Brazilians with less education more likely to report being in poor health, study finds

The study found that people in Brazil with less education were more likely to identify themselves as being in poor health. The data pictured are from the Brazil National Health Survey 2013. Credit: Julie McMahon, University of Illinois

Brazilians with less education are more likely to self-report as being in poor health, according to a study using data from nationwide surveys distributed every five years from 1998 to 2013. The study also found that general subjective health did not improve over the study period, even though more people gained education throughout the study, indicating that other factors associated with poor education may need to be addressed to improve self-perceptions of health.

17 may 2018--University of Illinois researchers Flavia Cristina Drumond Andrade, a professor of kinesiology and community health, and Jeenal Deepak Mehta, an undergraduate student, published the study in the journal PLOS ONE.
"Self-reported perceived health is an effective health indicator that has been shown to be a good predictor of mortality," Andrade said. "In social contexts such as developing countries, in which some diseases may go unnoticed or undiagnosed for a while, survey data can give a good sense of individuals' assessment of their overall health."
Andrade and Mehta used data from the 1998, 2003 and 2008 Brazilian National Household Sample Survey and the Brazil National Health Survey 2013. The surveys included many factors, such as education levels, employment, race, location and health. Participants reported themselves as being in "good" or "poor" health.
Overall, the percentage of those who reported themselves as being in poor health was fairly small—the highest being 5.9 percent in 2013. However, when the researchers separated the respondents by education level, they found that the less education a group had, the higher the percentage of self-reported poor health.
The gradient was sharp, and consistent across all years of the survey: Those with no education were seven to nine times more likely to report poor health than those with at least some college.
"Often, those with lower education experience worse employment—with lower wages, worse working conditions and less access to health care—than those with more education," Andrade said. "They may also engage in unhealthy lifestyle behaviors, in part due to lower health knowledge and in part due to economic restrictions. All these conditions put them in relative disadvantage, which could be translated as worse perceived health."
Over the course of the surveyed years, Brazil experienced a period of educational development, Andrade said. The percentage of those who had completed high school rose from 13.9 percent in 1998 to 28.6 percent in 2013, and the percentage of those with some college or more rose from 9 percent to 19.1 percent. Yet the overall percentage of self-reported poor health has not varied largely, and even rose a bit in 2013, although education levels rose.
Again, the researchers noticed a difference in health reporting over time according to education levels.
"There was a worsening of self-reported perceived health among those with primary or secondary education. This is important because most Brazilians are in this group—74.8 percent in 1998 and 68 percent in 2013. On the other hand, we do not see this pattern among those with some college or more. For them, the levels of poor self-reported health did not change."
The researchers posit that these changes may be related to the slowing of economic growth that Brazil experienced over the last two survey cycles.
"Those with less education often suffer with lower incomes and more during these economic decelerations. When relative conditions worsen, perceptions of health and well-being also tend to get worse among those at the bottom of the social scale," Andrade said.
In addition, Andrade urges those seeking to improve general health in Brazil to address not only education but also the aging of the population—the average age of the survey respondents increased from 40 to 44 years over the study period—and the prevalence of chronic conditions, such as diabetes, that were reported on the surveys.
"With increases in age, there are also increases in poor self-perceived health," Andrade said. "Along with the demographic transition, there were also increases in the prevalence of some chronic conditions, which also impacts the perception of health. Therefore, efforts to prevent and control chronic conditions are necessary to improve self-perceptions of health in Brazil."

More information: Flavia Cristina Drumond Andrade et al, Increasing educational inequalities in self-rated health in Brazil, 1998-2013, PLOS ONE (2018). DOI: 10.1371/journal.pone.0196494


Provided by University of Illinois at Urbana-Champaign

Brazil hires 4,000 Cuban doctors to treat poor

Brazil will import thousands of Cuban doctors to work in areas where medical services and physicians are scarce, and Foreign Minister Antonio Patriota defended the plan Thursday as a way to give "the best possible medical services for the Brazilian population."

23 aug 2013--The Health Ministry said in a statement posted on its website that it signed an agreement with the Pan-American Health Organization to hire 4,000 Cuban doctors, who are expected to arrive in Latin America's biggest country by the end of the year. The first 400 are scheduled to arrive within the next few days.

