Geneva Health Forum Archive

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Poverty and the Urban Health Challenge in Nigeria.

Author(s) Geoffrey Nwaka1.
Affiliation(s) 1Humanities and Social Sciences, Abia State University, Uturu, Nigeria.
Country - ies of focus Nigeria
Relevant to the conference tracks Social Determinants and Human Rights
Summary As we consider the post-2015 development agenda, the battle for sustainability in Africa will be won or lost in the cities. The paper considers how poverty and slum conditions in Nigerian cities can best be addressed and reversed.
Background Poverty and slum conditions pose a serious public health challenge to Nigeria’s rapidly expanding urban population. Almost everywhere in these cities environmental amenities lag behind population growth. Some elite neighborhoods enjoy relatively high quality housing and residential environments, but the bulk of the urban poor live in appalling and health threatening conditions. Inadequate housing, sanitation and waste management, and the poor state of public health infrastructure have led to the spread of a wide variety of water-borne and other communicable disease. Nutritional standards are low, and food contamination is common, especially in the extensive street food industry. Indoor pollution from open fires and stoves in poorly ventilated homes is known to be responsible for many respiratory ailments among women and children who are constantly exposed to toxic fumes in the cooking areas. As environmental and health problems overlap, the poor suffer disproportionately from the adverse health effects of environmental problems. Many of the Millennium Development Goals – in health, environmental sustainability, poverty reduction and enhanced international development assistance - will not be met in Africa despite improvements in some areas.
Objectives The paper considers how best to reach the poor, decrease inequalities in access to health services, ways to forestall the growth and spread of slums, and reduce poverty which leads to slum conditions.
Methodology I have drawn from historical material and social science literature. I have also interacted over the years with the urban poor, informal sector workers, and government officials concerned with urban health and development. Many of the insights from the UN sponsored conferences of the 1990s, the Habitat Agenda, ILO's Decent Work Agenda, WHO's Healthy Cities Programme, the work of the Cities Alliance for Cities Without Slums, and some of the more recent ideas from Rio+20, and the various 'Consultations' for the Post-2015 Development Agenda will be brought to bear on the analysis.
Results .The current pattern of government spending on the health sector tends to favor the well off in society who are the main users of curative health services. The central argument is that human development ought to be at the center of the concern for sustainable urbanization in Africa. To achieve this, the paper considers how best to promote the growth of more inclusive and humane cities by reviewing discriminatory laws and codes which tend to inhibit the access of the poor to affordable land, healthcare and housing security.
Conclusion The concluding section stresses the need for appropriate and well targeted urban health and other interventions by state and local authorities, the international development community, private sector and civil society organizations, and the urban poor themselves in a collaborative effort to build safer, healthier and more equitable cities

Patients on the Move

Author(s): M. M. Kingma1
Affiliation(s): 1International Council of Nurses, Geneva, Switzerland
Key messages:

1 – Globalisation is affecting the health sector - expanding the health services provider market as well as the health professional labour market.
2 – Health tourism tends to introduce or facilitate the growth of the private sector health industry. This may result in intranational tensions and competing vested interests.
3 – Health tourism needs to be monitored and evaluated in terms of population access to care, service stan- dards, and local labour conditions.

Summary (max 100 words):

The international migration of health professionals has increasingly been on the political agenda, especially in the context of widespread shortages of employed care providers. Globalisation is a reality and recognised characteristic of today’s world. Health systems are faced with the challenge of increasing demands on their services and a relative decrease in funding. Privatisation in the health sector is increasing, including in areas known as health tourism – patients seeking care outside their country of residence. Health facilities are being established providing medical and surgical interventions, as well as health promotion services (e.g. massage, relaxation therapy) essentially for foreign patients. While recognised as an income generating initiative in many cases, the introduction of health tourism may distort the public/private mix within the national economy, increase the intranational “migration” of health professionals from the public to the private sector, influence educational and practice standards, challenge professional regulatory bodies, place new demands on health insurance systems and create wide disparities among the pay and working conditions on offer locally. Health tourism may also help retain health professionals by providing better employment and professional development opportunities, improve working conditions, advance health care, harmonize standards of service delivery, and disseminate evidence-based practice.

