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.

Access to health and social protection policies by homeless people during the COVID-19 pandemic: a mixed-methods case study on tailored inter-sector care during a health emergency.

Introduction: The article analyzed homeless people's (HP) access to health and social protection policies and tailored inter-sector care, including emergency measures, during the COVID-19 pandemic in Belo Horizonte (BH), capital of Minas Gerais state, Brazil. It intended to provide data on HP and evaluate existing public policies focused on vulnerable populations during this health emergency. Methods: The study adopted a mixed-methods design with triangulation of quantitative and qualitative data. Results: Social cartography showed that in the early months of the pandemic, the health administration had difficulty reordering the health system, which experienced constant updates in the protocols but was nevertheless consolidated over the months. The evidence collected in the study showed that important emergency interventions in the municipality of BH involved activities that facilitated access by HP to the supply of services. Discussion: The existence of national guidelines for inter-sector care for HP cannot be ruled out as a positive influence, although the municipalities are responsible for their implementation. Significantly, a health emergency was necessary to intensify the relationship between health and social protection services. Roving services were among those with the greatest positive evidence, with the least need for infrastructure to be replicated at the local level. In addition, the temporary supply of various inter-sector services, simultaneously with the provision of day shelters by organized civil society, was considered a key factor for expanding and intensifying networks of care for HP during the emergency phase. A plan exists to continue and expand this model in the future. The study concluded that understanding the inter-sector variables that impact HP contributes to better targeting of investments in interventions that work at the root causes of these issues or that increase the effectiveness of health and social protection systems.

Potential and challenges of health monitoring in the 2030 Agenda in Brazil. / Potencialidades e desafios do monitoramento da saúde na Agenda 2030 no Brasil.

This article has two integrated objectives: (i) to identify the representation of health in the 2030 Agenda from health-related indicators implemented by international and national institutions; and (ii) to compare the potential of platforms for monitoring Brazilian health commitments in the SDGs. It is argued that there are still important controversies brought about by the greater complexity of the 2030 Agenda, particularly in the operationalization of health-related indicators, whose determinants permeate many other objectives and goals. Finally, even though the picture of the country currently available on national and international platforms is already broad, improvements are required for more effective monitoring and evaluation of Brazilian commitments in the SDGs, with greater disaggregation and stratification of indicators in the population.

O presente artigo tem dois objetivos integrados: (i) identificar a representação da saúde na Agenda 2030, a partir dos indicadores relacionados à saúde operacionalizados por instituições internacionais e nacionais; e (ii) comparar as potencialidades das plataformas para o monitoramento dos compromissos de saúde brasileiros nos ODS. Argumenta-se que ainda existem controvérsias importantes trazidas pela maior complexidade da Agenda 2030, em particular na operacionalização dos indicadores relacionados à saúde, cujos determinantes perpassam muitos outros objetivos e metas. O monitoramento e avaliação mais efetivos dos compromissos brasileiros nos ODS requer melhoria, com maior desagregação e estratificação dos indicadores na população, ainda que o retrato do país hoje disponibilizado nas diversas plataformas nacionais e internacionais já seja amplo.

The sustainable health Agenda in the Americas: Pre-pandemic gaps and 2030 estimates of the SDGs indicators.

The preliminary assessments of the impact of the COVID-19 pandemic have recently rekindled worries about the feasibility of the Sustainable Development Goals (SDGs). Notwithstanding the concern voiced by key academic and political actors, the actual evidence on the current gaps and distance from the goals is still very much unknown. This study estimates the global evolution curves for each health-related SDGs indicator in the World Health Organization's SDGs platform. These curves synthesize the transnational trends at play in the evolution of each health-related topic, offering an average global counterfactual to compare with the actual information for each country. The empirical investigation focuses on the American continent, highlighting the health gaps before the COVID-19 outbreak in 33 countries of the region. The study also extrapolates these trends to predict the evolution of the health-related SDGs in each of these countries over the next decade using as the baseline scenario the International Monetary Fund's economic forecasts. The results show a widening gap in the region, associated with the differential economic capacity of these countries. Some bottlenecks are shared by most countries in the continent, especially in the themes of violence and infectious diseases. The latter is likely to improve faster than other health themes in the next decade, whereas improvements in the theme non-communicable diseases can be more challenging. The findings provide much needed comparative evidence to guide the countries in the region to set priorities and concentrate efforts to accelerate progress in the health-related SDGs.

