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Ciência & Saúde Coletiva

versão impressa ISSN 1413-8123versão On-line ISSN 1678-4561

Ciênc. saúde coletiva vol.23 no.6 Rio de Janeiro jun. 2018

http://dx.doi.org/10.1590/1413-81232018236.04822018 

ARTICLE

Changes in health and disease in Brazil and its States in the 30 years since the Unified Healthcare System (SUS) was created

Maria de Fátima Marinho de Souza1 

Deborah Carvalho Malta2 

Elisabeth Barboza França3 

Mauricio Lima Barreto4 

1 Instituto de Medicina Social, Universidade do Estado do Rio de Janeiro. R. São Francisco Xavier 524/1006 A, Maracanã. 20550-900 Rio de Janeiro RJ Brasil. fatima.marinho@saude.gov.br

2 Escola de Enfermagem, Universidade Federal de Minas Gerais (UFMG). Belo Horizonte MG Brasil.

3Faculdade de Medicina, UFMG. Belo Horizonte MG Brasil.

4 Instituto de Saúde Coletiva, Universidade Federal da Bahia. Salvador BA Brasil.

Abstract

The Unified Healthcare System (SUS) was created to ensure the population’s right to universal, free and comprehensive healthcare. This study compares the health indicators measured in 1990 to those measured in 2015 in Brazil and its states. The goal is to contribute to understanding the role SUS played in changing the nation’s health profile. Analyses use estimates in the Global Burden of Disease (GBD) study for Brazil and its states, and compares 1990 and 2015. The main results are increased life expectancy, as well as an increase in the population’s longevity measured in health-adjusted life expectancy. These in turn are due to a sharp decline in mortality due to transmissible diseases, in maternal and infant morbi-mortality, and avoidable causes of death. NTCDs are the leading cause of death, followed by violence. Poor diet is the leading risk factor, followed by metabolic issues. Tobacco use decreased over the period, as did infant malnutrition. In the thirty years since the SUS was created, health indicators in this country have improved, and major progress has been made to reduce inequality across the country’s regions.

Key words: Healthcare policies; Child mortality; Unified Healthcare System; Non-Transmissible; Chronic Diseases (NTCDs); Violence

Introduction

Congress approved a democratic constitution in 1988, and health is included as a right. The Unified Healthcare System (SUS) was then created to ensure the population’s right to free and comprehensive healthcare1.

Over the past 30 years, Brazil has undergone structural changes and become an emerging nation2. In terms of the SUS, we point to structuring measures and programs such as the Family Health Strategy (FHS), created in 1994 to guide the healthcare model to a more comprehensive approach, focusing on primary care and seeking to provide universal access to all Brazilians3. The Family Health Strategy has expanded greatly in the past decade, prioritizing vulnerable areas. According to the National Health Survey3, it now covers 53.4% of the population. The Brazilian National Vaccination plan, created in 1973, is an efficient provider of vaccines against numerous transmissible diseases. In fact, vaccine coverage in this country has helped reduce the number of immune preventable diseases4. The SUS also created a national policy to provide free and universal access to essential drugs5. In the past decade, the government decided that drugs to treat Non-Communicable Diseases would be provided to the population free of cost6,7, and created a program of Budget drugstores known as Aqui Tem Farmácia Popular. The Ministry of Health has ensured free and universal anti-retroviral treatment to those living with HIV/AIDS, and has taken numerous disease-prevention and health-promotion measures8,9. In 2006, the National Health Promotion Policy prioritized intersectoral measures as well as certain health determinants and conditionants10. Although Brazil is the world’s 2nd largest tobacco producer, it has played a key role in tobacco control, implementing regulatory measures that range from prohibiting tobacco advertising to the Tobacco-Free Environments Law signed in 2014. These measures have helped reduce smoking around the world11,12. In 2004, Brazil signed the World Health Organization’s Global Treaty on Diet, Physical Activity and Health to prevent obesity and Non-Communicable diseases13. In the past decade a pre-hospital service was created to care for the growing number of cardiovascular diseases, external causes among the population, etc.14.

Population ageing, decreasing fertility rates and other transformations in Brazilian society have brought with them new challenges for the healthcare system15. Demographic and epidemiological transitions have resulted in different health and disease patterns in different regions and states15. Studies show that the expansion of the SUS system over the past 30 years helped reduce the burden of disease in the population, and the inequalities across regions in this country15. Thus, it is important to analyze how the disease scenario has changed in Brazil over the past decades.

The current study compared the health indicators prevalent in 1990 and 2015 in Brazil and its states. The goal was to help understand the role SUS plays in changing the nation’s health profile.