The government is bringing in Cuban doctors after failing to attract enough Brazilian and foreign physicians to its "More Doctors" program meant to send professionals to work in needy urban and rural areas for three years.

The government created the program following mass street demonstrations across Brazil in which protesters demanded better public services.

The effort has drawn the ire of Brazilian doctors, who say there are plenty of homegrown physicians to work in those areas, if only the government would invest in hospital infrastructure and provide better wages in public health care. They also sharply criticize the qualifications of the Cuban doctors.

Government officials from President Dilma Rousseff on down have repeatedly criticized Brazilian physicians seeking to block the import of foreign doctors as elitists who only want to work in cities like Sao Paulo and Rio de Janeiro, where they can earn big incomes in pristinely equipped private hospitals. In July, the government proposed making medical students work in poor areas as part of their residencies, drawing widespread criticism from doctors as too much official meddling in training. Congress is expected to take up the measure in the coming months.

The Health Ministry said 3,500 cities and towns across Brazil are taking part in the "More Doctors" program and have requested 15,000 physicians. So far 1,300 have signed up. Of that total, 1,000 are Brazilian and 300 are either Brazilian who studied overseas or foreign doctors, mainly from Argentina, Spain and Portugal.

Foreign doctors in the program will receive a monthly salary of $4,080. In the case of the Cubans, the government will send their wages to Cuba's government through the Pan-American Health Organization. Cuba will then decide how much each doctor will receive.

Foreign doctors will have to first spend three weeks studying Brazil's public health system and the Portuguese language, the ministry said.

The Federal Medical Council, which oversees the licensing of Brazilian doctors, said in a statement that the hiring of Cuban doctors who cannot speak Portuguese and whose diplomas have not been revalidated locally violates Brazilian laws and human rights by endangering the lives of Brazilians in poor and remote regions.

Speaking to a congressional committee, Patriota defended the program, saying that "there are a lot of Cuban doctors willing to work in the interior of Brazil and many have experience working in areas like Africa."

The medical council's own statistics show that just 8 percent of Brazilian doctors work in cities of 50,000 people or less, which represent 90 percent of all the country's municipalities, illustrating the poor distribution of physicians.

Cuban medical schools graduate large classes each year, and those doctors have increasingly been a key source of revenue for the country since the medical missions program began in the early 1960s.

A Cuban Health Ministry official said last year that 38,868 Cuban medical workers, including 15,407 doctors, were working in 66 nations.

Some 30,000 Cuban health care professionals are believed to be in Venezuela alone, which provides the island with about 92,000 barrels of oil a day worth an estimated $3.2 billion a year.

Analysts say the export of medical services adds about $6 billion a year to Cuba's economy. By contrast, tourism, the official No. 1 source of incoming cash, brought in $2.5 billion in 2011, according to the most recent statistics available.

© 2013 The Associated Press. 

Brazil to lure foreigners to fill public health posts

Brazil launched a program Monday to lure thousands of foreign doctors to fill vacancies in its public health system, a move criticized by many domestic health care professionals.

10 july 2013--Improving public health services was one of the key demands made by hundreds of thousands of Brazilians who staged three weeks of nationwide street protests last month.

President Dilma Rousseff said the initiative , which will be implemented by presidential decree, will involve 10,000 posts and an investment of around $1.27 billion.

The government said the three-year posts, with a monthly pay of $4,500, would be filled mainly by Brazilian doctors, but foreign counterparts would also be used to fill the gap.

Those selected will begin working in mid-September, mainly in the country's hinterland and poor suburbs of major cities.

"Every Brazilian must have access to a doctor," Rousseff said. "Brazil is short of doctors. If we don't have enough in Brazil, we will look for good doctors wherever they are."

Foreign applicants must come from countries where there are more than 1.8 doctors per 1,000 inhabitants, such as Spain, Portugal, Argentina or Cuba.

But the daily Folha de Sao Paulo reported Monday that the government dropped plans to import thousands of Cuban doctors and instead decided to turn to those from Spain and Portugal. There was no explanation as to why.

"It is an emergency measure to resolve a serious and urgent problem," Rousseff said. "Nobody should be afraid, I will never take away jobs from our professionals or put the health of the population at risk."

The health ministry said there was a shortage of 54,000 doctors across the country.

