Current and Projected Mortality and Hospitalization Rates Associated With Conditional Cash Transfer, Social Pension, and Primary Health Care Programs in Brazil, 2000-2030.

Importance: The health outcomes of increased poverty and inequalities in low- and middle-income countries (LMICs) have been substantially amplified as a consequence of converging multiple crises. Brazil has some of the world's largest conditional cash transfer (Programa Bolsa Família [PBF]), social pension (Beneficio de Prestacão Continuada [BPC]), and primary health care (Estratégia de Saúde da Família [ESF]) programs that could act as mitigating interventions during the current polycrisis era of increasing poverty, slow or contracting economic growth, and conflicts. Objective: To evaluate the combined association of the Brazilian conditional cash transfer, social pension, and primary health care programs with the reduction of morbidity and mortality over the last 2 decades and forecast their potential mitigation of the current global polycrisis and beyond. Design, Setting, and Participants: This cohort study used a longitudinal ecological design with multivariable negative binomial regression models (adjusted for relevant socioeconomic, demographic, and health care variables) integrating the retrospective analysis from 2000 to 2019, with dynamic microsimulation models to forecast potential child mortality scenarios up to 2030. Participants included a cohort of 2548 Brazilian municipalities from 2004 to 2019, projected from 2020 to 2030. Data analysis was performed from September 2022 to February 2023. Exposure: PBF coverage of the target population (those who were poorest) was categorized into 4 levels: low (0%-29.9%), intermediate (30.0%-69.9%), high (70.0%-99.9%), and consolidated (≥100%). ESF coverage was categorized as null (0), low (0.1%-29.9%), intermediate (30.0%-69.9%), and consolidated (70.0%-100%). BPC coverage was categorized by terciles. Main outcomes and measures: Age-standardized, all-cause mortality and hospitalization rates calculated for the entire population and by age group (<5 years, 5-29 years, 30-69 years, and ≥70 years). Results: Among the 2548 Brazilian municipalities studied from 2004 to 2019, the mean (SD) age-standardized mortality rate decreased by 16.64% (from 6.73 [1.14] to 5.61 [0.94] deaths per 1000 population). Consolidated coverages of social welfare programs studied were all associated with reductions in overall mortality rates (PBF: rate ratio [RR], 0.95 [95% CI, 0.94-0.96]; ESF: RR, 0.93 [95% CI, 0.93-0.94]; BPC: RR, 0.91 [95% CI, 0.91-0.92]), having all together prevented an estimated 1 462 626 (95% CI, 1 332 128-1 596 924) deaths over the period 2004 to 2019. The results were higher on mortality for the group younger than age 5 years (PBF: RR, 0.87 [95% CI, 0.85-0.90]; ESF: RR, 0.89 [95% CI, 0.87-0.93]; BPC: RR, 0.84 [95% CI, 0.82-0.86]), on mortality for the group aged 70 years and older, and on hospitalizations. Considering a shorter scenario of economic crisis, a mitigation strategy that will increase the coverage of PBF, BPC, and ESF to proportionally cover the newly poor and at-risk individuals was projected to avert 1 305 359 (95% CI, 1 163 659-1 449 256) deaths and 6 593 224 (95% CI, 5 534 591-7 651 327) hospitalizations up to 2030, compared with fiscal austerity scenarios that would reduce the coverage of these interventions. Conclusions and relevance: This cohort study's results suggest that combined expansion of conditional cash transfers, social pensions, and primary health care should be considered a viable strategy to mitigate the adverse health outcomes of the current global polycrisis in LMICs, whereas the implementation of fiscal austerity measures could result in large numbers of preventable deaths.

Evaluation and Forecasting Analysis of the Association of Conditional Cash Transfer With Child Mortality in Latin America, 2000-2030.