Conclusion (max 400 words):

Health tourism is on the increase and predicted to be a growth industry in the years to come. Its introduction influences aspects far beyond health care, including the national economy, education, regulation, access to and quality of public sector services, insurance companies’ sustainability, the tourist industry and people’s expectations. Health tourism needs to be monitored and evaluated as a social phenomenon as well as studied in terms of impact on the accessibility and quality of care, patient outcomes, labour market and health personnel behaviours.

Vulnerable Populations and Inequalities in Health: The Case of Marginalized Women with Substance Abuse Problems

Author(s): M. P. Romero1
Affiliation(s): 1Researcher on medical sciences E. Direction of epidemiological and psychosocial research, National Institute of Psychiatry, Mexico city, Mexico

Vulnerable population, women, substance abuse, equity

Background: Interest in health inequalities has grown in recent years. The World Health Organization (WHO) defines them as health variations that are unnecessary, avoidable and unfair (Whitehead M, Dahall G, 2007). These inequalities are also gendered. Gender is a concept that incorporates the social factors associated with men and women’s different patterns of socialization, which in turn has to do with family roles, work expectations, types of occupation and social culture which also affect the process of health and illness. In this work we use the concept of gender quoting Ettore (2002): ‘gender is a process and an institution…As a process, gender is a part of all human interactions. Gender shapes the meaning of “female” and “male” and “masculinity” and “femininity” on cultural, political and economical levels. As an institution, gender is a part of culture just like other components of culture such as symbols, language, mores, norms, values and so on. Gender is a “stable” form of structured inequality and it is embedded in culture’ (p. 329). When women experience the damaging effects of gender whether as a social process or an institution, women are at a greater disadvantage because ‘masculinist’ (male privileging) more than gender-sensitive structures and paternalistic epistemologies predominate. In addition to gender inequalities, there are also social and economic inequalities that give rise to marginalized groups. Therefore, for vulnerable populations, ensuring healthcare coverage an access to good-quality, appropriate public and private sector services is an ongoing a challenging proposition (Ferguson 2007). Type of study: A non-experimental, descriptive, ex-post facto cross sectional study was undertaken in two women’s prison in Mexico city. A non probabilistic sample of 213 women was selected, with the following inclusion criteria: current or sometime consumers of alcohol, tobacco and drugs, aged between 18 and 65 who can read and write.

The aim of this paper is to discuss from the theoretical framework of gender perspective and vulnerable population’s literature, the burden of disease of substance abuse in vulnerable women, specifically data from a research with minor delinquents and women in prison.


Among the interviewed women 14.6% have lived in a shelter or NGO before the prison and 39.5% have lived in the street. The third part (30.5%) ran away from home at least once while being children and 21.6% live with persons different from their parents. On the day they committed the offence 41.8% were under the effects of drugs and 18.8% on alcohol. Among the drugs they used while or before committing the crime, 26.85 % had used cocaine. The most commonly reported crime among the interviewees was theft (51.6%) in different forms (non-specific/simple, qualified, aggravated, non-specified, burglary) followed by drug related offences (possession, traffic) 23.5 % and the third crime was homicide (8.5%). According to their response 43.7% reported having been in a correctional facility before.

Lessons learned:

Prison is an environment with special difficulty in the promotion of health. At the individual level, prison takes away autonomy and may inhibit or damage self-esteem. Common problems include bullying, mobbing and boredom, and social exclusion on discharge may be worsened as family ties are stressed by separation. However, imprisonment is also a unique opportunity for all aspects of health promotion, health education and disease prevention. Vulnerable groups as the women in prison and minor offenders are disadvantaged groups who would normally be hard to reach. It is the prison, therefore a prime opportunity to address inequality in health by means of specific health interventions as well as measures that influence the wider determinants of health (Haton P., 2007).

