Public policies challenges on the background of demographic transition and social changes in Brazil

Abstracts

This study aimed to analyze the changes in the demographic and social characteristics of the country and to discuss the challenge for developing public policies, using data from information systems and interviews with actors of social policies and healthcare in Brazil. A reduction was observed in fertility, natality and mortality rates with an increased life expectancy at birth, representing the third stage of demographic transition. An investment in health and education was identified as essential for the country to take advantage of this moment. There was a significant reduction in poverty, but in 2012, it still accounted for 15.9% of the population, a compelling reason for the maintenance, expansion and qualification of income transfer programs. The demographic transition provides opportunities for the development of policies that allows universal access to education, health and employment and that overcome the challenges of the country.

Demographic transition; Formulation of policies; Health services needs and demands

Este trabalho teve como objetivo analisar as mudanças ocorridas nas características demográficas e sociais do país e discutir o desafio do desenvolvimento de políticas públicas, utilizando dados dos sistemas de informações e entrevistas com atores das políticas social e de saúde do país. Percebeu-se a redução da fecundidade, da natalidade e da mortalidade com aumento da esperança de vida ao nascer, caracterizando a terceira fase da transição demográfica. O investimento na saúde e na educação foi considerado essencial para que o país possa aproveitar esse momento. Houve significativa redução da pobreza, mas, em 2012, ainda representava 15,9% da população, o que exige manutenção, expansão e qualificação dos programas de transferência de renda. A transição demográfica proporciona oportunidades para o desenvolvimento de políticas que permitam o acesso universal à educação, à saúde e ao emprego e que superem os desafios do país.

Transição demográfica; Formulação de políticas; Necessidades e demandas de serviços de saúde

El objetivo de este trabajo fue analizar los cambios habidos en las características demográficas y sociales del país y discutir el desafío del desarrollo de políticas públicas, utilizando datos de los sistemas de informaciones y entrevistas con los actores de las políticas social y de salud del país. Se percibió la reducción de la fecundidad, de la natalidad y de la mortalidad con el aumento de la esperanza de vida al nacer, caracterizando la tercera fase de la transición demográfica. La inversión en salud y educación se consideró esencial para que el país pueda aprovechar este momento. Hubo una significativa reducción de la pobreza, pero en 2012 ella todavía representaba el 15,9% de la población, lo que exige mantenimiento, expansión y calificación de los programas de transferencia de renta. La transición demográfica proporciona oportunidades para el desarrollo de políticas que permitan el acceso universal a la educación, a la salud y al empleo y que superen los desafíos del país.

Transición demográfica; Formulación de políticas; Necesidades y demandas de servicios de salud

Introduction

In an article about social inequality, the sociologist Octavio Ianni¹ argues that the social issue permeates the history of the Brazilian society. According to the author, this is a reflex of the existence of inequalities in diverse aspects, challenging diverse sectors of society.

A population with higher life expectancy and lower fertility rates undergoes changes in its age structure, favoring the increase in the working-age population and reducing the demographic dependency ratio. This characterizes the demographic bonus. The so-called window of opportunity, a special situation that arises during demographic transition, requires adequate policies so that demography can contribute to economic and social development and also to the development of the society’s welfare and care for the environment²,³.

However, this demographic transition is not neutral and, according to Brito⁴, it can influence the future of the Brazilian society, producing reflexes that can be positive or negative, depending on the investments made by the State and on the policies, programs and services implemented during this period of transformation of the country’s demographic structure.

Demo⁵believes that “only the policy that affects the structure of the social inequalities currently in force and reduces them can be called a social policy” (p. 33). Therefore, the policy must be emancipatory and redistributive, allowing more than social mobility: it must enable the conquest of a reduction in the country’s inequities.

In the field of health, recognizing the needs of different social groups through universal and redistributive policies means to assume the notion of equity defended by the Brazilian Health Reform⁶.

According to Paim⁷, the health reform agenda has not been completed yet. The Sistema Único de Saúde (Brazil’s National Healthcare System) is a conquest and part of the struggle of the Brazilian health movement. The author argues that it is impossible for the system to reach its objectives in a society like the Brazilian one, marked by historic levels of inequality, poverty and violence. Due to this, he defends the need to revisit the Reform’s ideals and expand its bases in order to “radicalize democracy and fight for the changes that were promised in its project” (p. 132).