Potencialidades e desafios do monitoramento da saúde na Agenda 2030 no Brasil / Potential and challenges of health monitoring in the 2030 Agenda in Brazil

Resumo O presente artigo tem dois objetivos integrados: (i) identificar a representação da saúde na Agenda 2030, a partir dos indicadores relacionados à saúde operacionalizados por instituições internacionais e nacionais; e (ii) comparar as potencialidades das plataformas para o monitoramento dos compromissos de saúde brasileiros nos ODS. Argumenta-se que ainda existem controvérsias importantes trazidas pela maior complexidade da Agenda 2030, em particular na operacionalização dos indicadores relacionados à saúde, cujos determinantes perpassam muitos outros objetivos e metas. O monitoramento e avaliação mais efetivos dos compromissos brasileiros nos ODS requer melhoria, com maior desagregação e estratificação dos indicadores na população, ainda que o retrato do país hoje disponibilizado nas diversas plataformas nacionais e internacionais já seja amplo.

Abstract This article has two integrated objectives: (i) to identify the representation of health in the 2030 Agenda from health-related indicators implemented by international and national institutions; and (ii) to compare the potential of platforms for monitoring Brazilian health commitments in the SDGs. It is argued that there are still important controversies brought about by the greater complexity of the 2030 Agenda, particularly in the operationalization of health-related indicators, whose determinants permeate many other objectives and goals. Finally, even though the picture of the country currently available on national and international platforms is already broad, improvements are required for more effective monitoring and evaluation of Brazilian commitments in the SDGs, with greater disaggregation and stratification of indicators in the population.

Challenges, consequences, and possible paths for confronting post-COVID-19 health inequalities and vulnerabilities / Desafios, consequências e possíveis caminhos para o enfrentamento das desigualdades e vulnerabilidades em saúde pós-Covid-19

ABSTRACT The article aims to discuss the challenges and consequences of health inequalities and vulnerabilities, focusing on current phenomena that have reshaped such context, namely financial crisis, fiscal austerity, and the COVID-19 pandemic. Differences between levels of access to wealth and opportunities among and within countries belonging to different income groups create and perpetuate social inequalities that frequently become health inequities. It is challenging to understand both the recent changes and the persistence of inequalities and social stratification, and the issue has thus taken on new dimensions that extrapolate studies focused exclusively on income distribution. The financial crisis, fiscal austerity, and the COVID-19 pandemic have aggravated preexisting health inequalities. Thus, the issue of inequalities in health should be an intrinsic part of public policy, with clear and stable standards and objectives based on explicit political agreements and a legal framework with sustainability ensured by an adequate financing policy. Only then will it be possible to achieve greater levels of equity, even in the face of dramatic situations such the one now faced by the world.

RESUMO O texto teve por objetivo discutir os desafios e as consequências das desigualdades e das vulnerabilidades em saúde, trazendo para discussão fenômenos atuais que vêm reconfigurando esse contexto - crise financeira, austeridade fiscal e pandemia da Covid-19. As diferenças nos níveis de accesso à riqueza e a oportunidades, presentes entre e dentro dos países de distintos grupos de renda, criam e perpetuam as desigualdades sociais, que, muitas vezes, tornam-se iniquidades em saúde. Compreender as recentes mudanças e, também, as permanências, no que se refere às desigualdades e à estratificação social, é desafiador, o que fez com que o tema adquirisse novas dimensões que ultrapassaram os estudos centrados exclusivamente na distribuição de renda. A crise financeira, a austeridade fiscal e a pandemia da Covid-19 agravaram as desigualdades em saúde já existentes. Assim, a questão das desigualdades na saúde deve ser intrinsecamente parte da política pública, com normas e objetivos claros e estáveis, baseados em acordos políticos explícitos e em uma estrutura legal, com sua sustentabilidade assegurada por uma política de financiamento adequada. Somente dessa forma, será possível alcançar maiores níveis de equidade, mesmo diante de situações dramáticas como a que se vive.

