Coverage and equity in reproductive and maternal health interventions in Brazil: impressive progress following the implementation of the Unified Health System

Social inequalities are still a major problem in Latin America in spite of recent economic growth [1, 2]. Health inequalities are also a leading health problem in the region [1–3]. In response to these challenges, substantial increases in public funding for social programmes and the adoption of relevant policies and strategic health-related initiatives took place in the region over the past few decades [3, 4]. Brazil provides an example of a distinct approach to health-system reform, combining poverty reduction strategies with the expansion of comprehensive primary health care services [5, 6]. Hence, lessons from the Brazilian experience are relevant for countries advancing in universal health coverage.

The health sector reform in Brazil is unique because it was driven by civil society rather than by governments, political parties, or international organizations [5, 7]. It was designed by militants of the so-called Sanitary Movement nearly a decade before health care was incorporated in the 1998 Constitution as a citizen’s right and State’s duty [7–9]. In the 1990’s health sector reform was institutionalised with the creation of a national Unified Health System (SUS, Sistema Único de Saúde), based on the principles of universality, equity, integrality and social participation [5, 8].

Since then, the SUS became a driving force for equalizing access to services by offering free and comprehensive health care for all, independent of contribution or affiliation [5, 9]. Other advances during the past 20 years included investments in human resources, primary care, science and technology, decentralization, widespread social participation, and growing public awareness of a right to health care. Among the many programs and policies put in place since the inception of SUS, two are of major importance. First, the Family Health Program changed the structure of traditional primary health care centres, adding community health workers and defining catchment areas for facilities. The program was targeted at the poorest, under-served urban neighbourhoods and rural areas [10]. Later, the Programa Bolsa Família, a conditional cash transfer program, unified several social benefit initiatives in one large program designed to provide extra cash to the poorest families in the country, conditional on use of health services by children and on regular school attendance. The program was successful in reducing income inequality [11], contributing to a significant decrease in childhood mortality, especially from poverty-related causes such as malnutrition and diarrhea [12]. In parallel, the country went through a period of rapid economic changes, with the control of hyperinflation in 1994, and strong economic growth between 2004 and 2011.

Despite criticisms regarding underfunding and poor management of the SUS, as well as of the unequal distribution of power and resources, [8] there is mounting evidence that health inequalities in Brazil have been steadily declining [5]. Since 1990’s, Brazil has increased intervention coverage in maternal and child interventions, reduced inequalities in terms of under-5 mortality and practically eliminated inequalities in stunting [2]. However, it is worth noting that most of this evidence is based on the Brazilian household survey conducted in 2006, and therefore, no reliable population-based data on maternal and child health has been available for the last 9 years. In this article, we describe how coverage and inequalities in reproductive and maternal health interventions evolved over time, based on the analyses of four national household surveys carried out from 1986 to 2013, covering a period of nearly three decades.

In spite of its economic growth up to the recent past, Brazil is still among the five Latin American countries with the greatest income inequalities [24, 25]. Nevertheless, our findings show improved equity in access to health services as can be seen by increased coverage in reproductive and maternal health interventions and the remarkable reductions in geographic and wealth-related inequalities. Even the poorest 20 % of women and those living in rural or remote areas achieved near universal coverage levels with preventive interventions by 2013. To date, this is the first study to examine the evolution of coverage and inequalities of a relevant set of maternal health interventions covering a period of three decades and including the most recent data from national household surveys in Brazil. In addition, this article presents the most complete evidence of universal coverage achievement in terms of maternal health interventions.

In terms of improving equity, the best possible combination is when both absolute and relative indices improve; this was the case Brazil for all selected interventions, that shows important progress across all quintiles of wealth index and also faster progress among the poorest 20 %.

Several factors seem to have contributed to increasing coverage and reducing inequalities, [6], including economic growth, reduction in income inequality, urbanisation, improved education, and decreased fertility. The control of hyperinflation in 1994, modernization of the Brazilian economy, high Gross Domestic Product (GDP) growth rates between 2004 and 2011, and increased social investment contributed to this positive scenario. Anti-poverty actions such as the conditional cash transfer programme (Programa Bolsa Família) are likely to have contributed to the changes.

Within the health sector, the creation of the tax-funded national health system (SUS) in 1988 extended free health care to a significant proportion of the population that was excluded until then, mostly rural workers and the unemployed or informal workers [5, 9]. Before the inception of SUS, Brazil’s healthcare system was based on private organizations that received large government subsidies. An important program was the Family Health Program (Programa Saúde da Família – PSF), established in the mid-1990s, which expanded the primary health care network to reach the poorest areas of the country. Its innovative approach of starting with areas that were devoid of any services, and the inclusion of community health workers to the health team was enormously successful, with its coverage expanding rapidly since its inception, reaching 55 % in 2012 [3, 4, 6, 9]. The SUS also includes a National Immunisation Programme (PNI) and the Farmácia Popular, a program that delivers free or heavily subsided medicines for diabetes, hypertension, asthma, and other common diseases through accredited private pharmacies [5, 26].