Importance: Latin America has implemented the world's largest and most consolidated conditional cash transfer (CCT) programs during the last 2 decades. As a consequence of the COVID-19 pandemic, poverty rates have markedly increased, and a large number of newly low-income individuals, especially children, have been left unprotected. Objective: To evaluate the association of CCT programs with child health in Latin American countries during the last 2 decades and forecast child mortality trends up to 2030 according to CCT alternative implementation options. Design, Setting, and Participants: This cohort study used a multicountry, longitudinal, ecological design with multivariable negative binomial regression models, which were adjusted for all relevant demographic, socioeconomic, and health care variables, integrating the retrospective impact evaluations from January 1, 2000, to December 31, 2019, with dynamic microsimulation models to forecast potential child mortality scenarios up to 2030. The study cohort included 4882 municipalities from Brazil, Ecuador, and Mexico with adequate quality of civil registration and vital statistics according to a validated multidimensional criterion. Data analysis was performed from September 2022 to February 2023. Exposure: Conditional cash transfer coverage of the target (lowest-income) population categorized into 4 levels: low (0%-29.9%), intermediate (30.0%-69.9%), high (70.0%-99.9%), and consolidated (≥100%). Main Outcomes and Measures: The main outcomes were mortality rates for those younger than 5 years and hospitalization rates (per 1000 live births), overall and by poverty-related causes (diarrheal, malnutrition, tuberculosis, malaria, lower respiratory tract infections, and HIV/AIDS), and the mortality rates for those younger than 5 years by age groups, namely, neonatal (0-28 days), postneonatal (28 days to 1 year), infant (<1 year), and toddler (1-4 years). Results: The retrospective analysis included 4882 municipalities. During the study period of January 1, 2000, to December 31, 2019, mortality in Brazil, Ecuador, and Mexico decreased by 7.8% in children and 6.5% in infants, and an increase in coverage of CCT programs of 76.8% was observed in these Latin American countries. Conditional cash transfer programs were associated with significant reductions of mortality rates in those younger than 5 years (rate ratio [RR], 0.76; 95% CI, 0.75-0.76), having prevented 738 919 (95% CI, 695 641-782 104) child deaths during this period. The association of highest coverage of CCT programs was stronger with poverty-related diseases, such as malnutrition (RR, 0.33; 95% CI, 0.31-0.35), diarrhea (RR, 0.41; 95% CI, 0.40-0.43), lower respiratory tract infections (RR, 0.66, 95% CI, 0.65-0.68), malaria (RR, 0.76; 95% CI, 0.63-0.93), tuberculosis (RR, 0.62; 95% CI, 0.48-0.79), and HIV/AIDS (RR, 0.32; 95% CI, 0.28-0.37). Several sensitivity and triangulation analyses confirmed the robustness of the results. Considering a scenario of moderate economic crisis, a mitigation strategy that will increase the coverage of CCTs to protect those newly in poverty could reduce the mortality rate for those younger than 5 years by up to 17% (RR, 0.83; 95% CI, 0.80-0.85) and prevent 153 601 (95% CI, 127 441-180 600) child deaths by 2030 in Brazil, Ecuador, and Mexico. Conclusions and Relevance: The results of this cohort study suggest that the expansion of CCT programs could strongly reduce childhood hospitalization and mortality in Latin America and should be considered an effective strategy to mitigate the health impact of the current global economic crisis in low- and middle-income countries.

Influence of Unhealthy Food Environment on Premature Cardiovascular Disease Mortality in Brazil: An Ecologic Approach.

INTRODUCTION: Cardiovascular disease is the main cause of general and premature death of adults aged 30-69 years in Brazil and around the world. Unhealthy food environments have been implicated as one of the factors associated with cardiovascular disease morbimortality because they affect people's health conditions and nutrition. This study aims to explore the association between unhealthy food environments (deserts/swamps) and premature cardiovascular disease mortality in the Brazilian population. METHODS: This is an ecologic study using data from 5,558 Brazilian municipalities in 2016. The cardiovascular disease mortality data were obtained from the Mortality Information System of the Ministry of Health. The study on mapping food deserts in Brazil, developed by the Interministerial Chamber of Food and Nutrition Security, was used to evaluate the physical dimension of food access. The authors calculated the standardized rates of premature general and specific cardiovascular disease (stroke and ischemic heart disease) causes of death in the same period. To characterize food environments, the density of unprocessed and ultraprocessed foods per 10,000 population in tertiles was used. Crude and adjusted negative binomial regression models were used to study the associations of interest. RESULTS: After the necessary adjustments (human development index, gross domestic product per capita, unemployment rate, Gini index and Family Health Strategy coverage), it was found that municipalities with low unprocessed food supply were at the highest risk of increased mortality among women with ischemic heart disease (rate ratio first tertile: 1.08 [95% CI=1.01, 1.15]). Conversely, the municipalities where there was a greater offer of ultraprocessed foods showed a higher risk of death from cardiovascular diseases (rate ratio second tertile: 1.17 [95% CI=1.12, 1.22]; rate ratio third tertile: 1.20 [95% CI=1.14, 1.26]), from strokes (rate ratio second tertile: 1.19 [95% CI=1.13, 1.25]; rate ratio third tertile: 1.22 [95% CI=1.15, 1.30]), and ischemic heart disease (rate ratio second tertile: 1.19 [95% CI=1.12, 1.25]; rate ratio third tertile: 1.22 [95% CI=1.13, 1.29]). CONCLUSIONS: This study's findings show an increase in the risk of cardiovascular disease, stroke, and ischemic heart disease mortality, especially in the municipalities where there was a greater offer of ultraprocessed foods. Initiatives aiming to minimize the effects of these food environments are urgently needed in the Brazilian context.