Methods

To analyze how the health of the Brazilian population has changed over time, this study used estimates published in the 2015 GBD (Global Burden of Disease) covering the country and the individual states16. In 2015, a GBD study by the University of Washington Institute for Health Metrics and Evaluation (IHME) analyzed 249 causes of death, 310 diseases and injuries, 2,619 unique sequelae and 70 risk factors using standardized methodology and different sources of data in 195 countries and territories16-18.

The first element of the GBD study’s analytical approach is an estimate of overall mortality to correct under notified deaths. This includes estimating the probability of death among those younger than 5 years of age (5q0), adult mortality (45q15), specific mortality by age and the inclusion of the possible effects of epidemics such as HIV/Aids, natural disasters and other fatal discontinuities17. The main sources of data on mortality among those younger than five in Brazil were the death records in the Mortality Information System, demographic censuses, household surveys - PNAD, the Sample-Based Household Survey, and PNDS, the National Survey of Demographics and Health, as well as the complete (PNDS) and abbreviated (censuses and PNAD) birth records. The estimating process used statistical models to adjust the different sources and address any possible inconsistencies between them19,20.

The second key component of GBD methodology is cause of death, and for this the main source of information was the Ministry of Health SIM or mortality information database. SIM entries with diagnoses that should not be considered the main cause of death, poorly defined or incomplete diagnoses, and entered as garbage19-21, were reassigned to non-garbage codes for each age-gender-year using specific redistribution algorithms. Causes of death were modeled using CODEm (Cause of Death Ensemble Model)19,20

The main sources of data for risk factor analyses were surveys such as the National Health Survey (PNS), Vigitel (telephone chronic disease risk factor surveillance and protection), the National Household Sample Survey (PNAD), and the National Student Health Survey (PeNSE), among others22.

The following metrics were used to describe the burden of disease in 1990 and 2015: absolute number of deaths, infant deaths per 1,000 live births at the country and state level, mortality for standardized causes by age (for the overall populations), death and disability adjusted life years (DALY), life expectancy and health-adjusted life expectancy (HALE), as well as ranked lists of the main causes of death and risk factors in 1990 and 2015. Greater details about the metrics are available in other publications16-20.

Metrics are shown with their uncertainty intervals (UI), which reflect the uncertainty in the parameter estimates for each state and period of study. Greater details are available in other publications.

Results

Table 1 shows an estimate of deaths and mortality rates for those under the age of 5 at the country and state level in 1990 and 2015. Mortality in Brazil was 52.5/1,000 live births in 1990, and 17.0/1,000 live births in 2016, a 67.6% drop. In 1990, 9 of the 11 states with the highest mortality rates for those under 5 are in the Northeast, all with rates over 60/1,000 live births. There was a 4.9-fold difference between the state with the highest mortality (Alagoas, 114.1/1,00 LB) and the state with the lowest mortality (Rio Grande do Sul, 23.2/1,000 LB), a difference of 91 deaths per 1,000 live births. By 2015 this had dropped to 2.3-fold between the state with the highest mortality (Acre, 27.0/1,000 LB) and the one with the lowest (Rio Grande do Sul, 12.0/1,000 LB), a difference of 15 deaths per 1,000 LB. In 2015, four of the ten states with the highest mortality rates were in the North.

Table 1 Mortality of children under 5 per 1,000 live births. Brazil and its states, 1990 and 2015. 

State 1990 2015 Percent change

n Rate/1,000 n Rate/1,000
Acre 993 67.7 482 27.0 -60.1
Alagoas 8409 114.1 1104 18.5 -83.8
Amapá 411 38.0 350 21.4 -43.8
Amazonas 3581 54.0 146 17.5 -67.6
Bahia 2405 75.2 5449 23.0 -69.4
Ceará 17627 95.5 3068 21.8 -77.2
Federal District 1057 26.3 606 14.5 -44.7
Espírito Santo 2551 39.8 816 14.8 -62.8
Goiás 3332 34.9 1556 16.5 -52.7
Maranhão 14222 86.3 3434 24.2 -71.9
Mato Grosso 2307 41.8 734 13.8 -67.1
Mato Grosso do Sul 1497 32.1 639 15.0 -53.3
Minas Gerais 15146 40.9 4271 15.3 -62.7
Pará 10323 63.1 2941 18.4 -70.9
Paraíba 5875 68.9 1069 16.6 -75.9
Paraná 6529 32.1 2105 13.8 -56.9
Pernambuco 16797 88.2 3065 20.7 -76.5
Piauí 4726 64.0 1197 23.0 -64.1
Rio de Janeiro 9655 37.9 2995 14.4 -62.0
Rio Grande do Norte 4907 74.3 790 14.9 -80.0
Rio Grande do Sul 458 23.2 1658 12.0 -48.3
Rondônia 1573 48.5 428 14.8 -69.5
Roraima 351 58.2 265 25.0 -56.9
Santa Catarina 3639 33.6 1392 15.9 -52.8
São Paulo 2276 33.1 8055 13.7 -58.5
Sergipe 3027 70.1 748 20.8 -70.4
Tocantins 1583 59.2 550 20.3 -65.8
Brazil 191505 52.5 51226 17.0 -67.7

Source: França et al.23.