The Brazilian healthcare system is a mix of public and private services, and users are free to choose between them. Public health services are provided mostly by public facilities at the primary care level, and by private and philanthropic hospitals at tertiary level. The system is financed through direct taxes and social contributions [5, 26]. Public funding for the SUS has been steadily increasing over the years in both absolute values and in proportion of GDP. The percentage of the GDP spent on health increased from 7.2 % in 2000 to 9.5 % in 2012, in addition, the government funding accounted for 47.5 % of the expenditure on health in 2012.

The public health expenditure share of the GDP in all levels of government – federal, state and municipal - increased from 2.9 to 3.9 % between 2000 and 2011 [27]. Despite these advances, the public health expenditure in Brazil is still much lower compared to other countries with universal health systems [28]. Total health expenditures per capita have also increased steadily over the years; however, the government still accounted for less than 50 % of total health expenditure by 2012 [29]. The remainder results from a combination of out-of-pocket and private insurance spending, which is among the highest levels of private spending on health in Latin America [30].

Additional evidence shows that out-of-pocket spending as a proportion of total spending varies little between the poorest and wealthiest classes [5, 31]. For instance, the catastrophic health expenditure (10 % or more of capacity to pay based on household consumption) was 18.4 % from the poorest and 17.7 % for the wealthiest in 2008–2009 [32]. However, rich and poor spend these funds in different ways. Among the latter, out-of-pocket expenditures are mostly due to purchasing medicines, whereas the richest spend most on private health insurance [5, 31].

Our results on C-section rates confirm the disturbing trends documented by the nationwide information system (DATASUS) [33]. Among the wealthiest quintile the proportion of C-sections was above 80 % in 2013. These rates are unacceptable high considering those recommended by WHO despite several efforts to encourage vaginal deliveries and limit C-sections: payment of delivery analgesia for SUS patients (1998), the Pact for C-section Rate Reduction between the Brazilian Ministry of Health and state health departments (2000), enforcement of a ceiling of 27 % C-section rate for states that did not sign the Pact (2002), and a national mass campaign, “Humanization of Normal Childbirth and Reduction of Unnecessary Cesareans” (2006) [34]. In Brazil, obstetricians assist almost all deliveries regardless of financing or budget constraints, and their convenience may play an important role in the decision about the type of delivery. There is widespread evidence that doctors’ attitudes during the prenatal and peri-delivery period may increase the likelihood of a C-section [34]. Unless strong and immediate action is taken, Brazil is at risk of reaching universal coverage for an intervention which is estimated to be necessary at most for 15 % of all deliveries [35].

A main limitation of our analyses is that some of the surveys failed to employ internationally-standardized questionnaires, so it was not possible to estimate key RMNCH indicators, nor to assess time trends for more than a few indicators. Standardized surveys, carried out every 3–5 years, are essential for monitoring progress and identifying trends in inequalities. It is worth noting that other relevant dimensions of social inequalities in intervention coverage were not assessed, including those associated with women’s schooling or ethnic group.

In summary, there was enormous progress from 1986 to 2013 for key interventions in reproductive and maternal health, both in terms of coverage and inequality. Disparities in C-section rates remain, but these are due to exceedingly high rates of unnecessary procedures among the rich, rather than low rates among the poor. Dissemination of the lessons learned is Brazil is particularly relevant in light of the focus on universal health coverage and equity which are key aspects of the Sustainable Development Goals (SDGs) of the 2030 Agenda for Sustainable Development adopted by world leaders in September 2015.

Despite such progress, the mortality rates of children and mothers remain several fold higher in Brazil than in the best-performing countries [36, 37] indicating that there is still much room for improvement. Substantial challenges remain for the Brazilian health system, including reforming its financial structure to ensure universality and long term sustainability, renegotiating public and private roles, and assuring quality and efficiency of care while minimizing medicalization and ensuring patient safety – as exemplified by the high C-section rates [5]. In terms of equity, the overarching challenge is how to reach those who are hardest to reach, such as rural populations in the Amazon rainforest and northeast regions, indigenous groups, and families living in Brazilian municipalities where with insufficient human resources for health [6]. Also, ensuring universal access is insufficient unless high-quality care is provided and missed opportunities for promoting other interventions is assured [5, 38, 39]. We hope that our findings will inform policy debates on strategies to achieve universal coverage and to reduce health inequalities in other low- and middle-income countries, and showcase the importance of tracking progress by regularly collecting data.