But Brazilian doctors' associations last month slammed the plan to lure foreign doctors, insisting that the problem was not a shortage of doctors but rather poor management and a lack of resources in the public health sector.

Doctors, nurses and other health care professionals last month joined the nationwide street protests to express their displeasure over the government program.

For a health reform model, try Brazil

During the Harvard-Brazil Symposium, Luciana Mendes Santos Servo (pictured), health coordinator at the Institute for Applied Economic Research in Brazil, traced the changes in that country to Brazil’s 1988 constitution, which recognized health as a right for citizens and created a government obligation to improve it. 

With the 2015 deadline to meet the United Nations' Millennium Development Goals (MDG) approaching, scholars and government officials gathered at the Harvard School of Public Health (HSPH) on Tuesday to search for lessons in the dramatic progress that Brazil has made in recent decades.

25 sept 2012--The eight Millennium Development Goals, adopted in 2000, set targets to attain international development objectives, including reducing extreme poverty and hunger; reducing child mortality; improving maternal health; achieving universal primary education; increasing equality for women; fighting AIDS, malaria, and other diseases; ensuring environmental sustainability; and fostering global partnerships for development.

The Harvard-Brazil Symposium, held in HSPH's Kresge Building, featured discussions of the health-related goals and of Brazil's progress in meeting them. It was sponsored by the Department of Global Health and Population, which is marking its 50th anniversary, as well as the Harvard Global Health Institute and Fundação Maria Cecilia Souto Vidigal.

Harvard School of Public Health Dean Julio Frenk, who sits on UN Secretary General Ban Ki-Moon's MDG Advocacy Group, introduced the event, saying that the goals' adoption marked the first time the world's nations agreed on common development objectives and on indicators to measure progress.

The result, he said, has been an unprecedented level of funding for the needs outlined, as well as progress that has been, in some cases, spectacular. Yet much remains to be done, making the search for examples that might be adapted to other situations an important strategy.

"The challenges that remain are enormous," Frenk said.

Luciana Mendes Santos Servo, health coordinator at the Institute for Applied Economic Research in Brazil, traced the changes in that country to Brazil's 1988 constitution, which recognized health as a right for citizens and created a government obligation to improve it.

That sparked the creation of several social welfare programs and reform of the health care system from one that was centered on hospitals and financed by private insurance, held mainly by those in the formal labor pool, to one that emphasized primary care and was open to all.

Brazil has already achieved the goals for reducing poverty and hunger and is on track to achieve the goals involving child mortality and universal education. Maternal health in the nation has improved, but the goal appears out of reach by 2015. Mendes credited three programs with the bulk of the change: a social security benefit for the elderly, a cash-transfer program for poor families, and a family health program that focuses on primary care.

The programs have provided additional benefits beyond health. The cash-transfer program for poor families, called Bolsa Familia, requires children to attend school, which has boosted school attendance, helping the nation to achieve universal primary school education.

While those programs appear to have been effective, some audience members questioned whether the cost burdens they put on government, particularly in an economic downturn, are sustainable. Mendes said that future financing will be a challenge, because she believes the government can't raise taxes further.

Eduardo Rios Neto, a professor at Brazil's Federal University of Minas Gerais, said the government programs were helped along by a period of economic growth and improvement of the labor market, and that, despite recent progress, social and income inequality in Brazil remain a major problem.

Brazil's progress doesn't mean its health challenges are over either, Mendes said. The rise of noncommunicable diseases, like heart disease, diabetes, and cancer, is a growing challenge.

"We have progressed, but we have some challenges," Mendes said.

Provided by Harvard University

Brazil alarmed over rising obesity rate

In Brazil, a country known for girls in mini-bikinis and where body-consciousness borders on obsession, nearly half the population is overweight, a study by the Ministry of Health released Tuesday found.

11 april 2012--"There is a tendency toward increased weight and obesity in the country. It's time to reverse the trend to avoid becoming a country like the United States," said Health Minister Alexandre Padilha.

According to the study, the percentage of overweight people increased from 42.7% in 2006 to 48.5% in 2011 while the obesity rate increased from 11.4% to 15.8% in the same period.

The highest rates for overweight were found among men 35 years old to 45 years old (63%) and women 45 years old to 54 years old (55.9%).

