Brazil: towards sustainability and equity in health.

With a new government in place since January and a woman, Dilma Rousseff , at the helm, together with an economic growth rate of 7·5% last year and a newly discovered oil fi eld off its coast, Brazil is a country in demand as a political and economic partner. Brazil now has an important and timely opportunity to cement its formidable health achievements towards its ultimate goal of universal, equitable, and sustainable health care to fulfi l the right to health enshrined in its 1988 constitution. To highlight this opportunity, The Lancet is publishing a Series of six papers that critically examine what the country’s policies have achieved and where future challenges might lie. The historical development of the current health system has several unique features. Jairnilson Paim and colleagues introduce the Series by pointing out that the recent political history of Brazil, with a military dictatorship until 1985, created the conditions for a strong civil-society movement that still fl ourishes today. That movement mounted a powerful drive for health reform, one that ultimately resulted in the Unifi ed Health System (SUS). These reforms defi ned health beyond its biomedical understanding. They included health’s social determinants, education, poverty reduction, and preventive measures in the broader context of health as a human right. A hallmark of the SUS is its promotion of community participation at all administrative levels. Going further back in time, public health has a long tradition in Brazil. A General Directorate of Public Health was created at the end of the 19th century. Oswaldo Cruz and Carlos Chagas, two of Brazil’s greatest scientifi c leaders, not only acted decisively against public health threats of the time, such as bubonic plague, yellow fever, and smallpox, but also laid the foundation for the internationally renowned Oswaldo Cruz Foundation (FIOCRUZ) which now employs over 7500 people across the country. From the beginning, public health was taken into the political and societal sphere and FIOCRUZ was, and remains to this day, a place where education, research, the production of medicines and vaccines, and advocacy go hand in hand. This positioning of health and public health at the heart of politics and society has sadly diminished in many countries today. Brazil has adopted a more assertive place globally, and understandably so. According to its Finance Minister, Guido Mantega, the country has now overtaken Britain and France to become the fi fth largest economy in the world (from a previous eighth position). Brazil will host the football World Cup in 2014 and the Olympics in 2016. Yet Dilma Rousseff has made the fi ght against poverty a central focus of her presidency. She has recently reaffi rmed her predecessor’s, Luiz Inácio Lula da Silva’s, commitment to eradicate poverty in the country. From being one of the most unequal countries in the world in 1989, many achievements have been made during the past two decades. The SUS has vastly improved access to primary and emergency care. Brazil has already achieved one target of the fi rst Millennium Development Goal (MDG)—a reduction in the number of underweight children by half—and the country is on track to meet MDG 4 (a two-thirds reduction in the mortality rate of children younger than 5 years). Brazil’s HIV/AIDS policies and achievements have been widely praised. Great progress has been made in reducing regional and socioeconomic inequalities and poverty. According to World Bank fi gures, poverty (at purchasing power parity of US$2 per day) has fallen from 20% of a population of about 190 million in 2004 to 7% in 2009. There is still much to do. The complex mix of public and private health provision needs urgent attention. Brazil has the highest rate of caesarean sections in the world, many high-technology interventions are done for the Published Online May 9, 2011 DOI:10.1016/S01406736(11)60433-9