Social Determinants of Health in Brazil Alberto Pellegrini

Social Determinants of Health in Brazil Alberto Pellegrini Filho Center for Studies, Policies and Information in Social Determinants of Health ENSP/FIOCRUZ (CEPI-DSS)

• Brazilian Commission on SDH • Center for Studies, Policies and Information on SDH (CEPI-DSS/ENSP/FIOCRUZ) • Post BNCSDH Initiatives

Brazilian Commission on SDH

SDH in the global agenda World Conference on SDH (Tim Evans modified) 1990 s: health as a private good SDH in WHO SDH reappear in Constitution the health for (1948) All agenda Social (1978) dimension lost relevance in the era of -U C campaigns PH (1950 s). O H W 1948 1978 2000 s: new WHO Commission opportunities for on SDH action on SDH G MD s He DH -S CS C W PH 1993 H D CS 1982 h alt rm o f e R 2000 2005 2011

Process of creation of BNCSDH • Commission was created in March, 2006 with sixteen personalities of social, economic, cultural and scientific life • This diversity is an expression of the recognition that health is a public good, constructed with the participation of all segments of the society

Composition of BNCSDH • • Adib Jatene Aloísio Teixeira César Victora Dalmo Dallari Eduardo E. G. Vieira Elza Berquó Jaguar Jairnilson Paim • • • Lucélia Santos Moacyr Scliar Roberto Smeraldi Rubem C. Fernandes Sandra de Sá Sônia Fleury Zilda Arns Paulo Buss (coord. ) A. Pellegrini (tech. secretary)

Population Economically Active accordingly to economic sectors Brazil – 1940 to 2000 Source: Instituto Brasileiro de Geografia e Estatística (IBGE).

Distribution of population (%) - Brazil – 1940 a 2000 Source: Instituto Brasileiro de Geografia e Estatística (IBGE).

Fertility rate – Brazil – 1940 a 2000 Source: Census (1940 -2000). IBGE

Fertility rates according characteristics 1996 - 2006. Total Fertilty Rate 6 Brazil Residence to socio-demographic Years of Schooling 5, 0 1996 2006 4, 2 4 2, 8 2, 5 2 3, 6 3, 5 3, 0 2, 3 1, 8 2, 4 2, 1 2, 0 1, 7 1, 6 1, 5 1, 0 0 Total urban rural none 1 to 3 4 5 to 8 9 to 11 12 or more

Life expectancy - Brazil and Regions – 1960 -2006 Source: IBGE e Simões

BNCSDH recommendations • To establish an ‘ SDH Observatory’ for monitoring health inequities and evaluation of policies and interventions on SDH; • To develop training courses on SDH approach for managers, health professionals and other social workers; • To develop studies and research projects on SDH; • To develop communication strategies about SDH to diverse social sectors • To create a mechanism in the Presidential Cabinet to coordinate intersectorial SDH actions (Mo. H acting as technical secretariat) • To create a high level Office in the Ministry of Health to promote SDH actions

Center for Studies, Policies and Information on SDH (CEPI-DSS/ENSP/FIOCRUZ)

Center for Studies, Policies and Information on SDH (CEPI-DSS) General Objective To support activities developed by government and civil society for the promotion of health equity through the production and dissemination of knowledge and information, training of personnel and evaluation of policies and programs on SDH

Center for Studies, Policies and Information on SDH (CEPI-DSS) • Observatory on Health Inequities: monitoring health inequities, follow-up and evaluation of interventions on SDH • Training activities for managers in the diverse spheres of public administration; • Studies and Research on SDH; • Promotion and participation on collaborative networks of researchers and managers; • Information and communication about SDH to government, professionals and general public: Portal SDH (www. dssbr. org) and VHL SDH (http: //bvsdss. icict. fiocruz. br)

Mortality by diabetes mellitus in people with 15 years or older according to years of schooling

Women between 50 and 69 years old that never did mamography according to years of schooling

Mortality by homicide in people with 15 years or older according to years of schooling

Mortality by homicide in people with 15 years or older according to years of schooling

Distribution of people (15 years or older) according to region and years of schooling Northeast Southeast

Child Mortality (less than 5 years) and illiteracy in Brazilian municipalities source: Celso Simões Northeast South

Special Issue on SDH of REPORTS IN PUBLIC HEALTH

Portal on SDH www. dssbr. org • • Observatory: Indicators and analysis News of interest on SDH Summaries and analysis of articles on SDH Basic and reference documents Opinions Interviews Bank of Experiences Blog; Twitter; Selected Links

Post BNCSDH Initiatives

Participation in Global and Regional Initiatives • Global: WCSDH, Rio +20, SDG and post 2015 development agenda • Region of Americas: OPS, UNASUR and MERCOSUR

Rio Declaration 1. Governance to tackle the root causes of health inequities: implementing action on social determinants of health; 2. Promoting participation: community leadership for action on social determinants; 3. The role of the health sector, including public health programs, in reducing health inequities; 4. Global action on social determinants: aligning priorities and stakeholders; 5. Monitoring progress: measurement and analysis to inform policies and build accountability on social determinants.