This means that, in this moment of transition, it is necessary to invest in the healthcare system, understanding its role as an inducer of economic development and, mainly, as a response to the new needs created by the demographic and epidemiological transformations.

Therefore, it is fundamental that investments stimulate the making of equitable public policies that recognize health as a right and prioritize needs as an essential category for the forms of justice⁸. Moreover, the investments must consider the challenges and the need to include the field of health in Brazil’s model of development, as our country has been marked by inequities since its origin⁹.

To achieve this, the present study proposes to analyze the transformations occurred in Brazil’s demographic and social characteristics, both in the current context of transition and with regard to the transformation of the demographic profile in the coming decades. In addition, it aims to investigate the relation between such transformations and planning, and to discuss policymaking, mainly in the area of health.

Method

By means of an exploratory and explanatory study, using the quantitative and qualitative approaches, the transformations occurred in Brazil’s demographic and social characteristics were described and analyzed, as well as their relationship to the planning and making of public policies.

To characterize the scenario, secondary data from the country’s main information systems were used. To analyze the planning of public policies in the context of transformations, eight actors who occupied relevant posts in health management (a former Health Ministry of Brazil, former secretaries with the Health Ministry, former state and municipal health secretaries) and in the legislature were interviewed, as well as intellectuals in the area of health and planners.

This study is part of a Doctoral dissertation in Public Health. All the selected participants constructed their story defending the right to health and were part of the political context, having participated in the organization of the country’s healthcare system since its origin.

Twelve indicators referring to Brazil’s demographic and socio-economic conditions were analyzed, relating to the period 1995 - 2010, the most recent period available in the information systems used in the study. Data from this period referring to the population derive from estimates and from the censuses carried out by the Instituto Brasileiro de Geografia e Estatística (IBGE - Brazilian Institute of Geography and Statistics).

Data related to education, by means of the average number of years of schooling of people aged 25 years and older, as well as the proportion of the population below the poverty line derived from Ipeadata, which is administered by the Instituto de Pesquisa Econômica Aplicada (IPEA – Institute of Applied Economic Research).

The other socio-economic indicators (percentage of the population served by the water supply network, garbage collection and sewage) and demographic indicators (total fertility rate; gross birth rate; life expectancy at birth; mortality rates) were obtained from the indicator matrix produced by the Rede Interagencial de Informações para a Saúde (Ripsa – Inter-agency Health Information Network).

To verify the temporal trend of the series and its significance, a linear trend analysis was carried out. All the decisions were made considering a 5.0% level of statistical significance. To facilitate the visualization of the study’s results, values were presented in three-year periods in the study’s Tables.

In addition to the simple linear trend, the indicators’ relative frequency was calculated. In some cases, the proportional variation in the studied period was analyzed based on the values observed in the last year and in the first year, through the equation: [(Last year indicator/ First year indicator) – 1] x 100.

Based on the conceptual framework of universalization, social control, financing of needs and decentralization of Brazil’s National Healthcare System, the quantitative and qualitative instruments were developed.

To analyze the social actors’ perception concerning the context of the demographic and social changes and of policymaking, the results were initially presented through the quantitative approach and, subsequently, the interviews were conducted, between June and July 2015.

The interviews were analyzed by means of the meaning condensation technique. According to this technique, after the definition of each participant’s natural units of meaning in each approached question, the central themes are defined and, finally, a synthesis is made through an essential description of the themes identified in the interview and related to the researched objectives¹⁰.

The dissertation project from which this article resulted was submitted to and approved by the Research Ethics Committee of the Aggeu Magalhães Research Center, Fundação Oswaldo Cruz, in the city of Recife, state of Pernambuco (Certificate of Submission for Ethical Appreciation no. 21258713.0.0000.5190).

Results and discussion

Brazil has experienced a fast process of demographic transition. Although the population grew between the assessed decades, the speed of this growth has been decreasing throughout the years. Up to the 1980s, the Brazilian population grew sharply, and the rhythm diminished from then onwards. Between 1950 and 1980, there was a growth of almost 130.0% and, in the following 30 years, the number of inhabitants increased by 60.3%. If the IBGE’s estimates are maintained, in 2040 the country’s population will have increased by 19.6% only, when compared to the number of inhabitants in 2010 (Table 1).

Table 1
Demographic evolution. Brazil, 1890 to 2040.

• Source: Instituto Brasileiro de Geografia e Estatística (Brazilian Institute of Geography and Statistics)
• * Proportional Variation: proportional variation in relation to the previous period.

