Social Determinants of Health in Brazil

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

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

3. Brazilian Commission on SDH

4. SDH in the global agenda (Tim Evans modified) World Conference on SDH 2000s: new opportunities for action on SDH WHO Commission on SDH 2011 1990s: health as a private good 2005 SDH reappear in the health for All agenda (1978) SDH in WHO Constitution (1948) Social dimension lost relevance in the era of campaigns (1950s). 2000 WHO PHC-U PHC-S Health Reforms MDG CSDH WCSDH 1993 1982 1978 1948

5. 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 Process of creation of BNCSDH

6. 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) Composition of BNCSDH

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

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

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

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

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

13. 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 (MoH acting as technical secretariat) • To create a high level Office in the Ministry of Health to promote SDH actions

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

15. 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

16. 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)

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

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

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

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

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

22. Child Mortality (less than 5 years) and illiteracy in Brazilian municipalitiessource: CelsoSimões Northeast South

23. Special Issue on SDH of REPORTS IN PUBLIC HEALTH

24. Portal on SDHwww.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

27. Post BNCSDH Initiatives

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

31. 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.

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

33. 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

34. 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.

35. 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

36. 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

38. Regional Conference on SDHNortheast • 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”.

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

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

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

42. 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

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

44. Technical cooperation on capacity building to implement Rio Declaration

45. 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 18.3 11.4 21.5 8.6 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 1.8 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 45.59.7 6.0 3.9 11.0 4.3 11.6 2.7 23.0 6.9 Causes of Infant MortalitySource: César Victora, CNDSS

46. Participation of Ministries in selected actions – 2004-2006

47. Participation in selected actions by theme – 2007

48. Total values executed by theme - 2006

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

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