The youngest group in the study were 18-to-24-year olds, where 30% of the men and 25% of the women were overweight.

"Adopting public policies for children and adolescents is essential to prevent people from becoming obese," the health minister said.

He said a third of Brazilians consume either high fat foods or sugared soft drinks at least five times a week.

The study showed nearly 40% of men and 22% of women exercise regularly.

The study was based on 54,000 interviews of adults across Brazil from January to December 2011.

The highest obesity rate was reported in Macapa at 21.4%, followed by Porto Alegre at 19.6%. Sao Paulo reported a 15.5% obesity rate while Rio de Janeiro came in at 16.5%.

Brazil's health care system vastly expands coverage, but universality, equity remain elusive

Two decades after Brazil's constitution recognized health as a citizen's right and a duty of the state, the country has vastly expanded health care coverage, improved the population's health, and reduced many health inequalities, but universal and equitable coverage remains elusive, experts from four major Brazilian universities and New York University have concluded.

13 may 2011--According to their analysis—one of six articles published in the medical journal The Lancet as a special series on health in Brazil—while federal expenditures have nearly quadrupled over the past 10 years, the health sectors' share in the federal budget has not grown, resulting in constraints on health care financing, infrastructure, and human resources.

The paper's co-authors were: Jairnilson Paim of the Federal University of Bahia; Claudia Travassos of Center for Communication, Scientific Information and Technology at the Oswaldo Cuz Foundation; Celia Almeida of the National School of Public Health, Oswaldo Cruz Foundation; Ligia Bahia of the Federal University of Rio de Janeiro; and James Macinko, an associate professor at New York University's Steinhardt School of Culture, Education, and Human Development.

After more than 20 years of a military dictatorship, Brazil created its present constitution in 1988, which included health as a right of citizenship. Health care reform in Brazil, then, occurred under unique circumstances--simultaneously with the process of democratization and spear-headed by health professionals along with civil society movements and organizations.

To meet this constitutional guarantee, the country established the Unified Health System, or Sistema Único de Saúde (SUS), which was based on the principles of universality, equity, integrality, and social participation. The SUS, which serves more than 192 million citizens, is supplemented by private insurers, which cover about 25 percent of Brazilians.

Overall, the Brazilian health system is made up of a complex network of complementary and competitive service providers and purchasers, forming a public–private mix that is financed mainly by private funds.

During the past two decades, the researchers noted, the SUS has undergone significant changes. Among these were granting municipalities greater responsibility for health service management, along with the flexibility and means which to bring about social participation in health policy making and accountability.

In the Lancet study, the researchers found vastly increased access to health care for a substantial proportion of the Brazilian population. In 2009 alone, the SUS financed about 12 million hospitalizations, delivered nearly 100 million ambulatory care procedures per month, and reached universal coverage of vaccination and prenatal care. It also expanded the supply of related human resources and technology, including enhanced production to meet most of the country's pharmaceutical needs.

But the researchers also observed that "the SUS is a health system under continual development that is still struggling to enable universal and equitable coverage."

"As the private sector's market share increases, interaction between the public and private sectors are creating contradictions and unfair competition, leading to conflicting ideologies and goals—notably, universal access vs. market segmentation," they wrote. "All of this has a negative effect on the equity of health-care access and outcomes."

Further complicating the nation's goal of universal coverage are constraints on federal funding. While federal expenditures have increased nearly four times over the past 10 years, they added, the health sectors' share in the federal budget has not grown, producing constraints on financing, infrastructure, and human resources.

"The development of the Brazilian health system reflects the uneven process of social, economic, and political development within the country," the researchers wrote. "Ultimately, to overcome the challenges that Brazil's health system faces, a revised financial structure and a thorough reassessment of public-private relations will be needed. Therefore, the greatest challenge facing the SUS is political. Such issues as financing, composition of the public–private mix, and the persistent inequities cannot be solved in the technical sphere only."

Provided by New York University

Study of health in Brazil highlights major progress

Major progress has been made in reducing the burden of infectious diseases in Brazil as part of a "remarkable" success story for health in the South American country, according to researchers on a series of papers published in The Lancet.

10 may 2011--After decades of marked social change, including the introduction of unified healthcare for all, Brazil can also celebrate a reduction in mortality from chronic diseases and huge inroads into improving maternal and child health. But the nation still faces problems – including some infectious diseases such as dengue and leishmaniasis, rising obesity and a high number of murders and road deaths.