Even with the demographic transition, but with gradually lower growth rates, Brazil still presents a population increase. If the reduction in the growth speed remains the same, it is estimated that, at the beginning of the decade of 2040, this increase will become negative and a process of reduction in the Brazilian population will begin¹¹ – a challenge for public managers.

In addition to the reduction in the growth speed, different behaviors are observed when the population’s age groups are analyzed.

Concerning the age group from 0 to 9 years, it is possible to notice that, although it increased in absolute values up to the 2010s, it decreased proportionally during the analyzed years. In the first studied year, children represented 29.2% of the country’s population, and they reached 15.1% in 2010. It is estimated that, in 2040, they will reach 23.0 million, representing only 10.1% of the Brazilian population (Table 1).

An inverse movement was observed in the age group older than 60 years, which has been growing sharply in Brazil. Data show that the Brazilian population has been ageing. In the first studied year, it represented 4.7% of the country’s total population. It reached 10.8% in 2010 and it is estimated to achieve 23.4% in 2040 (Table 1).

This ageing brings challenges to the State, mainly regarding demands on the healthcare and social security systems. Diseases do not affect exclusively more advanced ages; ageing can be healthy if health promotion and disease prevention actions are taken during the population’s entire life. These interventions are fundamental to reduce these challenges, which are current, but also forthcoming¹².

In spite of the fact that the elderly population has been growing sharply in the country for some years, one of the participants highlighted that the SUS (Brazil’s National Healthcare System) is not prepared to meet the needs generated by the population’s aging: “[...] A population that lives more and has a low quality of life tends to put pressure on the healthcare system, as they need more expensive and more specialized services. And we haven’t been preparing ourselves for this” (interviewee 1).

It would be fundamental to implement public policies that could meet the needs generated by fast demographic transformations. According to Batista, Jaccoud and El-Moor¹³, unlike the societies that aged in a slower rhythm and could adapt gradually to this situation, “Brazil faces the requirement of expanding the understanding of the demographic, economic and social implications of the ageing process somewhat urgently and organizing policies to face them” (p. 138).

Furthermore, as it was mentioned above, this demographic transition is not neutral. According to Brito¹⁴, it can “potentialize demographic possibilities” and favor the country’s development, or it can “increase the inequalities that mark the history of the Brazilian society” (p. 5).

The changes in the age structure of the Brazilian population result from alterations in the fertility, birth and mortality rates, which have been observed since the middle of the 20^th century. On Table 2, it is possible to see that the fertility rate decreased continually and reached a rate of 1.8 in 2010, an average that is lower than the population replacement level, which is 2.1.

Table 2
Evolution of demographic characteristics in Brazil in the period from 1995 to 2010

• Source: Rede Interagencial de Informações para a Saúde (Interagency Health Information Network), Sistema dei nformações sobre Mortalidade (Mortality Information System)

The child mortality rate presented an average annual reduction of 1.2 and, in 2010, it reached 16.0 deaths per one thousand live births. Life expectancy at birth, in turn, increased from 68.5 in 1995 to 73.4 years in 2010, an increase of almost five years (Table 2).

The reduction in the fertility, birth and child mortality rates and the increase in life expectancy at birth reflect the demographic transition process that started in Brazil in the 1950s and has become faster from 1980 onwards. This process resulted in a decrease in the population younger than 15 years and in a significant increase in the elderly population.

These changes favor economic growth, mainly during the window of opportunity. According to one of the interviewees, for the country to take advantage of the bonus that it has been experiencing, it would be necessary to invest in education, amplifying the access to it and, mainly, reversing educational indicators and qualifying them.

“[...] it’s not enough to have any schooling; it’s essential to eradicate illiteracy, as this is the point of departure to increase the number of years of schooling. It is fundamental to raise the schooling rate to place the population in the field of knowledge, technological innovation, incorporation of productivity factors […]”. (interviewee 8)

Investments in education would be necessary not only to foster the country’s development, but also to promote a healthy life. According to Sanchez and Ciconelli¹⁵, “the individuals’ educational level determines, in a significant way, individual access to social resources and, therefore, to healthcare” (p. 266).

