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

Giovanny V A França,Aluísio J D Barros,María Clara Restrepo-Méndez,Maria Fátima S Maia,Cesar G Victora

doi:10.1186/s12939-016-0445-2

Giovanny V A França, Aluísio J D Barros + Show 3 more

Open Access

https://doi.org/10.1186/s12939-016-0445-2

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Abstract

BackgroundThe Brazilian SUS (Unified Health System) was created in 1988 within the new constitution, based on the premises of being universal, comprehensive, and equitable. The SUS offers free health care, independent of contribution or affiliation. Since then, great efforts and increasing investments have been made for the system to achieve its goals. We assessed how coverage and equity in selected reproductive and maternal interventions progressed in Brazil from 1986 to 2013.MethodsWe reanalysed data from four national health surveys carried out in Brazil in 1986, 1996, 2006 and 2013. We estimated coverage for six interventions [use of modern contraceptives; antenatal care (ANC) 1+ visits by any provider; ANC 4+ visits by any provider; first ANC visit during the first trimester of pregnancy; institutional delivery; and Caesarean sections] using standard international definitions, and stratified results by wealth quintile, urban or rural residence and country regions. We also calculated two inequality indicators: the slope index of inequality (SII) and the concentration index (CIX).ResultsAll indicators showed steady increases in coverage over time. ANC 1+ and 4+ and institutional delivery reached coverage above 90 % in 2013. Prevalence of use of modern contraceptives was 83 % in 2013, indicating nearly universal satisfaction of need for contraception. On a less positive note, the proportion of C-sections has also grown continuously, reaching 55 % in 2013. There were marked reductions in wealth inequalities for all preventive interventions. Inequalities were significantly reduced for all indicators except for the C-section rate (p = 0.06), particularly in absolute terms (SII).ConclusionsDespite the difficulties faced in the implementation of SUS, coverage of essential interventions increased and equity has improved dramatically, due in most cases to marked increase in coverage among the poorest 40 %. An increase in unnecessary Caesarean sections was also observed during the period. Further evaluation on the quality of healthcare provided is needed.

Highlights

The Brazilian SUS (Unified Health System) was created in 1988 within the new constitution, based on the premises of being universal, comprehensive, and equitable
Brazil provides an example of a distinct approach to health-system reform, combining poverty reduction strategies with the expansion of comprehensive primary health care services [5, 6]
Lessons from the Brazilian experience are relevant for countries advancing in universal health coverage

Summary

Introduction

The Brazilian SUS (Unified Health System) was created in 1988 within the new constitution, based on the premises of being universal, comprehensive, and equitable. The health sector reform in Brazil is unique because it was driven by civil society rather than by governments, political parties, or international organizations [5, 7]. It was designed by militants of the so-called Sanitary Movement nearly a decade before health care was incorporated in the 1998 Constitution as a citizen’s right and State’s duty [7,8,9]. In the 1990’s health sector reform was institutionalised with the creation of a national Unified Health System (SUS, Sistema Único de Saúde), based on the principles of universality, equity, integrality and social participation [5, 8]

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