DOI: 10.1590/1413-81232018236.04822018 1737 Changes in health and disease in Brazil and its States in the 30 ARTICLE years since the Unified Healthcare System (SUS) was created Maria de Fátima Marinho de Souza 1 Deborah Carvalho Malta 2 Elisabeth Barboza França 3 Mauricio Lima Barreto 4 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 mea- sured in 1990 to those measured in 2015 in Brazil and its states. The goal is to contribute to under- standing the role SUS played in changing the na- tion’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 mea- sured 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 1 Instituto de Medicina by violence. Poor diet is the leading risk factor, fol- Social, Universidade do Estado do Rio de Janeiro. lowed by metabolic issues. Tobacco use decreased R. São Francisco Xavier over the period, as did infant malnutrition. In the 524/1006 A, Maracanã. thirty years since the SUS was created, health in- 20550-900 Rio de Janeiro RJ Brasil. fatima.marinho@ dicators in this country have improved, and ma- saude.gov.br jor progress has been made to reduce inequality 2 Escola de Enfermagem, across the country’s regions. Universidade Federal de Minas Gerais (UFMG). Belo Key words Healthcare policies, Child mortality, Horizonte MG Brasil. Unified Healthcare System, Non-Transmissible, 3 Faculdade de Medicina, Chronic Diseases (NTCDs), Violence UFMG. Belo Horizonte MG Brasil. 4 Instituto de Saúde Coletiva, Universidade Federal da Bahia. Salvador BA Brasil. 1738 et al. miological transitions have resulted in different Souza MFM Introduction health and disease patterns in different regions Congress approved a democratic constitution in and states15. Studies show that the expansion of 1988, and health is included as a right. The Uni- the SUS system over the past 30 years helped re- fied Healthcare System (SUS) was then created to duce the burden of disease in the population, and ensure the population’s right to free and compre- the inequalities across regions in this country15. hensive healthcare1. Thus, it is important to analyze how the disease Over the past 30 years, Brazil has undergone scenario has changed in Brazil over the past de- structural changes and become an emerging na- cades. tion2. In terms of the SUS, we point to structur- The current study compared the health indi- ing measures and programs such as the Family cators prevalent in 1990 and 2015 in Brazil and Health Strategy (FHS), created in 1994 to guide its states. The goal was to help understand the the healthcare model to a more comprehensive role SUS plays in changing the nation’s health approach, focusing on primary care and seeking profile. to provide universal access to all Brazilians3. The Family Health Strategy has expanded greatly in the past decade, prioritizing vulnerable areas. Methods According to the National Health Survey3, it now covers 53.4% of the population. The Brazilian To analyze how the health of the Brazilian pop- National Vaccination plan, created in 1973, is an ulation has changed over time, this study used efficient provider of vaccines against numerous estimates published in the 2015 GBD (Global transmissible diseases. In fact, vaccine coverage Burden of Disease) covering the country and the in this country has helped reduce the number individual states16. In 2015, a GBD study by the of immune preventable diseases4. The SUS also University of Washington Institute for Health created a national policy to provide free and Metrics and Evaluation (IHME) analyzed 249 universal access to essential drugs5. In the past causes of death, 310 diseases and injuries, 2,619 decade, the government decided that drugs to unique sequelae and 70 risk factors using stan- treat Non-Communicable Diseases would be dardized methodology and different sources of provided to the population free of cost6,7, and data in 195 countries and territories16-18. created a program of Budget drugstores known The first element of the GBD study’s analyt- as Aqui Tem Farmácia Popular. The Ministry of ical approach is an estimate of overall mortality Health has ensured free and universal anti-retro- to correct under notified deaths. This includes viral treatment to those living with HIV/AIDS, estimating the probability of death among those and has taken numerous disease-prevention younger than 5 years of age (5q0), adult mortal- and health-promotion measures8,9. In 2006, the ity (45q15), specific mortality by age and the in- National Health Promotion Policy prioritized clusion of the possible effects of epidemics such intersectoral measures as well as certain