In addition, the healthcare system would have to organize itself to meet the needs generated by current and future demand. The Brazilian demographic transition has been characterized by its accelerated speed, which requires a fast response from the healthcare system, as one of the interviewees emphasized:

“From the point of view of health, it is possible to notice that there is clarity concerning the demographic bonus that the country has been experiencing. So, this is the moment in which the healthcare system must structure itself for this increasing demand of the elderly population, a highly specialized demand […] that requires actions that are not isolated; actions that are coordinated in a large part of the professionals. So, the preparation of the healthcare system as a whole to meet this increasing demand - this is a great challenge”. (interviewee 3)

Moreover, in this context of demographic transition, it would be fundamental to carry out promotion and prevention actions targeted at the population, mainly due to social determinants and their influences on the health-disease process.

“[...] the Sistema Único de Saúde^d1 is an articulated public policy that involves all dimensions, like the social-sanitary infrastructure, work, income, leisure, education for the maintenance of healthy life standards […] but this implies that you must have a policy for these dimensions […]”. (interviewee 8)

Considering the social determination of the health-disease process, it is fundamental that the State considers itself responsible for the social development of the country, promoting universal policies, actions and strategies characterized by social cohesion¹⁶.

This means that efforts should be directed at the current generations of children and youths, mainly in the areas of health and education. Thus, not only a good quality of life would be guaranteed in the future, but also the development of the Brazilian society and of its economy in the next decades. If this does not happen, we will lose the window of opportunity and the demographic bonus will not have contributed to Brazil’s improvement¹⁷.

Regarding socio-economic indicators, significant trends of increase were noticed, together with a reduction in the poverty rate (Table 3).

Table 3
Socioeconomic indicators in Brazil in the period from 1995 to 2010

• Source: Instituto de Pesquisa Econômica Aplicada (Institute of Applied Economic Research) and Instituto Brasileiro de Geografia e Estatística (Brazilian Institute of Geography and Statistics)

These changes were only possible because, in recent years, the inequalities existing in Brazil were faced in a permanent way. One of the interviewees even highlighted some of the main aspects related to social changes:

“[...] the chronic weaknesses were only truly faced in a permanent way with the consolidation of income transfer policies unified in the Programa Bolsa Família^e2, with the maintenance of the connection between social security benefits and the value of the minimum wage, and with a deliberate policy of recovery of the minimum wage above inflation adjustment rates”. (interviewee 8)

In the studied period, the average number of years of schooling among people aged 25 years or older grew significantly in the entire period, with an average annual evolution of 0.1 years, increasing by 37.1%.

Access to high-quality education is fundamental so that people can develop their potentialities. According to the IBGE¹⁸, the increase in the average number of years of schooling can be used as a quantitative indicator of the school democratization process, that is, of a greater opportunity of access to teaching.

Despite the observed growth, data from the Human Development Report¹⁹show that the average number of years of schooling in Brazil in 2010 was only higher than the number presented by India, when the indicators of the countries that compose the BRICS (Brazil, Russia, India, China and South Africa) are analyzed.

According to the interviewees, Brazil has evolved in technical and higher education, but one of them argues that there are low investments in elementary and high school:

“Who is going to cover for the elderly population in the future? It is these people who are arriving now […] So, which is the strategic investment to them? Undoubtedly, education. It is the day-care center, it’s elementary school, and that’s where we have least advanced. […]”. (interviewee 5)

According to Castro²⁰, “in the more developed countries, education is part of social policies and composes the nucleus of the social promotion system through its capacity for broadening opportunities for individuals; in addition, it is a strategic element for economic development” (p. 674).

In the studied period, Brazil presented a significant reduction in poverty, mainly after 2003, with an average annual decrease of 2.6%, which may be related to the implementation of income transfer policies.

According to one of the interviewees, it is evident that it is necessary to expand and maintain the social policies so that the country can continue to advance in the area of social transformations: “[...] so that the social changes continue, it is necessary to maintain the social programs; I’m referring particularly to Programa Bolsa Família” (interviewee 1).

According to Marques²¹, the Federal Government recognizes that Programa Bolsa Família is the main program of its social policy. It was created to “face poverty and social divide”, debts of the historic inequality that marks the Brazilian society, and also to “promote the emancipation of poor families”.

According to Silva and Silva²², income transfer programs have been adopted as “the most important policy alternative” to face poverty and inequality in Latin America. The author cites the programs developed in Mexico, Argentina, Chile, Costa Rica, Uruguay, Honduras, Nicaragua and Brazil, and highlights that Bolsa Família is the greatest income transfer program in the world.