Between 1990 and 2015, life expectancy at birth in Brazil increased 6.5 years, from 67.9 to 74.4, and health adjusted life expectancy (HALE) increased 5.4 years, from 59.4 to 64.8. The fact and overall life expectancy and HALE show a similar increase in the number of years lived in good health. (Table 2)

Table 2 Comparison of the Standardized Mortality Rate (per 100,000, Life Expectancy at Birth (years), Health-Adjusted Life Expectancy (years) by state, 1990 and 2017. 

State Standardized Mortality Rate (per 100,000) Life expectancy at birth (years) HALE Health Adjusted Life Expectancy (years)

1990 2015 1990 2015 1990 2015
North
Acre 1058.4 852.9 67.8 72.8 59.2 63.5
(994.2-1129.8) (758.6-960.7) (66.8 - 68.7) (71.2 - 74.3) (56.7 - 61.6) (60.7 - 66.3)
Amapá 890.5 830.7 71.8 73.5 62.9 64.4
(822.7-971.1) (697.8-984.1) (70.7 - 72.8) (71.1 - 75.7) (60.2 - 65.3) (61.3 - 67.3)
Amazonas 1027.4 816.6 68.9 73.9 60.5 64.7
(946.4 - 1100) (720.5 - 928.4) (67.9 - 70) (72.1 - 75.4) (58 - 62.9) (61.8 - 67.4)
Pará 1022.2 823.3 68.5 73.7 60 64.4
(945.2 - 1108.5) (712.1 - 962.2) (67.3 - 69.6) (71.7 - 75.5) (57.5 - 62.4) (61.2 - 67.3)
Rondônia 1207.1 814.4 66.7 74.1 58.8 65
(1123 - 1288.7) (718.7 - 905) (65.6 - 67.7) (72.8 - 75.7) (56.4 - 61) (62.1 - 67.8)
Roraima 1096.9 802.5 67.5 73.8 59.4 64.6
(1040.3 - 1151.5) (725.9 - 889.7) (66.7 - 68.3) (72.3 - 75.2) (57 - 61.7) (61.8 - 67.3)
Tocantins 1012.8 881 68.9 72.7 60.5 63.7
(908 - 1137.6) (759.9 - 1017.6) (67.1 - 70.5) (70.7 - 74.6) (57.6 - 63.1) (60.8 - 66.5)
Northeast
Alagoas 1253.5 880.6 62.8 72.3 55.1 63.2
(1179.3 - 1332.4) (789 - 992.7) (61.6 - 64) (70.7 - 73.8) (52.5 - 57.5) (60.3 - 66.1)
Bahia 1059.2 861.1 67.4 72.8 59.1 63.6
(989 - 1129.5) (767 - 964.8) (66.4 - 68.4) (71.2 - 74.3) (56.6 - 61.5) (60.7 - 66.1)
Ceará 991.6 858.5 67.4 72.9 58.9 63.6
(930.2 - 1046.9) (766.4 - 962.7) (66.4 - 68.4) (71.3 - 74.4) (56.3 - 61.3) (60.7 - 66.5)
Maranhão 1290.2 936.9 63.5 71.5 55.7 62.5
(1184.7 - 1394) (804.5 - 1108.4) (62.2 - 65) (69.1 - 73.6) (53.2 - 58.2) (59.4 - 65.6)
Paraíba 995.1 876 68.8 72.9 60.3 63.7
(930.2 - 1057.4) (762.9 - 1009.1) (67.9 - 69.7) (70.9 - 74.6) (57.7 - 62.7) (60.7 - 66.7)
Pernambuco 1179.8 872 65 72.5 57.2 63.5
(1108.5 - 1257.5) (777.9 - 979.8) (63.8 - 66.2) (70.9 - 74.1) (54.6 - 59.5) (60.7 - 66.2)
Piaui 971.2 833.9 69.3 73.3 60.6 63.8
(905.8 - 1031.7) (732.9 - 939.2) (68.3 - 70.3) (71.6 - 74.9) (57.9 - 63.1) (60.8 - 66.6)
Rio Grande do Norte 912.3 752.7 69.7 75.1 61 65.6
(856.6 - 965) (673.8 - 834.6) (68.7 - 70.8) (73.8 - 76.4) (58.5 - 63.3) (62.8 - 68.5)
Sergipe 1031 827 68 73.4 59.6 64.2
(968.8 - 1098) (735 - 936.5) (67.1 - 68.9) (71.8 - 74.9) (57.2 - 62) (61.3 - 67.1)
Middle-West
Goiás 1136.8 819.8 68.3 73.8 60.2 64.6
(1079.5 - 1193.3) (741.3 - 909.9) (67.6 - 69) (72.5 - 75) (57.7 - 62.4) (61.7 - 67.2)
Mato Grosso 1085.7 837.7 68.7 73.7 60.3 64.4
(1005.5 - 1162.9) (735.7 - 940.1) (67.6 - 69.7) (72.3 - 75.3) (57.8 - 62.7) (61.4 - 67.2)
Mato Grosso do Sul 1045.4 811.7 69.8 74.1 61.1 64.7
(976.7 - 1107.5) (717.7 - 909.5) (68.9 - 70.6) (72.6 - 75.6) (58.5 - 63.5) (61.7 - 67.5)
Distrito Federal 943 614 71.5 78 62.6 67.9
(906.1 - 981) (554 - 678.9) (70.9 - 72) (76.8 - 79.1) (60.1 - 65) (64.8 - 70.9)
Southeast
Espírito Santo 1062.5 763.7 68.9 74.6 60.5 65.1
(1003.3 - 1129.3) (677.1 - 853.8) (68 - 69.8) (73.2 - 76.1) (57.8 - 63) (62.1 - 67.9)
Minas Gerais 1107.5 758.8 68.5 74.9 60.1 65.5
(1049.9 - 1168.3) (682.4 - 841.7) (67.7 - 69.3) (73.6 - 76.2) (57.7 - 62.4) (62.5 - 68.3)
Rio de Janeiro 1205.5 798.1 66.6 74.2 58.6 64.9
(1158.4 - 1252.4) (729.7 - 869.9) (66 - 67.3) (73.1 - 75.3) (56.4 - 60.8) (62.1 - 67.4)
São Paulo 1082.5 711.9 69 76.1 59.9 65.7
(1040.4 - 1124.7) (640.7 - 780) (68.5 - 69.6) (74.9 - 77.2) (57.4 - 62.3) (62.6 - 68.5)
South
Paraná 1125 805.8 69.2 74.3 60.7 64.7
(1067.7 - 1184) (721.5 - 902.4) (68.5 - 69.9) (72.9 - 75.6) (58.1 - 62.9) (61.8 - 67.3)
Rio Grande do Sul 1063.7 756.8 70.1 75.2 61.6 65.6
(1001.3 - 1126.1) (661.7 - 860.7) (69.4 - 70.9) (73.7 - 76.7) (59 - 63.8) (62.7 - 68.4)
Santa Catarina 1087.3 735.1 69.6 75.6 61.3 66.1
(1024.8 - 1151.5) (650.9 - 826.4) (68.8 - 70.4) (74.1 - 77) (58.9 - 63.5) (63 - 68.9)
Brazil 1.102.2 786.2 67.9 74.4 59.4 64.8
(1,085.9-1,118.6) (761.2-810.3) (67.5-68.2) (73.9-74.9) (56.9-61.7) (62.1-67.3)