Preference for Treatment Options: Experience from Rural Sri Lanka

Author(s): M. C. Weerasinghe*1, D. N. Fernando1
Affiliation(s): 1Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
Keywords: Treatment seeking, medical pluralism, Sri Lanka

Treatment seeking pattern is a key determinant for policy decisions in resource allocation in healthcare. Information on outpatient care is not routinely collected in most developing countries including Sri Lanka. Only available data on out patient care is mostly limited to the number of patient visits to state owned out patient facilities. However, it is estimated that over 50% of outpatient care in Sri Lanka occurs in the private sector. Unavailability of out patient care information adversely affects health planning. Hence, special studies are needed to obtain such information.


This study explored the treatment seeking pattern for eight illnesses in a rural community. Community based household survey was conducted using an interviewer administered questionnaire in a rural district in Sri Lanka. Households (n=1200) were selected using a multistage probability sampling method. Hypothetical situation on eight illnesses were used as tracers to record movement across different treatment options. The preferences were recoded as 1st 2nd and 3rd step of treatment pursued in a single illness episode.


Self-medication (63.5%; n=763) and home remedies (26.5% n=318) are preferred for fever in adults as the 1st step of treatment. For diarrhoea in adults state-western facility was preferred by 50.7% (n=608) as the first step which increased to 90% in the third step. For rheumatic complains 54.3% (n=652) preferred home remedies as the fist step. State-western was preferred for wheezing by 70% (n=840) as first step which increased to 85.6% (n=1028) as the third step. Traditional medicine was preferred for the treatment of fractures by the majority in all the steps (80.7%, 79.8% and 74.7% in three steps). Ritual practices were preferred by 64.1% (n=770) for psychological illness as the first step but declined to 47.1% (n=565) in the third step. For childhood illness state western facilities were increasingly preferred by the majority (80% in 3rd step; n=965).

Lessons learned: Treatment seeking pattern showed a shift from home based treatment towards state-western facilities in subsequent steps for most of the illnesses. Still existence of plural nature of treatment preferences is evident from the observed behaviour patterns in the rural population. This suggests the possibility of reducing demand for financially constrained state-western facilities through development and popularization of other healthcare options.

Conflicts in a Reproductive Health Meta Organization

Author(s): S. Anand1
Affiliation(s): 1Marketing, XIMB, Bhubaneswar, India
Keywords: Conflicts, power, partnerships, reproductive health services, meta organization

In India, Public health services are far from satisfactory. They are limited to preventive and promotion aspect in rural India. The quality of services being provided by public sector is quite low. The lower level is well established in many studies and observed both in tangible as well as non tangible aspect of services. Proportion of utilization of Private health facility is gradually increasing. Acceptance of failure of public health led to the outsourcing to private sector. However, from public point of view, any health service is just service whether it comes from public sector organization or private sector. Going by conservative definitions, it is the philosophy which drives the two sectors. On one hand, public health sector is likely to be driven by social welfare, local needs and justice objectives. On the other hand, private health sector is likely to be governed by profits, market forces competition, and global needs. However, these two sectors can not be seen as two extremes and many a times do not have uniform characteristics. Integration of these two requires understanding of the two sectors in its current form and finding out how these services are embedded in needs and context of the people.


This study was done to explore the dynamics of conflict of interests amongst various organizations in the reproductive health sector. This study is based upon in-depth interviews of DKT India (better known as Janani in India) officials, Government officials, its partners and clients. Along with interviews, observations of various operations of DKT India have been made. Interviews of officials in health secretariat, directorate of health services and population bureau have been conducted. To understand the conflict of interest semiotic analysis of observation study and interviews have been done.