However, one of the interviewees highlighted that the Programa Bolsa Família must become a basic income program and must lose its welfarist nature, so that, as a State policy, it can contribute even more to reduce social inequality in Brazil:

“[...] we must be able to maintain many policies; among them, the income transfer policies, especially the Programa Bolsa Família. As this program gradually incorporates new segments excluded from society, it needs to change its profile a bit. It must cease to be an income transfer program and become a program that guarantees basic income, in which the aim is to reach a per capita income that is acceptable for a country that has the demographic, economic and social characteristics that Brazil has”. (interviewee 7)

According to Buss²³, guaranteeing a minimum income to all the citizens of a country is one of the boldest strategies to be adopted by the State in the perspective of achieving some level of economic equity and eradication of poverty. To Suplicy²⁴, this is the citizenship income, which has been developed in countries like Denmark, United Kingdom, France, Portugal and others since the 1930s, in the form of income guarantee, with positive results.

Nevertheless, the majority of the interviewees agrees that the increase in family income alone is not enough to overcome the inequalities that exist in Brazil. This is not the only component of poverty that must be faced. According to one of them, other elements have not been achieved yet – important mechanisms that generate inequality in the country.

“[...] other components of poverty, apart from income, haven’t been tackled yet, and there’s still a portion of the population that you haven’t been able to reach with these two instruments, and they’re precisely the hardest to reach as, generally speaking, they’re the poorest, the most distant communities, large urban peripheries where people can’t even have access to the State and the State can’t have access to them, too […]”. (interviewee 5)

According to Amartya Sen²⁵, this is a frequent problem. The size of inequality cannot be measured based only on differences among the incomes of people in the society as, according to the author, “what we can or cannot do, can or cannot fulfil, also depends on the variety of physical and social characteristics that affect our lives and make us be what we are” (p. 60).

Data referring to sanitation conditions point to a positive evolution in the analyzed period (Table 3). Concerning sewage, Brazil presented, in 2011, the largest coverage of adequate sanitation when compared to the BRICS, but lagged behind Argentina and Chile which, like Brazil, are South American countries²⁶.

When sanitation services are adequately supplied, they reduce the effects of human action on the environment. When they are not, the precariousness of the sanitation supply generates a negative impact not only on the environment, but also on public health and, consequently, on development. This means that, ideally, services supply should be universal, and their coverage and the access to them should be guaranteed, but this does not occur in Brazil²⁷.

Despite the social changes that occurred in the first decade of this century, important inequalities are still observed in the country, consequences of a social debt that require a strong investment from the State so that they can be overcome. In 2012, 30.3 million Brazilians still lived below the poverty line²⁸, the average number of years of schooling was still low, and 35.5% of the population did not have access to a general sewage system. In a country characterized by inequality, overcoming this scenario is a challenge that is even bigger.

According to Barros et al.²⁹, even with the reduction in inequality that occurred in the first years of the 21^st century, Brazil still ranks in a negative position, presenting one of the highest degrees of income concentration in the world.

One of the interviewees believes that the continuity of the transformations in the country’s social standard will depend on the maintenance of the actions that were carried out in recent years, which have promoted important changes in the scenario of inequalities:

“What we verified in recent years is that there has been a reduction in this inequality. We are still unequal, but we are less unequal than before. What can happen? I think there’s always more than one scenario. If the actions and programs developed in the last ten years are maintained, I believe that the tendency is a reduction in inequality. […] If they’re not maintained […] we’ll have the other side happening: an increase in inequality”. (interviewee 4)

In addition to the consolidation of the actions carried out in recent years, other interviewees believe it is essential to associate them with broad and permanent social policies, in order to face the deficiencies that continue to make Brazil be one of the most unequal countries in the world.

“[...] investment in infrastructure, being capable of providing the country with conditions to go forward […] So, this I think is the great challenge. How the country’s growth with reduction in inequality, the expansion in access, can be sustained in the next years. We must maintain the perspective of economic development also targeted at reducing poverty and increasing income, and we must continue with this process of universalizing the access to treated water and sewage, improving housing conditions […]”. (interviewee 2)

“There must be a permanent policy […] a national plan for urban development […] An advanced policy of social and sanitary infrastructure”. (interviewee 8)

This would be the moment to invest in the healthcare system. It would be fundamental to amplify the State’s investment capacity, promoting a healthcare system that meets the challenges and the population’s needs, contributing to the promotion of social changes. In the perspective of one of the interviewees:

