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Public Health Policy in Brazil & Mexico

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Public Health Policy in Brazil & Mexico

Manoela Onofrio

Aalborg University

July 2010

    Public Health Policy in Brazil & Mexico 2010

    Aalborg University- Department of Master’s Programme in Culture, Communication History, International and Social and Globalization

    Studies

    Supervisor: Steen Fryba Christensen Student: Manoela Dias Onofrio

    th10 Semester: Master‘s Thesis

    Public Health Policy in Brazil and Mexico:

     Changing problems - Common solutions?

    July 2010

Total Number of pages: 72

    Total Number of characters (with spaces): 169,767

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    Public Health Policy in Brazil & Mexico 2010

Contents

    ABSTRACT ............................................................................................................................................... 5 ACRONYMS ............................................................................................................................................. 6 I. Globalization and its impact in Public Health......................................................................................... 7 I.1 ‘Double Burden’ in Latin America .................................................................................................... 8

    I.2 Problem Formulation ...................................................................................................................... 9 II. Methodology ..................................................................................................................................... 10 II.1 Use of Sources ............................................................................................................................. 10 II.2 Use of Theory .............................................................................................................................. 11 II.3 Analysis Structure ........................................................................................................................ 12 II.4 Delimitations and Reservations .................................................................................................... 15 II.5 Comparative Analysis of Public Policies ........................................................................................ 17 II.6 Terminology................................................................................................................................. 17 III. The Public Policy Process: Theoretical Perspectives .......................................................................... 18

    III.1 Ideologies, Exercise of Power and State Organization.................................................................. 19

    III.2 Functionalist Approaches: Rational decision-making ................................................................... 21

    III.3 Institutionalism ........................................................................................................................... 22

    III.3.1 Historical Institutionalism ..................................................................................................... 22 III.4 Social Constructivism .................................................................................................................. 24 III.5 Public Policy Process as Stages .................................................................................................... 26

    III.5.1 ‘Initiation’: Agenda-Setting in Health .................................................................................... 30

    III.5.2 Limitations of Stages Framework .......................................................................................... 33

    IV. Analysis: Public Health Policies in Brazil & Mexico ............................................................................ 34 IV.1 Diabetes: Directives for Policy ..................................................................................................... 35 IV.2 Brazil: Socio-economic Markers & Milestones ............................................................................. 37

    IV.3 Brazil: Healthcare Structure ........................................................................................................ 38 IV.4 Policy Initiation in Brazil .............................................................................................................. 41

    IV.4.1 CEA Structure ....................................................................................................................... 41 IV.5 Policy Implementation in Brazil ................................................................................................... 43

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    IV.5.1 Access to Treatment: Judicial Cases ..................................................................................... 46

    IV.5.2 Access to Treatment: State & Municipal Initiatives ............................................................... 49

    IV.6 Policy Evaluation & Outcomes in Brazil ....................................................................................... 50

    IV.7 Mexico: Socio-economic Markers & Milestones .......................................................................... 52

    IV.8 Mexico: Healthcare Structure ..................................................................................................... 54 IV.9 Policy Initiation in Mexico ........................................................................................................... 58

    IV.9.1 CEA Structure ....................................................................................................................... 60 IV.10 Policy Implementation in Mexico .............................................................................................. 61

    IV.11 Policy Evaluation & Outcomes in Mexico .................................................................................. 66

    V. Comparative Analysis: Public Health Policies in Brazil & Mexico ......................................................... 68

    V.1 Comparing Initiation Processes & Priority-setting ........................................................................ 70

    V.2 Comparing Policy Implementation and Evaluation ....................................................................... 73

    V.2.1 Outcomes ............................................................................................................................. 73 VI. Conclusions ...................................................................................................................................... 75 VI.1 Perspectives ............................................................................................................................... 77 VIII. Bibliography ................................................................................................................................... 78 ANNEX 1: Script for in-Depth Interview .................................................................................................. 87 ANNEX 2: Interview Transcripts ............................................................................................................. 89

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    Public Health Policy in Brazil & Mexico 2010

    ABSTRACT

    Diabetes, a chronic disease which occurs when the body is unable to produce insulin, has become a major health burden in developing countries. If left untreated, or under poor control, diabetic patients will develop severe complications, such as eye disease, kidney failure and amputations, which represent loss in quality of life for the patient and increased costs to healthcare systems. Diabetes is part of a significant change in the epidemiological patterns of developing countries in the last decades: while still unable to curb infectious diseases, such as dengue, malaria and tuberculosis, these countries are facing growing rates of diabetes and other lifestyle diseases. This combination of factors creates a ‗double burden‘ for healthcare systems.