Findings confirm the hypothesis that today it is not a public-private partnership but public-private partnership(S). DKT International, a reproductive healthcare organization, working in many countries, also collaborates with many other players apart from government. In such scenario, the quality becomes an issue of care and regulation. As on one hand, it has to be ensured that healthcare services are being provided. At the same time, clients need to be protected against negligence and exploitation. That requires efforts of regulation not only from the government, but self regulation. Partnership(S) also reflects upon the culture of organizations e.g. in this case DKT India, its associates and Policy of DKT International. Therefore, the issue is not partnership per se, but collaboration amongst various stake holders including the clients. So, we seem to be referring to multi-level partnership paradigm. It gets well reflected in the argument that such collaboration between organisations and communities is likely to provide the genesis for meta-organisations (Anand, S, 2006).

Lessons learned:

The findings very clearly show that there are conflicts at various levels within DKT India, within department of government and between partners. Due to lack of openness & trust, conflict of interest prevails. There is clear lack of a policy which could integrate various players in meta organization. Findings very clearly indicate that power play rules the decision making and do not allow any structure to emerge which does not fit into its power game. The ‘zero sum game’ cognition not only promotes the culture of violence within meta-organization but also creates problem in delivery of quality for reproductive health services in India.

Why Doctors Strike in Public Health Systems in India: Lessons for Medical Education and Addressing Migration of Healthcare Workforce

Author(s): A. Das1
Affiliation(s): 1Director, Centre for Health and Social Justice, New Delhi, India
Keywords: Medical ethics, health systems, workers rights, training, medical education, health policy, India

India is emerging as a global economic superpower but lags behind many nations in health related MDG indicators. India has a severe shortage of doctors in the public sector and huge public healthcare crisis. The new public health policy in India, the National Rural Health Mission promises an improvement in the public health system and in improvement in basic public health indicators. It is based on the principles of comprehensive primary healthcare. There have been a large number of strikes by young doctors and doctors in training in India over the last couple of years. These have taken place in tertiary teaching hospitals and across many states. The reasons have varied but there are strong links to young doctors wanting privileges and personal opportunities. These include refusal to undergo compulsory rural or public sector posting, or seeking opportunities to go abroad.


The paper is based on newspaper and other secondary reports of a range of strikes across various states in India over the period of the last three years since the National Rural Health Mission was announced. The reasons given for the strikes by young doctors or doctors in trainings, as well as the provocations are examined. The response from the health bureaucracy is examined in the context of the national constitution and health policy guidelines.


The paper provides a short historical summary of the growth of western medical training in the country over the last one hundred and fifty years. The paper examines the changing context of western medicine in providing healthcare to rural and poor citizens in India and the role of the public and private healthcare sector. The paper examines the strikes by young doctors in the context of the growing private sector medical industry and the phenomenon of ‘medical tourism’ that has come up in the country. The paper also examines the validity of strikes by doctors and doctors in training in the context of medical ethics and worker rights.

Lessons learned:

Medical education needs to be guided by a number of factors. While it is necessary to provide up-to-date medical information, and build adequate clinical skills, it is also essential to ground it in the constitutional character of the country and in medical ethics. Doctors are not technical agents in a market place selling healthcare innovations but agents responding to the social and political reality relating to health in the country in which they are trained. The application of these principles in designing medical education curriculum may prevent widespread migration of medical personnel from developing countries.

Implementation of Actions of Health Promotion and Prevention from Diseases in the Healthcare Private Sector in Brazil: Actions, Challenges and Perspectives from the National Supplementary Health Agency


D. Conte Alves*1, A. Abib1, K. Coelho1, C. Zouain1, J. Torres1, R. Cachapuz1, V. Cardoso1, M. Mello1, K. Audi1, A. Cavalcanti1, J. Pinho1, M. Oliveira1

Affiliation(s): 1GGTAP-DIPRO, National Supplementary Health Agency - Ministry of Health, Rio de Janeiro, Brazil

State regulation; private healthcare system; health system policies; health promotion and prevention from diseases.