“[...] the aging rate of the population will increase, the population will be more exposed to the external causes, to homicides, to traffic accidents. Consequently, this population will generate new epidemiological indicators […] that will be reversed only with intense and preventive health policies […]”. (interviewee 8)

Another interviewee views the field of health not only as a result, but also as an inducer of the advances observed in the country:

“Undoubtedly, there’s an important aspect that is the contribution of health as a result of sustainable development, but also as a cause of sustainable development, that is, the fact that Brazil has a universal healthcare system [...] has also played a very important role in the improvement in these indicators. […] Countries whose level of economic development is similar to ours, that have healthcare systems with partial coverage of the population, […] had a lower performance compared to ours during these years”. (interviewee 2)

According to Gadelha et al⁹, health is a field of particular relevance to the country’s social and economic cohesion. Different lines of analysis incorporate health in its relation to development, and understand it, among diverse aspects, as an “essential component of quality of life and public intervention in the social area; a field that induces economic growth, investments and policies, and is fundamental to the configuration of modern social protection systems” (p. 3005).

Final remarks

It can be noticed, based on the results of this study, that significant transformations have occurred in Brazil’s demographic and social structure. Whereas the changes in the country’s population, which characterize the demographic transition that began in the middle of the 20^th century, have been fast, the social changes occurred in Brazil were intensified mainly in the first ten years of this century.

The demographic transition has brought and will bring specific demands, requiring opportune answers, many of which have not been implemented yet. This challenge is amplified with the association of the inequalities that still persist and need to be faced in the country.

Brazil has been experiencing a unique moment. The window of opportunity occurs only once during the process of demographic transition and investments by means of social and structuring public policies can assure the advance of the transformations and reduce the impact of the demands, which are both current and forthcoming. A reduction in the country’s inequities would depend on the adoption, by the Brazilian State, of a social project that guarantees the population’s rights.

Health plays a fundamental role in this scenario of reduction in inequalities. Brazil’s universal and unified healthcare system, organization of the care model and guarantee of access to meet the needs generated by the new demographic profile represent not only the defense of the constitutional right, but also the promotion, as we discussed here, of social welfare.