Source: Global Burden of Disease study.

Age-standardized mortality rates for both genders dropped 28.7% (UI: 26.1-31.1) between 1990 and 2015, from 1,102.2 (UI: 1,085,9-1,118,6) to 786.2 per 100,000 inhabitants (UI: 761.2-810.3). (Table 2) Age-standardized mortality rates dropped across Brazil, however at different rates depending on the region. The largest decreases were recorded in the more developed regions - the South (30%) and Southeast (32%), while the smallest ones were in the North (20%) and Northeast (21%). (Table 2)

The Federal District performed better in all health metrics. In 2015, the state of São Paulo - the wealthiest in the nation - came in second and third in terms of life expectancy and HALE at birth respectively. In 2015, the lowest life expectancy at birth was in states of the northeast: Maranhão, Alagoas and Pernambuco at 71.5 years (UI=69.1-73.6), 72.3 years (70.7-73.8) and 72.5 years (70.9-74.1) respectively. However, these states also had the largest increase in life expectancy compared to 1990 - 12.6% for Maranhão, 15.1% for Alagoas and 12.1 for Pernambuco (Table 2).

Table 3 shows the number of deaths and age-standardized rates for selected causes of death in both genders in Brazil in 1990 and 2015. In 2015, there were some 1.3 million deaths in Brazil, a 28.7% reduction in the overall mortality rate. Non-Communicable diseases are the leading cause of death - 75% or 1 million. However, NCD as a cause of death dropped 25% in this same period, from 816.6 to 611.3/100,000 inhabitants. There was a significant drop in cardiovascular (40.5%) and chronic respiratory diseases (29.9%). Cancers remained stable within the UI. Deaths due to diabetes increased 12.6% and mental disorders and substance abuse increased in absolute number, but again within the UI. Violence and accidents accounted for some 168 thousand deaths in 2015, a 22.8% drop in the period. Deaths due to traffic accidents dropped 30.9% and those due non-intentional accidents 33.2%. Deaths due to interpersonal violence remained essentially unchanged. Transmissible, infant/child and maternal diseases, along with nutritional disorders, were the cause of some 159 thousand deaths in 2015, a 31% drop compared to 1990, and a 47.1% reduction in the rate. We call attention to the mortality rate due to diarrhea (86.8%), meningitis (70.7%) and immune preventable diseases. Maternal causes dropped 56%, neonatal causes 56.7% and nutritional causes 50.2% (Table 3).

Table 3 Number of deaths and age-standardized rates for selected causes of death in both genders Brazil, 1990, 2015. 

Cause of Death Number of Deaths Standardized rate of death (per 100,000)

1990 2015 % change 1990-2015 1990 2015 % change 1990-2015
All causes 911.317 1.357.434 49 1.102,2 786,2 -28,7
(896.944-925.847) (1.312.612-1.400.906) (43,8-54,5) (1085,9-1118,6) (761,2-810,3) (-31,1--26,1)
A – Transmissible, maternal, neonatal and nutritional diseases 233.554 159.917 -31,1 178,5 93,8 -47,1
(222.998-240.244) (139.858-170.945) (-38,7--26,5) (168,3-183,4) (81,4-100,7) (-52,7--43,6)
A.1 HIV/AIDS and tuberculosis 13.740 26.812 94,9 12,8 12,5 -2,6
(11.664-15.402) (23.412-31.197) (62,5-140,2) (10,7-14,8) (10,9-14,6) (-19,2-20,3)
A.2 – Diarrhea, lower respiratory tract diseases and other infectious causes 119.418 85.657 -27,3 101,6 52,9 -47,2
(111.562-124.075) (65.814-94.532) (-41,7--20,4) (92,4-105,8) (40,7-58,6) (-56,6--42,1)
A.2.1 – Diarrheic diseases 46.035 6.343 -86,2 29,6 3,9 -86,8