In Brazil, there are two health systems, the public and the private one. Although the country has a public system that guarantees the universality, it also counts on a meaningful private healthcare sector, which is submitted to State regulation by the National Supplementary Health Agency (Agência Nacional de Saúde Suplementar - ANS), created in 2000, which acts on regulation, control and inspection of private health plans (PHP). Nowadays, the sector counts on, approximately, two thousand active PHP, and 47 millions of beneficiaries (fourth part of Brazilian population). In order to remodel the current assistential pattern developed in this sector, based on curative actions, to an attention model that emphasizes quality and integrated actions, ANS’s policies have been inducing PHP to develop health promotion and disease prevention programmes.


The aim of this work is to present the actions, challenges and perspectives of the ANS so that the PHP can develop health promotion and diseases prevention programmes. As methodology, the qualitative approach was used to evaluate the implementation process, through documental analysis, bibliographic research and analysis of data of the sector.


The first stimulating policy counted on the adoption of promotion and prevention programmes to a stimulus turned to some PHP that needed more time to provide financial guarantees demanded from the agency. Approximately, 416 programmes distributed among 90 PHP were approved. The directions taken on by ANS are established by Ministry of Health and then, PHP were stimulated to develop actions of health promotion and disease prevention that brought up questions about lifestyle and habits, screening and attention to diseases in all care levels, based on demographic profile, morbidity and mortality of their consumers, with the objective to develop integral practices in healthcare management. Other requirements of control used by ANS are the active search by the PHP, the identification of the population in risk, the adoption of screening and prevention protocols, as well as the effective populational coverage of these programmes. The PHP are also evaluated through the indicators of the Supplementary Health Qualification Programme (Programa da Qualificação da Saúde Suplementar) through many different indicators. The Qualification Programme also assesses healthcare delivery by PHP. In 2008, the ANS will realize a survey to know the characteristics of the health promotion and prevention from risk and disease programmes done by the PHP all over the country.

Lessons learned:

From the implementation of ANS’s actions on, the subject was introduced to the regulation discussion agenda, pointing out the model organization based on health attention areas and the PHP responsibility to their beneficiaries´ health, which contributed to the incorporation of multi-professional attention to the developed programmes. PHP’s management focus on the security logic and financial-economic dimension, the attention model based on curative actions and on procedures accomplishment, and the indiscriminate consume of technologies were considered challenges to the implementation of ANS’s policies. In the beginning of 2008, the ANS will realize a survey to know the characteristics of the health promotion and prevention from disease programmes done by the PHP all over the country. So, the perspectives point to the formulation of new strategies of stimulus by ANS in order to improve health indicators of private healthcare system and remodel the current assistential pattern developed in the sector.

Use of Private Sector and Out-of-Pocket Payment for Antibiotics In Spite of a Policy Granting Formal Access to Free Healthcare and Drugs for Children in a Poor Area of Peru

Author(s): C. Kristiansson*1, M. Petzold2, H. Rodriguez3, E. Gotuzzo4, L. Pacheco5, A. Bartoloni6, A. Bechini7, M. Larsson1, G. Tomson1
Affiliation(s): 1HCAR, Div. International Health, Karolinska Institute, Stockholm, 2Nordiska Högskolan för folkhälsovetenskap, Göteborg, Sweden, 3Health Directorate of Loreto, Iquitos, 4Inst. Med. Trop. A. von Humboldt, Universidad Peruana Cayetano Heredia, Lima, 5Health Directorate of San Martin, Tarapoto, Peru, 6UFDID, 7Dept. Public Health, University of Florence, Italy

Health policy, access to health, household survey, state health insurance, antibiotic use, health seeking behaviour, health financing


The Peruvian state insurance Seguro Integral de Salud (SIS) was created in 2001 to improve access to health. One of its strategies was to provide healthcare and medicaments free of charge for all children up to 15 years of age in provinces where poverty exceeded 60%. As shown in the framework of this study (Project ANTRES; EC-INCO DEV) a high percentage of caregivers in the Amazonian area consulted public sector health facilities for their sick children in the year 2002. However, the health seeking behaviour during the subsequent years, after some years of SIS implementation, has not previously been assessed. Little is known in general about health policy implementations and effects of health insurance on health seeking and drug use.