Brazilian Food Banks: Overview and Perspectives.

In recent decades food banks have become a worldwide response to the contradicting the coexistence of food losses and waste, on the one hand, and hunger and food insecurity on the other. In Brazil, food banks had a rapid expansion, becoming the object of public policy on Food and Nutrition Security and of non-profit private institutions. Our study presents an unprecedented overview of all the food banks currently active in the Brazilian territory, discussing their performances and perspectives. We conducted descriptive research, aiming to characterize the number, spatial distribution, performance, and modalities of operation of the Brazilian food banks. We mapped 217 active food banks and they all participated in the study. The results revealed the important capillarity of the food banks, which exist in all 27 Brazilian federative units, but also demonstrate the potential and need for expansion. Most of the Brazilian food banks has commercial establishments as their largest donor partners and have fruits and vegetables as their most donated items. They mostly complement the feeding of families at social risk and children served by social institutions. Food and nutrition education actions are offered by all the studied units to donor partners and beneficiary institutions and families.

Social isolation relaxation and the effective reproduction number (Rt) of COVID-19 in twelve Brazilian cities.

We analyzed the social isolation relaxation strategies adopted by the twelve biggest Brazilian cities in 2020, in relation to the number of cases, number of deaths and the effective reproduction number (Rt), which are internationally considered the fundamental epidemiological criteria for allowing wider population mobility in public spaces. The Brazilian central government has not set unique guidelines neither for closure nor for opening, and states and cities have taken the lead in strategy definition. Until July 31 2020, in Belém do Pará, Fortaleza, Manaus, Recife and Rio de Janeiro, where the epidemic peak had already been surpassed, and in Salvador and São Paulo, in which the peak seemed to be already reached, the Rt curve followed a decreasing path after the openings. Porto Alegre, a city in which the epidemic curve was flattened, had an increase in Rt after the start of relaxation. In Belo Horizonte, Brasília, Curitiba and Goiânia, where the curve was also flattened, the Rt remained stable after the opening. The decision on how to operationalize the relaxation of social isolation and the speed with which it happened was heterogeneous among the cities studied. Also, broad population testing strategies were not done in any of the cities.

A encruzilhada da judicialização da saúde no Brasil sob a perspectiva do Direito Comparado / Comparative law and the crossroads of the judicialization of health in Brazil / El derecho comparado y la encrucijada de la judicialización de la salud en Brasil

Objetivo: impacto da judicialização da saúde em diversas partes do mundo aponta para uma encruzilhada entre diversas formas de lidar com o fenômeno, em razão disso, o objetivo é contribuir para esse debate a partir de um panorama da judicialização no Brasil e um comparativo com experiências de outros países. Metodologia: tratou-se de revisão narrativa sobre o tema da judicialização da saúde em perspectiva comparada. A pesquisa foi dividida em duas etapas: contextualização da judicialização da saúde no cenário internacional, utilizando método comparativo na perspectiva do Direito Comparado, e a revisão narrativa sobre a judicialização da saúde no Brasil. Foram utilizados 46 trabalhos: 19 internacionais e 27 brasileiros. Resultados: duas abordagens diferentes para a judicialização da saúde se destacam nos estudos comparativos: a latino-americana e a sul-africana. Na primeira, o fenômeno apresenta maior magnitude com as decisões privilegiando o mínimo existencial, é especialmente complexo no Brasil, Colômbia e Costa Rica; na segunda a reserva do possível se sobressai nas decisões. A análise dos trabalhos realizados no Brasil subsidiou a construção de uma linha do tempo, proporcionando um panorama geral da judicialização no Brasil, e a trajetória desse fenômeno fluido, que se modificou ao longo do tempo à medida que novas problemáticas e formas de lidar foram surgindo e se desenvolvendo. Conclusões: o estudo evidencia que a judicialização da saúde é um fenômeno multifacetado, trazendo à tona um dilema entre vários caminhos a seguir. Porém, é um tema carente de estudos sobre o ponto de vista do usuário e dos desfechos sanitários decorrentes das ações judiciais. A complexidade do fenômeno culmina na diversidade de intervenções nos países, gerando conflitos entre garantir o direito à saúde e limitações orçamentárias. Conclui-se que a judicialização tem pontos positivos e negativos: ela é solução, mas também é problema.