Referências

• ¹
  Ianni O. A questão social. Rev USP [Internet]. 1989 [citado 30 Nov 2014]; 3:145-53. Disponível em: http://www.usp.br/revistausp/03/17-octavio.pdf
  » http://www.usp.br/revistausp/03/17-octavio.pdf
• ²
  Alves JED, Vasconcelos DS, Carvalho AA. Estrutura etária, bônus demográfico e população economicamente ativa no Brasil: cenários de longo prazo e suas implicações para o mercado de trabalho. Brasília (DF): Cepal, Ipea; 2010. (Textos para discussão Cepal).
• ³
  Alves JED. O fim do bônus demográfico e o processo de envelhecimento no Brasil. Rev Portal Divulg. 2015; 5(45):6-17.
• ⁴
  Brito F. A reinvenção da transição demográfica: envelhecer antes de enriquecer? Belo Horizonte: UFMG/Cedeplar; 2010.
• ⁵
  Demo P. Participação e planejamento: arranjo preliminar. Rev Adm Publica. 1991; 52(3):31-54.
• ⁶
  Albuquerque MSV, Costa AM, Lima LP, Melo Filho DA. Equidade e inclusão de grupos sociais na política de saúde: o caso do Recife, Brasil. Rev Bras Saude Matern Infant. 2011; 11(1):73-82.
• ⁷
  Paim J, organizador. O que é o SUS. Rio de Janeiro: Fiocruz; 2009. Avanços e desafios do SUS; p. 125-38.
• ⁸
  Vieira-da-Silva LM, Almeida Filho N. Eqüidade em saúde: uma análise crítica de conceitos. Cad Saude Publica. 2009; 25 Supl 2:217-26.
• ⁹
  Gadelha CAG, Vieira C, Lima L, Baptista TWF. Saúde e territorialização na perspectiva do desenvolvimento. Cienc Saude Colet. 2011; 16(6):3003-16.
• ¹⁰
  Kvale S. An introdution to qualitative research interview. Thousand Oaks: Sage; 1996.
• ¹¹
  Mendes ACG, Sá DA, Miranda GMD, Lira TM, Tavares RAW. Assistência pública de saúde no contexto da transição demográfica brasileira: exigências atuais e futuras. Cad Saude Publica. 2012; 28(5):955-64.
• ¹²
  Kalache A. O mundo envelhece: é imperativo criar um pacto de solidariedade social. Cienc Saude Colet. 2008; 13(4):1107-11.
• ¹³
  Batista AS, Jaccoud LB, El-Moor PD. Envelhecimento e dependência: desafios para a organização da proteção social. Brasília (DF): Ministério da Previdência Social, Secretaria de Previdência Social; 2008.
• ¹⁴
  Brito F. Transição demográfica e desigualdades sociais no Brasil. Rev Bras Estud Popul. 2008; 25(1):5-26.
• ¹⁵
  Sanchez RM, Ciconelli RM. Conceitos de acesso à saúde. Rev Panam Salud Publica. 2012; 31(3):260-8.
• ¹⁶
  Costa GD, Cotta RMM, Ferreira MLSM, Reis JR, Franceschini C. Saúde da família: desafios no processo de orientação do modelo assistencial. Rev Bras Enferm. 2009; 62(1):1113-8.
• ¹⁷
  Carvalho JAM, Wong LR. Plano Nacional de Pós Graduação 2011/2020. Brasília (DF): Capes; 2010. (Documentos Setoriais Capes; v. 2).
• ¹⁸
  Instituto Brasileiro de Geografia e Estatística. Síntese de Indicadores Sociais. Rio de Janeiro: IBGE; 2012.
• ¹⁹
  Programa das Nações Unidas. Relatório do Desenvolvimento Humano 2011. Sustentabilidade e equidade: um futuro melhor para todos. New York: PNUD; 2011.
• ²⁰
  Castro JA. Evolução e desigualdade na educação brasileira. Educ Soc. 2009; 30(108):673-97.
• ²¹
  Marques RM. Política de transferência de renda no Brasil: a experiência do Bolsa Família. Soc Cult. 2008; 11(2):237-43.
• ²²
  Silva e Silva MO. Desigualdade, pobreza e programas de transferência de renda na América Latina [Editorial]. Rev Polit Publica. 2009; 13(2):157-9.
• ²³
  Buss PM. Globalização, pobreza e saúde. Cienc Saude Colet. 2007; 17(6):1575-89.
• ²⁴
  Suplicy EM. Renda de cidadania: a saída é pela porta. São Paulo: Cortez; 2002.
• ²⁵
  Sen AK. Desigualdade reexaminada. Mendes RD, tradutor. Rio de Janeiro: Record; 2012.
• ²⁶
  Organización Mundial de la Salud. Estadísticas sanitarias mundiales [Internet]. Ginebra: OMS; 2013 [citado 30 Set 2013]. Disponível em: http://apps.who.int/iris/bitstream/10665/82218/1/9789243564586_spa.pdf?ua=1
  » http://apps.who.int/iris/bitstream/10665/82218/1/9789243564586_spa.pdf?ua=1
• ²⁷
  Saiani CCS, Galvão GC. Evolução das desigualdades regionais do déficit de acesso a serviços de saneamento básico no Brasil: evidências de um incentivo adverso dos objetivos de desenvolvimento do milênio? [Internet]. In: Anais do 39° Encontro Nacional de Economia (ANPEC); 2011; Foz do Iguaçu, Brasil. Foz do Iguaçu: Associação Nacional dos Centros de Pós-Graduação em Economia; 2011 [citado 30 Set 2013]. Disponível em: https://www.anpec.org.br/encontro/2011/inscricao/arquivos/000-ef4fffdd4b9dabf74ef5fa3c2062987e.pdf
  » https://www.anpec.org.br/encontro/2011/inscricao/arquivos/000-ef4fffdd4b9dabf74ef5fa3c2062987e.pdf
• ²⁸
  Instituto de Pesquisa Econômica Aplicada. Indicador número de indivíduos pobres [Internet]. Brasília: IPEA; 2014 [citado 18 Set 2014]. Disponível em: http://www.ipeadata.gov.br
  » http://www.ipeadata.gov.br
• ²⁹
  Barros R, Carvalho M, Franco S, Mendonça R. Determinantes da queda na desigualdade de renda no Brasil. Brasília (DF): Ipea; 2010. (Texto para discussão; nº 1460).

Publication Dates

• Publication in this collection
  16 Nov 2016
• Date of issue
  Apr-Jun 2017

History

• Received
  07 Mar 2016
• Accepted
  30 June 2016