Long-term impact of a conditional cash transfer programme on maternal mortality: a nationwide analysis of Brazilian longitudinal data.

BACKGROUND: Reducing poverty and improving access to health care are two of the most effective actions to decrease maternal mortality, and conditional cash transfer (CCT) programmes act on both. The aim of this study was to evaluate the effects of one of the world's largest CCT (the Brazilian Bolsa Familia Programme (BFP)) on maternal mortality during a period of 11 years. METHODS: The study had an ecological longitudinal design and used all 2548 Brazilian municipalities with vital statistics of adequate quality during 2004-2014. BFP municipal coverage was classified into four levels, from low to consolidated, and its duration effects were measured using the average municipal coverage of previous years. We used negative binomial multivariable regression models with fixed-effects specifications, adjusted for all relevant demographic, socioeconomic, and healthcare variables. RESULTS: BFP was significantly associated with reductions of maternal mortality proportionally to its levels of coverage and years of implementation, with a rate ratio (RR) reaching 0.88 (95%CI 0.81-0.95), 0.84 (0.75-0.96) and 0.83 (0.71-0.99) for intermediate, high and consolidated BFP coverage over the previous 11 years. The BFP duration effect was stronger among young mothers (RR 0.77; 95%CI 0.67-0.96). BFP was also associated with reductions in the proportion of pregnant women with no prenatal visits (RR 0.73; 95%CI 0.69-0.77), reductions in hospital case-fatality rate for delivery (RR 0.78; 95%CI 0.66-0.94) and increases in the proportion of deliveries in hospital (RR 1.05; 95%CI 1.04-1.07). CONCLUSION: Our findings show that a consolidated and durable CCT coverage could decrease maternal mortality, and these long-term effects are stronger among poor mothers exposed to CCT during their childhood and adolescence, suggesting a CCT inter-generational effect. Sustained CCT coverage could reduce health inequalities and contribute to the achievement of the Sustainable Development Goal 3.1, and should be preserved during the current global economic crisis due to the COVID-19 pandemic.

Shifts towards overweight and double burden of malnutrition among socio-economically vulnerable children: a longitudinal ecological analysis of Brazilian municipalities.

OBJECTIVE: To investigate the shifts and factors associated with different scenarios resulting from the prevalence of child stunting and overweight in Brazilian municipalities. DESIGN: This is an ecological study using municipality-level panel data of stunting and overweight prevalence and socio-economic characteristics from 2008 to 2014. The municipalities were classified according to the WHO-UNICEF prevalence thresholds for stunting and overweight and were categorised into four nutritional scenarios: no burden (prevalence of stunting < 20 % and overweight < 10 %), stunting burden (prevalence of stunting ≥ 20 % and overweight < 10 %), overweight burden (prevalence of stunting < 20 % and overweight ≥ 10 %) and double burden (prevalence of stunting ≥ 20 % and overweight ≥ 10 %). SETTING: Totally, 4443 Brazilian municipalities. PARTICIPANTS: Aggregated data of children under 5 years old enrolled in the Brazil's conditional cash transfer programme (Bolsa Família). RESULTS: A mean reduction from 14·2 % to 12·7 % in the prevalence of stunting and an increase from 17·2 % to 18·4 % in the prevalence of overweight were observed. The predominant scenarios were overweight burden and double burden. The odds of both scenarios increased with higher gross domestic product (GDP) per capita and decreased with higher unemployment rates. Stunting and double burden decreased with higher expected years of schooling, and stunting burden increased with household crowding. CONCLUSION: Our findings indicate an advanced nutrition transition stage in Brazil, associated mainly with municipal GDP per capita growth, which has contributed to increasing the burden of overweight alone or coexisting with stunting (double burden) among children in the most socio-economically vulnerable strata of the population.