Objective: the impact of the judicialization of health in various parts of the world points to a crossroads between diverse waysof dealing with the phenomenon, therefore, the work aims to contribute to this debate from an overview of judicialization in Brazil and a comparison with experiences from other countries. Methodology: this was a narrative review on the theme of the judicialization of health in a comparative perspective. The research was divided into two stages: contextualization of the judicialization of health in the international scenario, using a comparative method from the perspective of Comparative Law, and a narrative review on the judicialization of healthin Brazil. Forty-six works were used: 19 international and 27 Brazilian. Results: two different approaches to the judicialization of health stand out in comparative studies: the Latin American and the South African. In the first, the phenomenon presents greater magnitude with decisions favoring the minimum existential, it is especially complex in Brazil, Colombia, and Costa Rica; in the second, the reserve of the possible stands out in the decisions. The analysis of the work conducted in Brazil supported the construction of a timeline providing an overview of judicialization in Brazil, and the trajectory of this fluid phenomenon, which changed over time as new issues and ways of dealing with it emerged and developing. Conclusions: the study shows that the judicialization of health is a multifaceted phenomenon, bringing to light a dilemma between several paths to be followed. However, it is a subject that lacks studies on the user's point of view, and on the health outcomes resultedfrom lawsuits. The complexity of the phenomenon culminates in the diversity of interventions in countries, generating conflicts between guaranteeing the right to health and budgetary limitations. It is concluded that judicialization has positive and negative points:it is a solution, but it is also a problem.

Objetivo: el impacto de la judicialización de la salud en diferentes partes del mundo apunta a una encrucijada entre diferentes formas de abordar el fenómeno, por lo que el trabajo tiene como objetivo contribuir a este debate desde un panorama de la judicialización en Brasil y una comparación con experiencias. de otros países Metodología: se trató de una revisión narrativa sobre el tema de la judicialización de la salud en perspectiva comparada. La investigación se dividió en dos etapas: la contextualización de la judicialización de la salud en el escenario internacional, utilizando un método comparativo desde la perspectiva del Derecho Comparado, y la revisión narrativa sobre la judicialización de la salud en Brasil. Se utilizaron 46 obras: 19 internacionales y 27 brasileñas. Resultados: en los estudios comparados se destacan dos enfoques distintos de la judicialización de la salud: el latinoamericano y el sudafricano. En el primero, el fenómeno presenta mayor magnitud con decisiones a favor del mínimo existencial, es especialmente complejo en Brasil, Colombia y Costa Rica; en el segundo, la reserva de lo posible se destaca en las decisiones. El análisis del trabajo realizado en Brasil apoyó la construcción de un cronograma que brinde un panorama de la judicialización en Brasil, y la trayectoria de este fenómeno fluido, que cambió con el tiempo a medida que surgían y se desarrollaban nuevos temas y formas de abordarlo. Conclusiones: el estudio muestra que la judicialización de la salud es un fenómeno multifacético, que saca a la luz un dilema entre varios caminos a seguir. Sin embargo, es un tema que carece de estudios sobre el punto de vista del usuario y sobre los resultados de salud derivados de los juicios. La complejidad del fenómeno culmina en la diversidad de intervenciones en los países, generando conflictos entre la garantía del derecho a la salud y las limitaciones presupuestarias. Se concluye que la judicialización tiene puntos positivos y negativos; es una solución, pero también es un problema.