A.2.6 – Meningitis (5.942-6.732) (-87,3--85) (28,3-31) (3,6-4,2) (-87,8--85,7)
A.2.11 - Measles 8.027 2.785 -67,2 4,8 1,5 -70,7
(6.256-8.844) (2.515-3.530) (-70,4--49,9) (3,7-5,2) (1,3-1,9) (-73,4--55,8)
A.2.11 - Sarampo 1.109 3 -99,7 0,6 0 -99,7
(806-1.492) (2-5) (-99,8--99,6) (0,4-0,7) (0-0) (-99,7--99,5)
A.3 – Neglected tropical diseases and malaria 9.541 7.486 -21,4 10,9 4,2 -61,7
(9.121-9.962) (6.918-8.049) (-27,9--14,9) (10,4-11,4) (3,9-4,5) (-65--58,4)
A.4 – Material disorders 3.081 1.972 -36 2 0,9 -56
(2.896-3.299) (1.786-2.165) (-43,2--27,9) (1,8-2,1) (0,8-0,9) (-61--50,4)
A.5 – Neonatal disorders 69.532 25.137 -63,9 35,8 15,5 -56,7
(67.501-71.533) (22.843-27.716) (-67,3--59,8) (34,7-36,8) (14,1-17,1) (-60,7--51,8)
A.6 – Nutritional disorders 13.570 9.568 -29,4 12,2 6 -50,2
(10.445-14.964) (7.584-10.585) (-35,5--23,1) (9,7-13,4) (4,8-6,7) (-54,1--46,3)
A.7 – Other transmissible maternal, neonatal and nutritional diseases 4.672 3.285 -29,2 3,3 1,7 -48,2
(3.734-5.905) (2.986-3.510) (-43,2--13,1) (2,8-4) (1,6-1,8) (-55,9--40,3)
B – Non-communicable diseases 542.832 1.029.499 89,7 818,6 611,3 -25,3
(532.149-554.906) (992.362-1.068.244) (82,4-97,2) (803,9-834,7) (589,8-633,9) (-28--22,6)
B.1 – Cancers 105.275 236.345 124,5 142,7 133,5 -6,5
(102.761-109.195) (226.265-248.290) (115,4-134,9) (139,2-149,1) (127,9-140,4) (-10,1--2,3)
B.2 – Cardiovascular diseases 267.634 424.058 58,2 429,5 256 -40,5
(262.150-273.226) (407.250-444.686) (51,7-66,3) (421,1-438,1) (246,3-268,3) (-42,9--37,5)
B.3 – Chronic respiratory diseases 41.272 79.651 92,8 69,9 49,7 -28,9
(40.138-42.445) (76.015-83.698) (83,3-103,1) (67,8-71,9) (47,3-52,3) (-32,6--25,1)
B.4 – Cirrhosis and other chronic liver diseases 22.783 36.607 60,5 25,7 18,9 -26,7
(21.290-23.771) (34.172-39.284) (50-72,7) (24,1-26,9) (17,6-20,3) (-31,2--21,3)
B.5 - Digestive Diseases 17.711 33.267 88,9 25,3 19,5 -22,4
(16.770-18.591) (28.455-35.152) (62,3-99,3) (24,1-26,5) (16,6-20,7) (-33,6--18,2)
B.6 – Neurological disorders 19.714 63.396 221,4 43,2 42,2 -2,5
(16.924-22.399) (53.548-73.278) (205,7-237,5) (36-50,3) (35,3-49,1) (-6-1,4)
B.7 – Mental disorders and substance abuse 5.079 11.037 117,7 4,6 5,3 14,4
(4.837-5.385) (10.308-11.828) (100,2-133,5) (4,4-4,9) (4,9-5,6) (5,4-22,5)
B.8 – Diabetes, urogenital, blood and endocrine disorders 45.922 124.066 170,8 65,9 73,9 12,6
(44.606-48.180) (117.671-130.022) (155,6-182,7) (63,9-69,2) (70-77,4) (6,2-17,3)
B.9 – Musculoskeletal disorders 1.454 3.553 142,4 1,6 1,9 19
(1.264-1.544) (3.277-4.182) (125,6-180) (1,4-1,7) (1,8-2,3) (10,5-38,9)
B.10 – Other non-communicable diseases 15.988 17.519 17,3 10 10,4 7,3
(13.668-22.657) (13.174-19.780) (-36,9-37,6) (8,7-13,8) (7,8-11,8) (-39,1-29,1)
C – Injuries 134.931 168.018 24,5 105,1 81,2 -22,8
(131.104-138.852) (159.904-177.046) (18,4-31,2) (101,7-108,1) (77,4-85,4) (-26,5--18,6)
C.1 – Traffic injuries 48.618 54.601 11,8 37,3 25,9 -30,9
(46.835-50.494) (51.381-60.111) (5,5-27,2) (36-38,6) (24,4-28,4) (-34,9--21,3)
C.3 – Self-aggression and interpersonal violence 51.048 75.273 48,2 36,4 34,3 -5,1
(48.599-55.573) (69.169-80.229) (30-57,5) (34,8-39,8) (31,7-36,6) (-16,9-0,8)
C.2 Accidents 34.975 38.144 8,8 31,2 20,9 -33,2
(32.391-36.301) (35.781-40.384) (3,1-17,3) (28,3-32,5) (19,6-22,2) (-36,8--27)
C.4 - Forças da natureza guerra e intervenção legal 290 NA -100 0,2 NA -100
(85-648) (NA-NA) (-100--100) (0,1-0,5) (NA-NA) (-100--100)