The objective of the study was to follow health seeking behaviour and antibiotic utilization over time in the urban Amazonian community of Moyobamba, San Martin, between the years 2002, with SIS recently introduced, and 2005, after some years of SIS implementation. Cross-sectional surveys using household interviews were carried out in 2002 and 2005. For each survey 800 children aged 6-72 months were sampled through a modified cluster sampling approach and their caregivers were interviewed on healthcare seeking strategies (public/private sectors; formal/informal providers), and medication in their children in relation to reported symptoms.


In 2002 and 2005, 32% and 43% respectively of caregivers sought help when their children were sick. In 2002 a high percentage of these (87%) had consulted a public sector health professional, but in 2005 the percentage had decreased significantly (65%; p<0.05), and significantly (p<0.05) more caregivers had consulted pharmacy staff (7% year 2002; 23% year 2005). In 2002 the majority (82%) of caregivers that consulted public sector health facilities exclusively sought help at these facilities without attempting self care. In 2005 the number of caregivers that exclusively sought help decreased significantly (p<0.05) to 37% and the majority tried to treat their children at home before seeking help. The percentage of children that received antibiotics free of charge after consulting a health professional decreased significantly (p<0.05) from year 2002 (82%) to year 2005 (55%).

Lessons learned:

The change in health seeking behaviour from prompt public health facility consultations to increased self care in combination with increased consultations at pharmacies and out of pocket payment for antibiotics could be due to problems both with the content of the SIS policy and with its implementation. The increase in the number of children caregivers paying for antibiotics in 2005 as compared to 2002 indicate that the SIS did not succeeded in providing medicines free of charge. The SIS policy revisions presently taking place in Peru should consider the importance of continuously monitoring the implementation of SIS, as barriers to healthcare remain although there is now formal access to free healthcare.

Collaboration between Educational Institutions and Government Health Department: Successful Partnership in Building an Urban Health Centre in Ahmedabad City, Gujarat, India

Author(s): K. V. Ramani*1, D. V. Mavalankar1
Affiliation(s): 1Centre for Management of Health Services, Indian Institute of Management, Ahmedabad, India

Health for urban poor, access, affordability, equity, Indian Institute of Management (IIMA), Gujarat Government health department, Ahmedabad City, public private partnership (PPP), GIS


Urbanization is an important demographic shift worldwide. India has an urban population of 300 million, with the slum population in urban areas registering a 5 % growth over the last few years. Responding to the healthcare needs of the urban poor is therefore very essential, but government resources are limited and its management capacity inadequate to manage healthcare services satisfactorily. Private sector is very active and is seen by the community to be more responsive, though very costly. The Government of India is therefore promoting Public Private Partnerships (PPP) to provide healthcare services that are available, accessible, affordable and equitable. With a view to improve the delivery of urban health services, particularly for the poor and the vulnerable, the Indian Institute of Management, Ahmedabad (IIMA) has undertaken a project on ‘Primary Health Services for the Urban Poor’ jointly with the Department of Health, Gujarat State to establish a PPP model urban health centre in Ahmedabad city.


The main objective of the IIMA project mentioned above is to design, develop, and implement a working PPP model for improved urban healthcare service delivery in Ahmedabad city, which has a population of 3.5 million with 35% living in slums. The project involves estimating the community needs, coordination with government and non-government organizations, conceptualizing a PPP model, and a successful implementation of the PPP model in one of the wards in Ahmedabad city (Ahmedabad city is divided into 43 administrative regions called wards). By collaborating with the Gujarat Government Health Department, this project also aims at strengthening the management capacity of the government officers so as to enable them to replicate the IIMA model to other cities throughout Gujarat state.