Social isolation relaxation and the effective reproduction number (Rt) of COVID-19 in twelve Brazilian cities / O relaxamento do isolamento social e o número efetivo de reprodução (Rt) do COVID-19 em doze municípios brasileiros

Abstract We analyzed the social isolation relaxation strategies adopted by the twelve biggest Brazilian cities in 2020, in relation to the number of cases, number of deaths and the effective reproduction number (Rt), which are internationally considered the fundamental epidemiological criteria for allowing wider population mobility in public spaces. The Brazilian central government has not set unique guidelines neither for closure nor for opening, and states and cities have taken the lead in strategy definition. Until July 31 2020, in Belém do Pará, Fortaleza, Manaus, Recife and Rio de Janeiro, where the epidemic peak had already been surpassed, and in Salvador and São Paulo, in which the peak seemed to be already reached, the Rt curve followed a decreasing path after the openings. Porto Alegre, a city in which the epidemic curve was flattened, had an increase in Rt after the start of relaxation. In Belo Horizonte, Brasília, Curitiba and Goiânia, where the curve was also flattened, the Rt remained stable after the opening. The decision on how to operationalize the relaxation of social isolation and the speed with which it happened was heterogeneous among the cities studied. Also, broad population testing strategies were not done in any of the cities.

Resumo Este trabalho analisou as estratégias de relaxamento do isolamento social adotadas pelas doze maiores cidades brasileiras em 2020, em relação ao número de casos, número de óbitos e ao número efetivo de reprodução (Rt), considerados internacionalmente os critérios epidemiológicos fundamentais para permitir uma maior mobilidade da população nos espaços públicos. O governo federal não estabeleceu diretrizes únicas nem para o fechamento nem para a abertura, e os estados e municípios assumiram o protagonismo na definição da estratégia. Até 31 de julho, em Belém do Pará, Fortaleza, Manaus, Recife e Rio de Janeiro, onde o pico epidêmico já havia sido ultrapassado, e em Salvador e São Paulo, em que o pico parecia já ter sido atingido, o Rt seguiu uma curva decrescente após as aberturas. Em Porto Alegre, aonde a curva epidêmica foi achatada, houve aumento do Rt após o início do relaxamento. Em Belo Horizonte, Brasília, Curitiba e Goiânia, nos quais a curva também foi achatada, o Rt manteve-se estável após a abertura. A decisão de como operacionalizar o relaxamento do isolamento social e a velocidade com que isso aconteceu foi heterogênea entre as cidades estudadas. Além disso, amplas estratégias de testagem populacional não foram realizadas em nenhuma das cidades.

Combination of conditional cash transfer program and environmental health interventions reduces child mortality: an ecological study of Brazilian municipalities.

BACKGROUND: This study aims to assess the interactive effects of Brazilian public interventions, environmental health programs (access to water, sanitation and solid waste collection) and a Conditional Cash Transfer Program (PBF), on the mortality reduction due to diarrhea and malnutrition among children under 5 years old. METHODS: The study design is ecological, with longitudinal analysis in a balanced panel. The period covered is 2006 to 2016, including 3467 municipalities from all regions of the country, which resulted in 38,137 observations. The generalized linear models were adjusted considering the Negative Binomial (NB) distribution for the number of deaths due to malnutrition and diarrhea, with fixed effects. NB models with and without zero-inflation were assessed. Subsequent interaction models were applied to assess the combined effects of the two public policies. RESULTS: In relation to the decline of mortality rates due to diarrhea in the municipalities, positive effect modification were observed in the presence of: high coverage of the target population by the PBF and access to water, 0.54 (0.28-1.04) / 0.55 (0.29-1.04); high coverage by the total population by the PBF and access to water, 0.97 (0.95-1.00) and high coverage by the total population by the PBF and access to sanitation, 0.98 (0.97-1.00). Decline on diarrhea mortality was also observed in the joint presence of high coverage of solid waste collection and access to water, categories 1 (> 60% ≤85%): 0.98 (0.96-1.00), 0.98 (0.97-1, 00) and 2 (> 85% ≤ 100%): 0.97 (0.95-0.98), 0.97 (0.95-0.99). Negative effect modification were observed for mortality due to malnutrition in the presence of simultaneous high coverage of the total population by the PBF and access to sanitation categories 1 (≥ 20 < 50%): 1.0061 (0.9991-1.0132) and 2 (≥ 50 < 100%): 1.0073 (1.0002-1.0145) and high coverage of the total population by the PBF and solid waste collection, 1.0004 (1.0002-1.0005), resulting in malnutrition mortality rates increase. CONCLUSION: Implementation of environmental health services and the coverage expansion by the PBF may enhance the prevention of early deaths in children under 5 years old due to diarrhea, a poverty related disease.