Source: Global Burden of Disease Study

Figure 1 compares the main causes of mortality in 1990 and 2015. Ischemic heart diseases were the leading cause of death in 1990 and 2015, followed by cerebrovascular disorders. Alzheimer’s dropped from 5th to 6th place. Lower respiratory tract infections came in third in 2015, while COPD dropped from 3rd to 4th place. Diabetes went from 7th to 5th and interpersonal violence from 9th to 7th. In 2015, traffic accidents were the 8th leading cause of death, followed by chronic kidney disease (9th) and lung cancer (10th). Diarrhea as a cause of death dropped significantly - from 8th in 1990 to 36th place in 2015, as did malnutrition (18th to 31st), and premature labor (19th to 30th).

Source: Global Burden of Disease Study. https://vizhub.healthdata.org/gbd-compare/

Figure 1 Standardized mortality rates (100,000 deahts) for the main causes of death, Level 3, GBD 2015. Brazil, 1990 and 2015. 

Figure 2 shows the changes in the main risk factors for all-cause DALY by gender between 1990 and 2015. In 1990, inadequate diet, smoking, high blood-pressure and maternal-infant malnutrition were the main risk factors for DALY among men and women. Inadequate diet topped the list throughout, with high blood pressure moving from 2nd to 3rd place among both men and women. Infant and child malnutrition dropped significantly, from 4th to 11th place among boys, and from 2nd to 6th place among girls. Smoking went from 2nd to 4th place among men, and from 4th to 5th among women (Figure 2).

