 5.3 per 1,000 people in Campinas and São José do Rio Preto, both in São Paulo state.⁴⁰ The prevalence of active epilepsy was higher in the more deprived social classes (range from A = richest to E = poorest) in Campinas and in São José do Rio Preto (Class D + E = 7.4 vs. Class A = 1.6 per 1,000). Over one third of patients with active epilepsy had inadequate treatment, including 19% who were on no medication. These data illustrate the treatment gap in the area.⁴⁰ In another study based on data from the central municipal pharmacy of Campinas and São José do Rio Preto in 2003, it was estimated that in the best-case scenario, 50% of patients with epilepsy were not on medication on a regular basis.⁴¹

Campinas and São José do Rio Preto are two cities located in one of the wealthier regions of Brazil, where there is a good public and private health care system and where the population has easy access to treatment.

Neurologists

Based on data furnished by a Novartis profile, 4,863 neurologists were identified in Brazil in 2005. This probably included clinical neurologists, pediatric neurologists, and some neurosurgeons who practice clinical neurology. According to the Brazilian Academy of Neurology, there are 1,197 members, and the Brazilian Epilepsy Society had 477 members in 2005. The distribution of the number of neurologists per 100,000 inhabitants in the different states is shown in FIGURE 1. An analysis of FIGURE 1 reveals a distinct relationship between the per capita income of the state and the number of accessible neurologists. The higher-income areas have more neurologists,

as in the case of the Federal District and the states of Rio de Janeiro, São Paulo, and Rio Grande do Sul. The latter state’s rates are close to those of the northeastern states in the United States.³⁸

Table 2 General Information about Brazil in 2000, 2003, and 2004

	2000	2003	2004
People
Population, total	170.1 million	176.6 million	178.7 million
Population growth (annual %)	1.2	1.2	1.2
National poverty rate (% of population)	··	··	··
Life expectancy (yr)	··	68.7	··
Fertility rate (births per woman)	··	2.1	··
Infant mortality rate (per 1,000 live births)	35.0	33.0	··
Under 5 yr of age mortality rate (per 1,000 children)	39.0	35.0	··
Births attended by skilled health staff (% of total)	··	··	··
Child malnutrition, weight for age (% of children under age 5)	··	··	··
Child immunization, measles (% of under 12 mo)	99.0	99.0	··
Prevalence of HIV, total (% of population aged 15–49)	··	0.7	··
Literacy rate, adult male (% of males ages 15 and above)	··	88.3	··
Literacy rate, adult female (% of females aged 15 and above)	··	88.6	··
Primary completion rate, total (% age group)	111.0	112.0	··
Primary completion rate, female (% age group)	111.0	··	··
Net primary enrollment (% relevant age group)	94.6	··	··
Net secondary enrollment (% relevant age group)	69.2	··	··
Environment
Surface area (km²)	8.5 million	8.5 million	··
Forests (1,000 km²)	5.4 million	··	··
Deforestation (average annual % 1990–2000)	0.4	··	··
Internal freshwater resources per capita (cubic meters)	··	30,680.2	··
CO₂ emissions (metric tons per capita)	1.8	··	··
Access to improved water source (% of total population)	··	··	··
Access to improved sanitation (% of urban population)	··	··	··
Energy use per capita (kg of oil equivalent)	1,091.3	··	··
Electricity use per capita (kWh)	1,877.5	··	··
Economy
GNI, Atlas method (current U.S.$)	620.8 billion	486.9 billion	552.1 billion
GNI per capita, Atlas method (current U.S.$)	3,650.0	2,760.0	3,090.0
GDP (current U.S.$)	601.7 billion	505.7 billion	604.9 billion
GDP growth (annual %)	4.4	0.5	5.2
GDP implicit price deflator (annual % growth)	9.8	15.0	8.1
Value added in agriculture (% of GDP)	7.3	5.8	5.2
Value added in industry (% of GDP)	28.0	19.1	17.2
Value added in services (% of GDP)	64.7	75.1	77.7
Exports of goods and services (% of GDP)	10.7	16.9	22.5
Imports of goods and services (% of GDP)	12.2	13.1	17.0
Gross capital formation (% of GDP)	21.5	17.3	19.2
Revenue, excluding grants (% of GDP)	··	··	··
Cash surplus/deficit (% of GDP)	··	··	··
Technology and infrastructure
Fixed lines and mobile telephones (per 1,000 people)	318.7	486.5	··
Telephone average cost of local call (U.S.$ per 3 minutes)	0.0	··	··
Personal computers (per 1,000 people)	50.1	··	··
Internet users (per 1,000 people)	29.4	··	··
Paved roads (% of total)	5.5	··	··
Aircraft departures	617.8 thousand	486.8 thousand	··
Trade and finance
Trade in goods as a share of GDP (%)	18.9	25.1	··
High-technology exports (% of manufactured exports)	18.6	12.0	··
Net barter terms of trade (1995 = 100)	100.0	··	··
Foreign direct investment, net inflows in reporting country (current U.S.$)	32.8 billion	10.1 billion	··
Present value of debt (current U.S.$)	223.8 billion	254.1 billion	··
Total debt service (% of exports of goods and services)	93.5	63.8	··
Short-term debt outstanding (current U.S.$)	31.0 billion	19.6 billion	··
Aid per capita (current U.S.$)	1.9	1.7	··
GDP, gross domestic product; GNI, gross national income. From Development Indicators Database. Available at: http://devdata.worldbank.org.easyaccess1.lib.cuhk.edu.hk/external/CPProfile.asp?SelectedCountry=BRA&CCODE+BRA&CNAME=Brazil&PTYPE=CP. Accessed August 2005.