Combined effects of conditional cash transfer program and environmental health interventions on diarrhea and malnutrition morbidity in children less than five years of age in Brazil, 2006-2016.

INTRODUCTION: Governmental measures aiming at social protection, with components of disease control, have potential positive impacts in the nutritional and health outcomes of the beneficiaries. The concomitant presence of these measures with environmental sanitation interventions may increase their positive effect. The context of simultaneous improvement of social protection and environmental sanitation is found in Brazil since 2007 and an assessment of the combined effects of both programs has not been performed so far. OBJECTIVE: To evaluate whether interaction effects between improvement of access to water, sanitation and solid waste collection with the Bolsa Família Program [PBF] were related to better responses in the reduction of morbidity due to diarrhea and malnutrition in children less than five years of age, acknowledging the positive results of these improved conditions and the PBF separately in coping with these diseases. METHODS: Descriptive and inferential analyses were performed through Generalized Linear Models of the Negative Binomial type of fixed effects, with and without addition of zeros. Interaction models were inserted in order to evaluate the outcomes when the two public policies of interest in the current study were present simultaneously in the municipalities. RESULTS: Interaction with negative effect when a concomitantly high municipal coverage of the Bolsa Família Program and adequate access to sanitation and solid waste collection were present. In contrast, regardless of municipal coverage by the PBF, the simultaneous presence of water and sanitation (0.028% / 0.019%); water and solid waste collection (0.033% / 0.014%); sanitation and solid waste collection (0.018% / 0.021%), all resulted in a positive effect, with a decrease in the average morbidity rates for both diseases. CONCLUSION: Investments aimed at universalizing water, sanitation and solid waste collection services should be priorities, aiming at reducing the incidence of morbidity due to malnutrition and diarrhea and preventing deaths from these poverty-related diseases.

Quantifying convergence on health-related indicators of the 2030 agenda for sustainable development.

The extended scope and complexity of the United Nations 2030 agenda entail important challenges for the operationalization of the health-related sustainable development goal (SDG) indicators. Divergences in concepts, agendas and implementation strategies among institutions have fostered the parallel development of alternative and concurrent indicators. We aim to determine the convergences and divergences between five key institutions: the Global Burden of Disease Study (GBD), the Pan American Health Organization, the Sustainable Development Solutions Network, the World Bank and the World Health Organization (WHO). Of the 104 health-related indicators listed by these five institutions, 60 are consistent with official Inter-agency and Expert Group SDG indicators. Our analysis considers the indicators included, and the themes these indicators cover, in each institution list and each institution online platform. We quantified convergence in indicators between the institutions themselves, but also between the institutions and the official Inter-agency and Expert Group. Our results indicate important divergences; only 22 of the 60 indicators are included in the lists of all five institutions. The level of adoption of the official metrics varies from 40.5% (15/(47-10)) for the GBD to 86.2% (25/(29-0)) for the World Bank. WHO, the official curator of the Inter-agency and Expert Group SDG indicators, is only convergent with the official metrics by 72.1% (31/(45-2)). Our analysis, and the resulting awareness of the differences, potentialities and limitations of indicators and platforms, provides important contributions to enable the achievement of the health-related SDGs and deliver the promise of the 2030 agenda.