Source: Malta et al.22.

Figure 2 17 main level 2 risk factors for all-cause DALYs for (A) men and (B) women, 1990 and 2015 GBD Brazil, 2015. 

Over this period, BMI went from 8th to 5th among men, and from 5th to 3rd among women. Drug and alcohol use went from 5th to 4th among men, and high fasting glucose levels from 6th to 4th among women. Other behavioral factors also contributed to worsening DALY, such as insufficient physical activity, unsafe sex and all metabolic risks. Environmental risk factors, including air pollution, deceased, while occupational risks increased (Figure 2).

Discussion

These findings show that in the 25-year period analyzed (1990 to 2015), which covers much of the SUS existence, there have been many changes in the health/disease profile of the Brazilian population, most of them positive. It also shows a decrease in the inequalities in health indicators across the states.

A sharp decline in mortality due to transmissible diseases, in maternal-infant morbi-mortality and avoidable causes of death have increased life expectancy and increased the population’s longevity measured in healthy life-years. NCD remain the leading cause of death, despite an overall reduction in mortality rates and in death due to cardiovascular and respiratory diseases. On the other hand, deaths due to diabetes increased in this period. Violence killed over 168 thousand Brazilians in 2015. As these can be fully avoided, a decrease in this rate is a major challenge for the coming decades. Poor diet is the leading risk factor, followed by metabolic factors. In the 25-year period smoking decreased substantially, as did infant malnutrition. All of these changes coincided with re-democratization and significant economic growth. A number of social protection policies were instated at this time, along with the unified healthcare system (SUS), the definitive strategy to promote a society with a healthcare system suited to its needs. Along with economic and social advances, there is evidence that the SUS contributed to the changes observed, and in particular to reduce the inequality that prevails in this country.

The GBD study is innovative as it records the nation’s health-disease burden using corrected estimates, new metrics such as DALY, and expected health-adjusted life expectancy, all of which provide new data on population health and new views for healthcare professionals and managers24.

Between 1990 and 2015 overall mortality in Brazil dropped and life expectancy at birth went up. Higher life expectancy at birth is the result of socioeconomic income distribution policies, programs such as Bolsa Familia (family stipend), increased employment in the past decade and other policies to reduce inequality15. Better coverage and access to healthcare services and a rapid change in the population age pyramid also contributed25,26. Life expectancy improved in Brazil more than in other Latin American countries such as Argentina, Chile, Colombia and Mexico17.

Successful aging, or increased health-adjusted life expectancy (HALE) are often used as indictors of quality of life27. HALE estimates the expected number of “healthy years” for a population of a given age27. This indicator includes a dimension of quality of life3, as long-life may not be the same as healthy-life27.

Szwarcwald et al.27 analyzed data from the National Health Survey and found significant differences in HALE by state – as much as seven years –, and by socioeconomic class. The current study found that HALE had increased significantly between 1990 and 2015, but also found differences by state. The highest HALE was found in the Federal District and Santa Catarina, although both within the UI.

This study shows that between 1990 and 2015, Child Mortality dropped significantly in all states, and there was also a major decline in the differences between states. Mortality dropped more significantly in the northeast states23,28. A 2013 UN Report29 pointed to the decline in Child Mortality in Brazil, highlighting intersectoral measures and the Unified Healthcare System (SUS) offering things such as pre-natal, delivery and infant (first-year of life) care. The Family Health Strategy also had a positive impact on reducing Child Mortality29, especially neonatal mortality. Measures to address malnutrition and diarrhea, and campaigns to foster breastfeeding helped keep down Child Mortality rates in the period28. Other measures, such as increasing the number of high-risk beds and easier access to care during delivery helped reduce neonatal death23,28. The report also highlights social service policies such as the Bolsa Família (Family Stipend) income transfer program29, and a number of improvements in living conditions and infant and child healthcare23.