    Brazil and Mexico, the two most populous countries in Latin America, have followed this pattern, and currently present very high prevalence rates of diabetes.

    Considering that the care and prevention of diabetes is not only a health issue, but also a political one, in which public policies greatly affect how the disease evolves, it is of interest to ask: how are public health policies in Brazil and Mexico addressing the recent rise of diabetes in these countries? This project aimed at answering this question through a critical and comparative analysis of the public health policies in the two countries for the period of 2000 to 2010; more specifically on two levels: a) policy initiation and the use of Cost-effectiveness analysis (CEA) and b) policy implementation and evaluation. The project drew from a multidisciplinary theoretical background, including historical institutionalism and functionalist approaches, policy stages framework, so that each stage could be properly characterized and addressed.

    The research showed that initial efforts towards diabetes in Brazil and Mexico may have been instigated by the influence of intergovernmental organizations, and since then political attention towards the condition has grown gradually over the past decade. The formulation of the policies for diabetes demonstrated a degree of convergence between the two countries. Nonetheless, the actual implementation of these policies was directly affected by the different institutional arrangements and structures of the two healthcare systems. The analysis of the Mexican and Brazilian policies also reveal a parallel effort regarding health promotion as well as the use of CEA, with considerable structural changes done to the countries to promote both. While some landmarks have been achieved, latest assessments indicate that there is still inequality in access and quality of treatment, and the figures related to diabetes are still on the rise. Nevertheless, considering the efforts are recent, more research is needed in the future to assess their effectiveness, and whether or not they were able to curb the expansion of diabetes and foment a healthier population in Brazil and Mexico.

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    ACRONYMS

    ANS - Agencia Nacional de Saúde Suplementar (National Agency of Supplementary Health)

    ANSA - Acuerdo Nacional para la Salud Alimentaria (National Agreement for Food Health)

    ANVISA - Agência Nacional de Vigilância Sanitária (Brazilian Sanitary Surveillance Agency)

    CENAVE - Centro N. de Vigilancia Epidemiologica y Control de Enfermedades (National Center for Health Surveillance)

    CENETEC - Centro Nacional de Excelencia Tecnologica en Salud (National Center for Technological Excellency in Health

    CIT - Conselho Intergestores Tripartite (Brazilian Tripartite Council)

    CMED - Câmara de Regulação do Mercado de Medicamentos (Regulation Chamber for the Pharmaceutical Market)

    CNHD - Coordenacao Nacional de Hipertensão Arterial e Diabetes M. (National Coordination of Hypertension and Diabetes)

    CNS - Conselho Nacional de Saúde (Brazilian National Council of Health)

    CNS - Consejo Nacional de Salud (Mexican National Council of Health)

    CONASEMS - Conselho Nacional de Secretarias Municipais de Saúde (National Council of Municipalities Health Secretariats)

    CONASS - Conselho Nacional de Secretários de Saúde (National Council of Health Secretariats)

    ELSA-Brasil - Estudo Longitudinal de Saúde do Adulto (Longitudinal study in Adult Health)

    FENAD - Federação Nacional das Assoc. e Entidades de Diabetes (Brazilian National Diabetes

    Federation)

    IBGE - Instituto Brasileiro de Geografia e Estatística (Brazilian Institute of Geography and Statistics)

    IMSS - Instituto Mexicano de Seguridad Social (Mexican Institute of Social Security)

    INEGI - Instituto Nacional de Estadística y Geografia México (Mexican Institute of Statistics and Geography)

    ISSSTE - Instituto de Seguridad y Servicios Sociales de los Trabajadores (Institute for social security and services for workers)

    NCD - Non-communicable disease

    NDP - National Diabetes Plan

    SCTIE - Secretaria de Ciência, Tecnologia e Insumos Estratégicos (Secretariat for Science, Technology and Strategic inputs)