La complexité et l'envergure de l'Agenda 2030 des Nations Unies représentent d'importants défis pour la concrétisation des indicateurs régissant l'objectif de développement durable (ODD) visant à assurer la santé et le bien-être de tous. Les divergences de concepts, de programmes et de stratégies de mise en œuvre au sein des institutions ont engendré l'apparition simultanée d'indicateurs alternatifs et concurrents. Nous cherchons à identifier les convergences et divergences entre cinq institutions clés: l'étude sur la charge mondiale de morbidité (GBD), l'Organisation panaméricaine de la Santé, le Réseau des solutions pour le développement durable, la Banque mondiale et l'Organisation mondiale de la Santé (OMS). Sur les 104 indicateurs de santé repris par ces cinq institutions, 60 sont compatibles avec ceux du Groupe d'experts interinstitutionnel sur les indicateurs des ODD. Notre analyse tient compte des indicateurs inclus, ainsi que des domaines dont ils traitent, dans chaque liste institutionnelle et sur chaque plateforme institutionnelle en ligne. Nous avons quantifié la convergence d'indicateurs entre les institutions elles-mêmes, mais aussi entre ces institutions et le Groupe d'experts interinstitutionnel officiel. Nos résultats révèlent d'importantes divergences; seulement 22 des 60 indicateurs figurent dans les listes des cinq institutions. Le niveau d'adoption des paramètres officiels varie de 40,5% (15/(47­10)) pour le GBD à 86,2% (25/(29­0)) pour la Banque mondiale. L'OMS, administratrice officielle du Groupe d'experts interinstitutionnel sur les indicateurs des ODD, ne s'aligne sur les paramètres officiels qu'à 72,1% (31/(45­2)). Notre analyse et sa mise en évidence des différences, des possibilités et des limites des indicateurs et plateformes, contribue grandement à progresser vers la réalisation des ODD en matière de santé, et vers la concrétisation des promesses de l'Agenda 2030.

El amplio alcance y la complejidad del programa de las Naciones Unidas para 2030 implica importantes desafíos para la puesta en práctica de los indicadores del objetivo de desarrollo sostenible (ODS) relacionado con la salud. Las divergencias en los conceptos, los programas y las estrategias de aplicación entre las instituciones han fomentado la elaboración paralela de indicadores alternativos y simultáneos. Nos proponemos determinar las convergencias y divergencias entre cinco instituciones clave: el Estudio sobre la Carga Mundial de la Enfermedad (GBD, por sus siglas en inglés), la Organización Panamericana de la Salud, la Red de Soluciones para el Desarrollo Sostenible, el Banco Mundial y la Organización Mundial de la Salud (OMS). De los 104 indicadores relacionados con la salud enumerados por estas cinco instituciones, 60 son coherentes con los indicadores oficiales del ODS del Grupo Interinstitucional y de Expertos. Nuestro análisis tiene en cuenta los indicadores incluidos, y los temas que cubren estos indicadores, en cada lista de instituciones y en la plataforma en línea de cada institución. Cuantificamos la convergencia en los indicadores entre las propias instituciones, pero también entre las instituciones y el Grupo Interinstitucional y de Expertos oficial. Nuestros resultados indican importantes divergencias; solo 22 de los 60 indicadores están incluidos en las listas de las cinco instituciones. En cuanto al nivel de adopción de los indicadores oficiales varía entre el 40,5% (15/(47-10)) en el caso del GBD y el 86,2% (25/(29-0)) en el caso del Banco Mundial. La OMS, la comisaria oficial de los indicadores del ODS del Grupo Interinstitucional de Expertos, solo converge con los parámetros oficiales en un 72,1% (31/(45-2)). Nuestro análisis, y la consiguiente conciencia de las diferencias, potencialidades y limitaciones de los indicadores y plataformas, aporta importantes contribuciones para permitir el logro de los ODS relacionados con la salud y cumplir con el compromiso del programa de 2030.

Monitoring the progress of health-related sustainable development goals (SDGs) in Brazilian states using the Global Burden of Disease indicators.