The thirty years since the SUS has existed have seen major progress in coverage and access to primary care, now available to more than half the population. Access to medicines, vaccines, disease prevention and health promotion measures have also improved30. These measures, better/expanded sanitation and social protection programs have all helped cut down the number of infectious diseases such as diarrhea, respiratory infections, TB, immune preventable diseases and infant and maternal mortality4,15,30,31. Diarrhea for example, dropped to 39th in the ranking of causes of death. The past 25 years in Brazil have also seen major changes in the nation’s demographics. As the population ages. the country is also experiencing a transition in epidemiology, leading to important changes in the morbi-mortality profile. NCD account for about 75% of all deaths and for loss of quality of life32. However, the study also shows that rates are declining as a result of different measures, among them increased healthcare for adults33, and the nation’s commitment to the theme, defining targets to control NCD32. In 2011, the government launched a plan to address NCDthat includes health promotion, disease prevention and care6. In 2011, voluntary agreements with the food industry reduced the amount of salt in ultra-processed foods, and eliminated trans-fats6,7. In 2014, the government launched the Healthy Nutrition Guide34, and in 2011 the Academia da Saúde (Health Gym) created incentives for physical activity and other health promotion measures35. Universal access to all three levels of healthcare (primary, secondary and tertiary)36,37 is another important measure. In the case of cardiovascular diseases this includes access to drugs such as blood pressure drugs, beta-blockers, statins, etc.36.

Patients with diabetes have access to oral hypoglycemics and insulin. National Health Survey data shows that more than 80% of those with diabetes and/or hypertension in Brazil have access to healthcare services and medicines and, when required, to experts, tests and hospitalization38.

The study shows that inadequate diet is the main contributor to the burden of disease, measured by DALYs, and particularly Non-Communicable Diseases (NCD)39. It is essential to invest in measures to deter the increase in obesity, such as regulatory measures to tax unhealthy foods such as soft-drinks and other ultra-processed foods6,7,22,33.

Smoking has fallen in the ranking of risk factors, as the number of smokers in Brazil has declined sharply11,12,39. In 1989 36.4% of the population smoked, while in 2013 this was down to 15%, one of the lowest rates in the world12. Regulatory measures such as forbidding advertising and health warnings, among others, explain this drop11,12,40. The Tobacco Free Environment Law, signed in 2011 and regulated by Presidential Decree in 2014, prohibits smoking in closed public environments, prohibits cigarette advertising and promotions, and expanded the warning messages on tobacco packaging. Taxes on tobacco products also increased12,40.

Over the past decade, the Ministry of Health created a broad system to monitor NCD, which includes health surveys and Health Information Systems to monitor trends, risk factors and protection against NCD7,41.

Finally, the results point to external causes of death, which did drop over the period, but are still quite prevalent, especially interpersonal violence and traffic accidents. These are particularly prevalent among young people and contribute to premature mortality during the productive years16. Also worth noting are premature deaths due to HIV and its rising importance as a cause of early death in recent decades, and SUS actions to ensure access to diagnosis and treatment. Brazil led global measures to break patents to manufacture generic drugs, especially those used to treat HIV, offering ample access to medication to those with the disease8,9.

Conclusion

The SUS faces many challenges, among them new epidemics, neglected diseases, vector control, the magnitude of NCD and violence. Understanding the pattern of health and the associated trends over the past decades allows us to take a critical look at healthcare policies and the SUS, and to assess progress made and limitations in addressing health issues. This study is innovative as it contributes new metrics to monitor the health of the population, such as Health-Adjusted Life Expectancy (HALE), and Disability-Adjusted Life Years (DALY), among others.

In terms of SUS activities, we highlight the expansion of the Family Health Strategy, emergency and pre-hospital care, expanded treatment of cancer and cardiovascular diseases, a more extensive vaccine calendar and health promotion and disease prevention measures. Other contributions are regulatory measures to reduce tobacco use, programs to encourage physical activities, and intersectoral violence-prevention programs, all of which helped improve the indicators analyzed in this paper. These positive findings are directly related to implementing highly cost-effective interventions by the Unified Healthcare System, such as expanding primary care, drug distribution to those at high risk of developing cardiovascular diseases, and measures to control tobacco use39. Addressing ischemic heart disease is a dual challenge for the Brazilian healthcare system, as it includes health promotion measures and better specialized care to deliver better results in managing cardiovascular diseases37.

We also point to the rapidly growing elderly population, as life expectancy increases and regional differences decrease. This will demand a new healthcare system and social security policies. Healthy aging is a challenge of our times and will require an innovative healthcare policy that promotes health and reduces the burden of disease. However, approval of Constitutional amendment 95, which makes it impossible to grow the resources available for healthcare and other social policies, is a serious threat to these new demands42. Budget cuts will have an impact on population health indicators43, so studies to monitor trends such as those presented here are essential to measure the health and living conditions of the Brazilian population.

In short, advances made by the Unified Healthcare System and better economic planning, such as real increases in the minimum wage, progress made in housing and basic sanitation policies and other distributive social protection measures, such as the family stipend, have created a positive scenario for important improvements in health conditions and an increase in health-adjusted life expectancy among the population of this nation44,45.

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Received: January 12, 2018; Revised: January 30, 2018; Accepted: February 27, 2018

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