health as HIV/Aids, natural disasters and other fatal dis- determinants and conditionants10. Although continuities17. The main sources of data on mor- Brazil is the world’s 2nd largest tobacco producer, tality among those younger than five in Brazil it has played a key role in tobacco control, im- were the death records in the Mortality Informa- plementing regulatory measures that range from tion System, demographic censuses, household prohibiting tobacco advertising to the Tobac- surveys - PNAD, the Sample-Based Household co-Free Environments Law signed in 2014. These Survey, and PNDS, the National Survey of De- measures have helped reduce smoking around mographics and Health, as well as the complete the world11,12. In 2004, Brazil signed the World (PNDS) and abbreviated (censuses and PNAD) Health Organization’s Global Treaty on Diet, birth records. The estimating process used statis- Physical Activity and Health to prevent obesity tical models to adjust the different sources and and Non-Communicable diseases13. In the past address any possible inconsistencies between decade a pre-hospital service was created to care them19,20. for the growing number of cardiovascular diseas- The second key component of GBD meth- es, external causes among the population, etc.14. odology is cause of death, and for this the main Population ageing, decreasing fertility rates source of information was the Ministry of Health and other transformations in Brazilian society SIM or mortality information database. SIM en- have brought with them new challenges for the tries with diagnoses that should not be consid- healthcare system15. Demographic and epide- ered the main cause of death, poorly defined or 1739 Ciência & Saúde Coletiva, 23(6):1737-1750, 2018 23(6):1737-1750, Coletiva, & Saúde Ciência incomplete diagnoses, and entered as garbage19-21, and overall life expectancy and HALE show a were reassigned to non-garbage codes for each similar increase in the number of years lived in age-gender-year using specific redistribution al- good health. (Table 2) gorithms. Causes of death were modeled using Age-standardized mortality rates for both CODEm (Cause of Death Ensemble Model)19,20 genders dropped 28.7% (UI: 26.1-31.1) be- The main sources of data for risk factor anal- tween 1990 and 2015, from 1,102.2 (UI: 1,085,9- yses were surveys such as the National Health 1,118,6) to 786.2 per 100,000 inhabitants (UI: Survey (PNS), Vigitel (telephone chronic disease 761.2-810.3). (Table 2) Age-standardized mor- risk factor surveillance and protection), the Na- tality rates dropped across Brazil, however at dif- tional Household Sample Survey (PNAD), and ferent rates depending on the region. The largest the National Student Health Survey (PeNSE), decreases were recorded in the more developed among others22. regions - the South (30%) and Southeast (32%), The following metrics were used to describe while the smallest ones were in the North (20%) the burden of disease in 1990 and 2015: absolute and Northeast (21%). (Table 2) number of deaths, infant deaths per 1,000 live The Federal District performed better in all births at the country and state level, mortality for health metrics. In 2015, the state of São Paulo - standardized causes by age (for the overall pop- the wealthiest in the nation - came in second and ulations), death and disability adjusted life years third in terms of life expectancy and HALE at (DALY), life expectancy and health-adjusted life birth respectively. In 2015, the lowest life expec- expectancy (HALE), as well as ranked lists of the tancy at birth was in states of the northeast: Ma- main causes of death and risk factors in 1990 and ranhão, Alagoas and Pernambuco at 71.5 years 2015. Greater details about the metrics are avail- (UI=69.1-73.6), 72.3 years (70.7-73.8) and 72.5 able in other publications16-20. years (70.9-74.1) respectively. However, these Metrics are shown with their uncertainty in- states also had the largest increase in life expec- tervals (UI), which reflect the uncertainty in the tancy compared to 1990 - 12.6% for Maranhão, parameter estimates for each state and period of 15.1% for Alagoas and 12.1 for Pernambuco (Ta- study. Greater details are available in other pub- ble 2). lications. 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. Results In 2015, there were some 1.3 million deaths in Brazil, a 28.7% reduction in the overall mortal- Table 1 shows an estimate of deaths and mortal- ity rate. Non-Communicable diseases are the ity rates for those under the age of 5 at the coun- leading cause of death - 75% or 1 million.