BACKGROUND: Measuring the Global Burden of Disease (GBD) has been the key to verifying the evolution of health indicators worldwide. We analyse subnational GBD data for Brazil in order to monitor the performance of the Brazilian states in the last 28 years on their progress towards meeting the health-related SDGs. METHODS: As part of the GBD study, we assessed the 41 health-related indicators from the SDGs in Brazil at the subnational level for all the 26 Brazilian states and the Federal District from 1990 to 2017. The GBD group has rescaled all worldwide indicators from 0 to 100, assuming that for each one of them, the worst value among all countries and overtime is 0, and the best is 100. They also estimate the overall health-related SDG index as a function of all previously estimated health indicators and the SDI index (Socio-Demographic Index) as a function of per capita income, average schooling in the population aged 15 years or over, and total fertility rate under the age of 25 (TFU25). RESULTS: From 1990 to 2017, most subnational health-related SDGs, the SDG and SDI indexes improved considerable in most Brazilian states. The observed differences in SDG indicators within Brazilian states, including HIV incidence and health worker density, increased over time. In 2017, health-related indicators that achieved good results globally included the prevalence of child wasting, NTD, household air pollution, conflict mortality, skilled birth attendance, use of modern contraceptive methods, vaccine coverage, and health worker density, but poor results were observed for child overweight and homicide rates. The high rates of overweight, alcohol consumption, and smoking prevalence found in the historically richest regions (i.e., the South and Southeast), contrast with the high rates of tuberculosis, maternal, neonatal, and under-5 mortality and WASH-related mortality found in the poorer regions (i.e., the North and Northeast). CONCLUSIONS: The majority of Brazil's health-related SDG indicators have substantially improved over the past 28 years. However, inequalities in health among the Brazilian states and regions remain noticeable negatively affecting the Brazilian population, which can contribute to Brazil not achieving the SDG 2030 targets.

Fiscal austerity and the health sector: the cost of adjustments / Austeridade fiscal e o setor saúde: o preço do ajuste

Abstract Fiscal austerity policies have been used as responses to economic crises and fiscal deficits in both developed and developing countries. While they vary in regard to their content, intensity and implementation, such models recommend reducing public expenses and social investments, retracting the public service and substituting the private sector in lieu of the State to provide certain services tied to social policies. The present article discusses the main effects of the recent economic crisis on public health based on an updated review with consideration for three dimensions: health risks, epidemiological profiles of different populations, and health policies. In Brazil, the combination of economic crisis and fiscal austerity policies is capable of producing a direr situation than those experienced in developed countries. The country is characterized by historically high levels of social inequality, an under-financed health sector, highly prevalent chronic degenerative diseases and persisting preventable infectious diseases. It is imperative to develop alternatives to mitigate the effects of the economic crisis taking into consideration not only the sustainability of public finance but also public well-being.

Resumo Políticas de austeridade fiscal têm sido utilizadas como respostas à crise econômica e deficit fiscal tanto em países desenvolvidos como em desenvolvimento. Embora variem quanto ao conteúdo, intensidade e cronograma de implementação, tais modelos preconizam a redução do gasto público, promovendo também a diminuição do investimento social, a retração da máquina pública e a substituição do Estado pelo setor privado na provisão de determinados serviços vinculados a políticas sociais. Este artigo debate os principais efeitos da crise econômica recente sobre a saúde da população, tendo sido baseado em uma revisão atualizada, considerando-se três dimensões: riscos à saúde, perfil epidemiológico das populações e políticas de saúde. A crise econômica no Brasil, combinada com a política de austeridade fiscal, pode produzir um contexto mais grave do que o vivenciado pelos países desenvolvidos. O país apresenta altos níveis históricos de desigualdade social, subfinanciamento do setor saúde, alta prevalência de doenças crônico-degenerativas e persistência de doenças infeciosas evitáveis. É imperativo que se construam alternativas para se mitigar os efeitos da crise econômica, levando-se em conta não apenas a sustentabilidade das finanças públicas, mas também o bem-estar da população.