Covid-19 pandemic implications for food and nutrition security in Brazil. / Implicações da pandemia COVID-19 para a segurança alimentar e nutricional no Brasil.

The emergence of COVID-19 in Brazil further explained the massive discrepancy between different social realities coexisting in the country, rekindling the discussions about food and nutrition security, similarly to what has been happening in other countries facing the same pandemic situation. In this paper, we argue that the risks to hunger and food security in Brazil have been present since 2016 and are now being exacerbated due to the emergence of the COVID-19 epidemic. This situation requires knowing the extent and magnitude of the issue and articulation of measures in the three governmental spheres(federal, municipal and state) to ensure access to adequate and healthy food and reduce the disease's adverse effectson the diet, health, and nutrition among the most vulnerable people. Thus, this work aims to contribute to the debate on the measures to be adopted by governments and society to promote and ensure food and nutrition security and prevent insecurity and the expansion of hunger during and after the social and health crisis created by the pandemic.

Implicações da pandemia COVID-19 para a segurança alimentar e nutricional no Brasil / Covid-19 pandemic implications for food and nutrition security in Brazil

Resumo O surgimento da COVID-19 no Brasil explicitou ainda mais a enorme discrepância entre diferentes realidades sociais que coexistem no país, reacendendo as discussões acerca da segurança alimentar e nutricional, à semelhança do que vem acontecendo em outros países que enfrentam a mesma situação de pandemia. Argumenta-se neste trabalho que os riscos para a Segurança Alimentar e Nutricional (SAN) e a fome dos brasileiros já vinham se apresentando desde 2016, sendo agora aprofundados pela emergência da epidemia da COVID-19, passando a exigir compreensão da extensão e da magnitude dos problemas e articulação de medidas governamentais nas três esferas de gestão (federal, municipal e estadual), que possam assegurar o acesso à alimentação adequada e saudável, com vistas a reduzir os impactos negativos da doença na condição de alimentação, saúde e nutrição dos mais vulneráveis. Assim, este texto pretende contribuir para o debate sobre as medidas a serem adotadas pelos governos e sociedade para promover e garantir a SAN e impedir que a insegurança e a expansão da fome avancem durante e após a crise social e sanitária gerada pela pandemia.

Abstract The emergence of COVID-19 in Brazil further explained the massive discrepancy between different social realities coexisting in the country, rekindling the discussions about food and nutrition security, similarly to what has been happening in other countries facing the same pandemic situation. In this paper, we argue that the risks to hunger and food security in Brazil have been present since 2016 and are now being exacerbated due to the emergence of the COVID-19 epidemic. This situation requires knowing the extent and magnitude of the issue and articulation of measures in the three governmental spheres(federal, municipal and state) to ensure access to adequate and healthy food and reduce the disease's adverse effectson the diet, health, and nutrition among the most vulnerable people. Thus, this work aims to contribute to the debate on the measures to be adopted by governments and society to promote and ensure food and nutrition security and prevent insecurity and the expansion of hunger during and after the social and health crisis created by the pandemic.

Faces da desigualdade no Brasil: um olhar sobre os que ficam para trás / Faces of inequality in Brazil: a look at those left behind

RESUMO Este artigo analisou avanços na redução das desigualdades no Brasil durante o período de 2003 a 2015, para além da perspectiva de renda. Os dados refletem que, embora transformações relevantes tenham ocorrido, mesmo assim, o Brasil persiste como um dos países mais desiguais do mundo. Entretanto, ao colocar uma lupa nos dados de acesso a bens e serviços dos 5% e dos 20% mais pobres disponibilizados pela Pesquisa Nacional por Amostra de Domicílios (PNAD), os achados se contrapõem ao lugar comum de que só se promoveu acesso à renda e ao consumo dos mais pobres no período estudado, inexistindo alterações significativas no quadro de acesso a direitos básicos, políticas públicas de educação, saúde e de infraestrutura.

ABSTRACT This article analyzed advances in the reduction of inequalities in Brazil during the period from 2003 to 2015, in addition to the income perspective. The data reflect that, although relevant transformations have occurred, nevertheless, Brazil persists as one of the most unequal countries in the world. However, by placing a magnifying glass on the data about access to goods and services of the poorest 5% and 20% made available by the National Household Sample Survey (PNAD), the findings contradict the commonplace that only access to income and the consumption of the poorest was promoted in the period studied, without significant changes in the framework of access to basic rights, public policies of education, health, and infrastructure.