    SPSS - Sistema de Protección Social en Salud (System for Social Protection in Health)

    SUS - Sistema Único de Saúde (Unified Health System)

    SVS - Secretaria de Vigilância da Saúde (Health Surveillance Secretariat)

    UNEME - Unidades de Especialidades Médicas (Medical Specialties Unit)

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I. Globalization and its impact in Public Health

    Globalization has impacted many aspects of our daily lives. When understood in the context of health, it has consequences for both health determinants and health effects in the population. The increasing urbanization, industrialization, diet and life style changes worldwide (Lee et al. 2002; Parish 2006) have led to an outburst of non-communicable diseases (NCDs), namely diabetes, cardiovascular diseases, chronic respiratory diseases and cancers, all over the world (Parish 2006: 1). NCDs are now the world's biggest killers, causing an estimated 35 million deaths each year - 60% of all deaths globally (WHO Action Plan 2008).

    While communicable diseases (CDs) such as tuberculosis or malaria - ―have never been

    contained by the artificial boundaries established by nation states (…) and are carried through

    and influenced by a number of vectors‖ (Parish 2006:1), there are now commonalities among

    states as it relates to NCDs. This global ―obesogenic‖ environment one which fosters low

    levels of physical activity and easier access to energy rich diets (WHO 2004) increases

    exponentially the risk of developing one NCD in particular: diabetes.

    Diabetes is a chronic disease, at present incurable, that occurs when the pancreas does not produce enough insulin (a hormone that regulates sugar levels in the blood), or when the body cannot use the insulin effectively (IDF Online). There are two main types of diabetes: type I and type II; with the latter being the most common (90-95% of all diabetes cases); its onset linked to genetic factors, but obesity, physical inactivity and unhealthy diet are main causal factors (Ibid). If uncontrolled, diabetes leads to severe complications: amputations, blindness, kidney and circulatory disease (ADA Online). Complications not only impact patients, diminishing quality of life and leading to premature deaths, but also add significant costs to health care systems: direct health care costs of diabetes range from 2.5% to 15% of annual health care budgets, depending on local diabetes prevalence and the sophistication of the treatment available (WHO Diabetes Online). Moreover, the biggest increase of type 2 diabetes is among adults of working age (Narayan et al. 2010), which has implications on labor, productivity and overall household income.

    The fact that it is a chronic disease also means that treatment is extended to a person‘s entire life cycle. For patients suffering from type 1 diabetes, treatment is a daily task: it requires

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    a strict regimen of carefully calculated diet, planned physical activity, home blood glucose testing several times a day, and daily insulin injections (IDF treatment Online). For type 2 diabetes, treatment also includes diet control, exercise, and may require oral hypoglycemic drugs

    to lower their blood sugar, and/or insulin injections at some point (Ibid). It is a life-long commitment on the part of the person with diabetes (Ibid).

    At present, it is estimated that 171 million people worldwide have diabetes, with this figure likely to double by 2030 (Ibid). The figures show an additional worrisome aspect: four out of five people with diabetes now live in developing countries, with most affected being men and women of working age (IDF Online). It has also been estimated that by 2030, three-quarters of the total number of diabetes patients will be living in low-income countries (Dooley 2009). Low and middle-income countries (LMIC) will, therefore, bear the brunt of the diabetes burden. I.1 ‘Double Burden’ in Latin America

    Middle income countries in Latin American, like Brazil and Mexico, follow these gruesome patterns in a precise manner: both countries have a high diabetes prevalence rates - currently at 6.4% and 10.8% respectively (IDF Atlas) as well as high rates of risk factors - most importantly, obesity. Almost 50% of the Mexican adult population and nearly one third of Mexican children are overweight or obese (Sánchez-Castillo 2004) while Brazil has also experienced a significant increase of obesity prevalence, and this prevalence is proportionally higher in low-income families (Pinheiro et al. 2003). This is explained by the fact that high calorie diets tend to be cheaper, and overconsumption comes not despite poverty, but because of it (Davis 2010). These levels of obesity also suggest that prevalence of diabetes will continue to grow in upcoming decades, since as many as 80% of cases of type 2 diabetes are linked with overweight or obesity, in particularly abdominal obesity (Sánchez-Castillo 2004).