The Lancet's Series on Health in Brazil takes a comprehensive look at the consequences of changes in Brazil such as the creation of the Unified Health System (Sistema Unico de Saude/SUS) in 1988 which marked a crucial turning point. Key improvements in infrastructure have also been made over the past few decades – for example, in 1970 only a third of homes had indoor water compared with 93% by 2007. Edited by leading child health epidemiologist Professor Cesar Victora, of the Universidade Federal de Pelotas, Brazil, who is an honorary professor at the London School of Hygiene & Tropical Medicine, the Series issues a call for coordinated action to continue improving and concludes by saying: "The challenge is ultimately political, requiring continuous engagement by Brazilian society as a whole to secure the right to health for all Brazilian people."

Professor Laura Rodrigues, who was born and trained in Brazil but has worked at the London School of Hygiene & Tropical Medicine since 1981, co-authored one of the six papers in the series. The infectious disease epidemiologist and Head of the Faculty of Epidemiology and Population Health said that although deaths by external causes remain too high, the situation in Brazil overall is a "remarkable success".

"Brazil is changing and this Series explores the stories behind the changes," she says. "It looks at the links between political and economic development and healthcare, and shows that changes in those areas have had a clear impact on the health and wellbeing of Brazil's population. The overall picture in Brazil is a remarkable success.

"There is a lot to be learned from this Series - in particular in the context of Brazil's position in the world and attitudes to national healthcare. We are seeing a significant rearrangement of countries' positions in global terms."

In their paper – studying successes and failures in the control of infectious diseases -
Professor Mauricio Barreto, of the Instituto de Saúde Coletiva and Federal University of Bahia, Salvador-Bahia, Brazil (an LSHTM alumnus), and colleagues including Prof Rodrigues examine why some programmes have worked and others have not.

Control of diseases such as cholera, diarrhoea, Chagas disease, and those preventable by vaccination such as tetanus and polio have all been successful, having each provided universal access to preventable measures and to treatment free at the point of use. According to the paper, these policies need to be reinforced due to challenges such as increasing prevalence and transmission of drug resistance.

They describe the HIV/AIDS plan, which is the largest distributor of free antiretrovirals in the world, as a partly successful programme ( although no less successful than in most developed countries) and point out that tuberculosis control has also improved, partly due to increased HIV control and also specific roll out of treatment programmes, especially those offering directly supervised treatment.

But a small number of failures are noted. Dengue fever is a new public health problem, with some 3.5 million cases reported in the past decade, with 12,000 leading to the more serious dengue haemorrhagic fever, and some 900 deaths. Rates of the most serious forms of Dengue are six times what they were in the 1990s with no safe vaccine available.

Visceral leishmaniasis control is also poor, with current efforts focusing on control of the sandfly vectors and removing domestic animals that can act as reservoirs. The only available treatment currently is highly toxic and while accessible and suitable in urban areas with medical support, this toxicity makes treatment in remote rural areas inappropriate.

The authors conclude: "A pressing need exists to develop new treatments and vaccines for those diseases which have proved difficult to control. In Brazil, biomedical and epidemiological research is thriving, as is public health research into infectious diseases, with much collaboration with developing and developed countries...the fast growth in medical research must be sustained—efforts must go towards identification of new treatments (eg, for leishmaniasis) new vaccines (eg, for dengue) and more effective ways to deliver specific care."

In a Comment for the Series, Ricardo Uauy, Professor of Public Health Nutrition at the London School of Hygiene & Tropical Medicine, says Brazil's "sense of national purpose and pride provides the strength with which the country collectively addressed the challenge of better health for all".

Exploring the impact of the Brazil experience in Latin America, he argues that Brazil turned traditional thinking that countries should first achieve economic growth before spending on social programmes on its head. "Brazil showed the opposite – ie, you need to invest in human and social capital to achieve and sustain economic growth," he writes. "In Brazil those who were intolerant to business as usual were responsible for making injustices a thing of the past; and for placing progress towards a better world at the top of the priority list. Brazil has given us a reason to be proud of our profession in this ever-changing environment."

Provided by London School of Hygiene & Tropical Medicine