A look at the food and nutrition agenda over thirty years of the Unified Health System. / Um olhar sobre a agenda de alimentação e nutrição nos trinta anos do Sistema Único de Saúde.

Food and nutrition are basic requirements for the promotion and protection of health. Nutrition monitoring and dietary recommendations are included in the mission of the Unified Health System (SUS, in its Portuguese acronym), as established by the Organic Health Law no. 8,080 of 1990. This article presents and discusses the food and nutrition agenda of the SUS and its interface with Food and Nutrition Security, its benchmarks, progress and challenges. This essay was guided by biographical and documentary research and, above all, by the experiences and perceptions of the authors, who, at various times and in various contexts, have been and continue to be actors of Brazil's food and nutrition agenda. We emphasise the idea of the SUS, with its accomplishments and shortcomings, as a living system derived from the technical, ethical and political commitments of its administrators, workers, academics and society as a whole. Thus, we seek to contribute to the debate about the Brazilian path to the construction of a public social welfare system committed to health and adequate nutrition as a human rights.

A alimentação e a nutrição são requisitos básicos para a promoção e a proteção da saúde. A vigilância nutricional e a orientação alimentar estão inclusas no campo de atuação do Sistema Único de Saúde (SUS), conforme estabelecido na Lei Orgânica da Saúde nº 8.080 de 1990. O presente artigo apresenta e discute a agenda de alimentação e nutrição no SUS e sua interface com a Segurança Alimentar e Nutricional, seus marcos históricos, avanços e desafios. Este ensaio foi orientado por pesquisa biográfica e documental e, sobretudo, no resgate das experiências e percepções das autoras que, em diferentes momentos e contextos, foram e são sujeitos da agenda de alimentação e nutrição no Brasil. Reforçamos assim a ideia do SUS, com suas conquistas e imperfeições, como um sistema vivo e derivado do compromisso técnico-ético-político dos gestores, dos trabalhadores, da academia e da sociedade como um todo. Desta forma, buscamos contribuir com o debate sobre a trajetória brasileira de construção de um sistema público de proteção social que se comprometeu com o direito humano à saúde e à alimentação adequada.

Um olhar sobre a agenda de alimentação e nutrição nos trinta anos do Sistema Único de Saúde / A look at the food and nutrition agenda over thirty years of the Unified Health System

Resumo A alimentação e a nutrição são requisitos básicos para a promoção e a proteção da saúde. A vigilância nutricional e a orientação alimentar estão inclusas no campo de atuação do Sistema Único de Saúde (SUS), conforme estabelecido na Lei Orgânica da Saúde nº 8.080 de 1990. O presente artigo apresenta e discute a agenda de alimentação e nutrição no SUS e sua interface com a Segurança Alimentar e Nutricional, seus marcos históricos, avanços e desafios. Este ensaio foi orientado por pesquisa biográfica e documental e, sobretudo, no resgate das experiências e percepções das autoras que, em diferentes momentos e contextos, foram e são sujeitos da agenda de alimentação e nutrição no Brasil. Reforçamos assim a ideia do SUS, com suas conquistas e imperfeições, como um sistema vivo e derivado do compromisso técnico-ético-político dos gestores, dos trabalhadores, da academia e da sociedade como um todo. Desta forma, buscamos contribuir com o debate sobre a trajetória brasileira de construção de um sistema público de proteção social que se comprometeu com o direito humano à saúde e à alimentação adequada.

Abstract Food and nutrition are basic requirements for the promotion and protection of health. Nutrition monitoring and dietary recommendations are included in the mission of the Unified Health System (SUS, in its Portuguese acronym), as established by the Organic Health Law no. 8,080 of 1990. This article presents and discusses the food and nutrition agenda of the SUS and its interface with Food and Nutrition Security, its benchmarks, progress and challenges. This essay was guided by biographical and documentary research and, above all, by the experiences and perceptions of the authors, who, at various times and in various contexts, have been and continue to be actors of Brazil's food and nutrition agenda. We emphasise the idea of the SUS, with its accomplishments and shortcomings, as a living system derived from the technical, ethical and political commitments of its administrators, workers, academics and society as a whole. Thus, we seek to contribute to the debate about the Brazilian path to the construction of a public social welfare system committed to health and adequate nutrition as a human rights.