    Nonetheless, diabetes is not the only public health concern in Latin America. Concurrently with the rise of diabetes and other NCDs, healthcare systems in the region are still hampered by high rates of infectious diseases, generating what many scholars have coined ‗the

    double burden‘: the world‘s poor increasingly experiencing the collision of traditional pandemics

    and the modern environmental health risks (Johnson 2009;Leeder 2009). As an example of this extremely dynamic environment, as recent as March 2010, the Pan American Health

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    Organization PAHO, released a report that several Latin American countries should be "bracing (…) for a particularly virulent outbreak of the mosquito-borne tropical disease known

    as dengue fever‖ in the upcoming months (PAHO 2010). Traditionally, LMIC governments

    allocate fewer resources to non-communicable diseases than infectious ones; are less well equipped to deal with the consequences of chronic diseases (Davis 2010); and they commonly face financial stresses in their health care sectors (Oortwijn & Banta 2010).

    This growing complexity in health poses a problem for the proper identification and prioritization of conditions/diseases within policy-making bodies and healthcare systems. In order to understand how these changes impact governmental actions, it can be interesting to look at the public policy process; with attention focused upon how policy decisions are made and how they are shaped into action (Hill 2005: 5).

    It is important to note that the rise of diabetes in LMIC is part of a larger picture, if we consider that ―the health status of individuals and populations is a significant barometer of social progress, broadly reflecting the sustainability of the current, and prospective, forms of how we order our lives both locally and globally‖ (Lee et al. 2002: 3). The growing body of academic

    evidence linking health and long term economic development for developing countries (WHO 2001; OECD 2002) highlights the importance of studying such health issues.

    I.2 Problem Formulation

    Due to this multifaceted health landscape, it is of interest to ask: How are public health

    policies in Brazil and Mexico addressing the recent rise of diabetes in these countries?

    By investigating the Mexican and Brazilian public policy processes, with a focus in diabetes, this study aims to answer the problem in two levels: a) by evaluating the priority-setting process and readiness to deal with this shifting health environment and b) by analyzing the implementation and effectiveness of the policies closely related to diabetes. Furthermore, by critically comparing the two countries, the policies and processes can be more richly characterized. A further motivation for investigating policies comparatively is that results may provide insight into the dialogue and knowledge transfer among states, especially considering the shared factors influencing diabetes. More details of this analysis structure will be provided in the following chapter, Methodology.

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    Public Health Policy in Brazil & Mexico 2010

    In order to tackle the question above, this project is divided into 4 main sections: a) methodological and theoretical approaches, b) analysis of the Brazilian & Mexican health policies separately, c) comparisons between the two countries and d) a final chapter for conclusions and perspectives.

    II. Methodology

    In this section, the methodological considerations will be presented, as they help pave the way to properly answer the problem formulation.

    The methodology will be based in a qualitative analysis of the public policy process in the two countries, and then a comparative analysis of the two.

    II.1 Use of Sources

    The analysis is based mainly on secondary data, for both countries. These sources include regulatory documents, such as the congressional Bills and records, constitutional amendments, official applications and licenses. Additional material such as governmental websites, communication material, official statements and media interviews are also an important source of information. A bias is to be expected, particularly in what relates to the selection of the policy, as well as the outcomes.

    In order to overcome possible biases, a triangulation of sources will be used, with the purpose of increasing the credibility and validity of the results. As per the definition of O‘Donoghue & Punch, triangulation is the ―method of cross-checking data from multiple sources

    to search for regularities in the research data" (2003: 78).

    As the second vertex of sources, scholarly essays will be utilized, particularly in relation to the analysis of the evaluation of implementation and general outcomes of the public policies. The body of academic work produced in Brazil and Mexico, as well as internationally, to address public health policies in the region has been extensive. However, they illustrate one of the major disadvantages when using secondary data: inherent in its nature, the data collected in academic articles and papers may not have been collected to answer the specific research questions of this study, and particular information may be lacking. In any case, it is only possible to work with the data that exists. In this sense, many of the academic articles analyzed in this study evidence the

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