The chosen sample ward, Vasna, did not have any government health facility, and so the poor people of Vasna ward were depending entirely on the expensive private sector for meeting their healthcare needs. The PPP model urban health centre, which IIMA helped the State Government to set up in Vasna ward, is today offering primary healthcare services, almost free of any user charges, to more than 100 outpatients per day. It provides access to 2/3rd of the slum population within a 1KM road distance. This new urban health centre is the first of its kind in India offering consultation, investigation, and medication under a single roof. The location for the Vasna urban health centre was made by relying on Geographic Information system (GIS) methodology. IIMA has also developed a legally binding MoU between the various partners for service delivery. Gujarat Government has adopted our PPP arrangement and has started planning for replicating the IIMA model of urban health centres throughout Gujarat state.

Lessons learned:

Establishing a PPP requires a legal framework acceptable to all the partners, commitment of resources, as well as clarity on the roles, responsibilities and accountability of all the partners to provide a given set of services at a desired level of quality and at affordable user charges. Formalizing such an arrangement between partners requires conceptualizing a framework for PPP to manage the delivery of health services effectively and efficiently. The success of our project largely depends on the efforts of IIMA, a leading academic institution in India, and the Government Health department, in bringing together a number of public and private partners for ensuring good quality, affordable and accessible primary healthcare services to the urban poor.

Making the Right to health a Reality in the Context of Social Inequalities and Rapid Economic Change in Brazil

Author(s): V. S. P. Coelho*1, A. Shankland2
Affiliation(s): 1Citizenship and Development Group, Brazilian Centre of Analysis and Planning, Sao Paulo, Brazil, 2IDS, Falmer, United Kingdom

SUS, the brazilian public health system; rights; social excluded groups; decentralization; PSF Family Health Program; health councils, accountability


In the two decades since Brazil recognised access to healthcare as a Constitutional right, the country has undergone wide-ranging transformations that have left their mark on the profile of the population and on the country’s health system. Initially, a brief overview of the changes that have taken place in recent years in the socio-demographic and epidemiologic profile of the Brazilian population is presented, showing the challenges facing the healthcare system. We go on to present a brief overview of the system, which includes both the publicly-funded services provided by the SUS (Unified Healthcare System) and those financed and provided by the private sector. Our analysis concentrates on the public sector, which is the sole source of healthcare for approximately 70% of the country’s population.


We outline the chief mechanisms – programs, financing and management – that have ensured the SUS’s capacity to respond to the challenges pointed out previously. We argue that two of the key mechanisms are the establishment of transparent financing mechanisms for promoting universal coverage within a highly decentralised health system where most service delivery responsibilities lie at the municipal level, and the innovative approaches to democratic accountability.
Some 32% of Brazil’s population of 184 million people are considered to be living in poverty. Despite a recent decline in overall income inequality, indicators show expressive inequalities in both income and life expectancy between rural and urban populations, and between the population as a whole and minority ethnic populations, in particular Afro-descendent and indigenous groups. It should also be noted that 85% of Brazil’s population lives in cities, with metropolitan areas expanding rapidly throughout the country. In this context, a key challenge is to overcome urban bias in health system organisation and healthcare models, ensuring the realisation of the universal right to healthcare among minority populations living in remote rural areas where municipal service delivery capacity is weakest.


Since it was established in the late 1980s as a public health system with universal and unconditional coverage, the SUS has achieved a rapid expansion in access to services. A key driver of this expansion has been the system of direct central government transfers to the municipal level, tied to the delivery of priority packages such as the Family Health Program or PSF (Programa Saúde da Família). The statutory participation and accountability institutions, known as Health Councils (Conselhos de Saúde) have facilitated coordination between health system managers, service providers and civil society groups. However, both the transfer system and the accountability institutions have been less successful in guaranteeing service quality, and in particular in ensuring that service provision models such as the PSF are adapted to address the specific health needs of the most marginalised and vulnerable population groups. In this presentation we focus on the ways in which the SUS is dealing with these challenges, and the innovative approaches emerging from ongoing change processes such as the reforms in health service provision for indigenous peoples.