National Initiatives: Definition of strategies to implement WCSDH recommendations Regional Conferences on SDH

Objectives • To perform regional health situation analysis with SDH approach • To review on going policies and programs on SDH in the Region • To discuss implementation of WCSDH recommendations in the regional context • To make recommendations for actions in the Region with respective follow-up and evaluation mechanisms

Participants • Representatives of different sectors of the three spheres of government; • Representatives of civil society active in the Region; • Regional and national specialists; • Regional Institutions of education, research and administration; • CONASS, CONASEMS, ABRASCO.

Activities • • Definition of regional institution: Aggeu Magalhães Institute/FIOCRUZ for the first Conference in Northeast Publication of documents, news, opinions, interviews, experiences and other source of information about the Region in www. dssbr. org; Elaboration of working documents: - description and analysis of regional health situation with SDH approach; - on going policies and programs including recommendations to overcome identified problems; Regional Conference with 400 invited participants and Web broadcasting

• • • Regional Conference on SDH Northeast, september 2013: Why Northeast? Region with the biggest social and health inequities in the country Presence o research centers to analyze different aspects of regional situation Important economic, political and social changes with impact on SDH Good representation of government, civil society and academic leadership FIOCRUZ NE

Regional Conference on SDH Northeast • Plenary Sessions: “Northeast: recent development, challenges ahead”, “SDH and Health situation in NE” and “Polices and Programs in NE related to SDH”; • Parallel sessions: “Water and Sanitation”, “Big projects and their impact in Health”, “Access and quality of health services”, “Violence and drugs” and “Food and nutrition security”.

Thank you! Alberto Pellegrini Filho Director Center for Studies, Policies and Information on SDH (CEPI-DSS) National School of Public Health/FIOCRUZ. phone: 55 -21 -2598 -2894 e-mail: pellegrini@fiocruz. br web: dssbr. org and bvsdss. icict. fiocruz. br

Modes of Production of Knowledge (Gibbons) “Traditional” (Mode 1) “Locus” of Institutions with walls, production of mainly universities and knowledge research institutions Research agenda Types of research Approach Agendas defined by researchers according to development of their disciplines Basic (to know to understand) vs. Applied (to know to utilize) Disciplinary Socially distributed (Mode 2) Collaborative networks of institutions Agendas defined in contexts of application Problem solving Transdisciplinary

Modes of Production of Knowledge (Gibbons) Relationship between producers and users of knowledge Unidirectional and “a posteriori” transfer of knowledge Criteria for evaluation Scientific Merit Continuing exchange of knowledge Scientific merit and social relevance Means of dissemination of results Financing Scientific Journal Public resources Several media Diversity of public and private sources Management of scientific activity Centralized planning Creation of spaces/opportunities for

Disminución de la desigualdad em A. Latina por país 2000 -2010 (% de cambio anual del Gini) Fuente: Nora Lustig, Luis F. Lopez-Calva e Eduardo Ortiz-Juarez

Coeficiente de Gini en Argentina, Brasil y Mexico 1992 -2010 Fuente: Nora Lustig, Luis F. Lopez-Calva e Eduardo Ortiz-Juarez

Technical cooperation on capacity building to implement Rio Declaration Institutional Development Governance Social participation Health sector Global action Monitoring Methodologies/ Technologies Human Resources development

Causes of Infant Mortality Source: César Victora, CNDSS Cause Ano North NE SE South CO Brazil Perinatal 1985 -87 2003 -05 42. 1 61. 2 42. 9 62. 2 48. 9 61. 0 46. 4 58. 7 48. 7 57. 2 46. 5 60. 9 Malformations 1985 -87 2003 -05 4. 9 12. 7 3. 6 11. 4 8. 1 8. 6 18. 3 11. 4 21. 5 20. 0 7. 1 15. 7 Respiratory Infections 1985 -87 2003 -05 11. 5 8. 2 11. 4 6. 9 15. 7 6. 6 14. 2 5. 9 12. 9 6. 8 13. 9 6. 9 Diarrhea 1985 -87 2003 -05 30. 1 5. 1 27. 0 7. 1 11. 8 12. 5 1. 9 12. 9 3. 1 17. 3 4. 2 Other infections 1985 -87 2003 -05 5. 3 5. 2 6. 1 4. 2 5. 3 4. 2 6. 0 3. 1 7. 1 3. 8 5. 7 4. 2 Other causes 1985 -87 2003 -05 6. 1 7. 6 9. 0 8. 2 10. 2 8. 1 9. 5 8. 9 9. 8 9. 1 9. 5 8. 1 Ill-defined Causes 1985 -87 2003 -05 23. 9 11. 0 45. 5 9. 7 6. 0 3. 9 11. 0 4. 3 11. 6 2. 7 23. 0 6. 9

Participation of Ministries in selected actions – 2004 -2006

Participation in selected actions by theme – 2007

Total values executed by theme - 2006 US$ (1. 000) % Agriculture 78, 289 0, 86 Nutrition 770, 950 8, 47 Environment/ Housing 87, 377 0, 96 Education, Sport and 42, 865 culture 0, 47 Prevention of Violence 29, 977 0, 33 Socail Protection 8, 081, 656 88, 75 Employment and productive inclusion 15, 367 0, 17 Total 9, 106, 481 100

Women with 25 years or older that never did screening for cervix cancer according to years of schooling

% of live newborns in hospital births according to years of schooling

% of live newborns in hospital births according to years of schooling

% of live newborns with 7 or more pre-natal visits according to mother’s years of schooling

% of live newborns with 7 or more pre-natal visits according to mother’s years of schooling