For a health reform model, try Brazil

The eight Millennium Development Goals, adopted in 2000, set targets to attain international development objectives, including reducing extreme poverty and hunger; reducing child mortality; improving maternal health; achieving universal primary education; increasing equality for women; fighting AIDS, malaria, and other diseases; ensuring environmental sustainability; and fostering global partnerships for development.

The Harvard-Brazil Symposium, held in HSPH's Kresge Building, featured discussions of the health-related goals and of Brazil's progress in meeting them. It was sponsored by the Department of Global Health and Population, which is marking its 50th anniversary, as well as the Harvard Global Health Institute and Fundação Maria Cecilia Souto Vidigal.

Harvard School of Public Health Dean Julio Frenk, who sits on UN Secretary General Ban Ki-Moon's MDG Advocacy Group, introduced the event, saying that the goals' adoption marked the first time the world's nations agreed on common development objectives and on indicators to measure progress.

The result, he said, has been an unprecedented level of funding for the needs outlined, as well as progress that has been, in some cases, spectacular. Yet much remains to be done, making the search for examples that might be adapted to other situations an important strategy.

"The challenges that remain are enormous," Frenk said.

Luciana Mendes Santos Servo, health coordinator at the Institute for Applied Economic Research in Brazil, traced the changes in that country to Brazil's 1988 constitution, which recognized health as a right for citizens and created a government obligation to improve it.

That sparked the creation of several social welfare programs and reform of the health care system from one that was centered on hospitals and financed by private insurance, held mainly by those in the formal labor pool, to one that emphasized primary care and was open to all.

Brazil has already achieved the goals for reducing poverty and hunger and is on track to achieve the goals involving child mortality and universal education. Maternal health in the nation has improved, but the goal appears out of reach by 2015. Mendes credited three programs with the bulk of the change: a social security benefit for the elderly, a cash-transfer program for poor families, and a family health program that focuses on primary care.

The programs have provided additional benefits beyond health. The cash-transfer program for poor families, called Bolsa Familia, requires children to attend school, which has boosted school attendance, helping the nation to achieve universal primary school education.

While those programs appear to have been effective, some audience members questioned whether the cost burdens they put on government, particularly in an economic downturn, are sustainable. Mendes said that future financing will be a challenge, because she believes the government can't raise taxes further.

Eduardo Rios Neto, a professor at Brazil's Federal University of Minas Gerais, said the government programs were helped along by a period of economic growth and improvement of the labor market, and that, despite recent progress, social and income inequality in Brazil remain a major problem.

Brazil's progress doesn't mean its health challenges are over either, Mendes said. The rise of noncommunicable diseases, like heart disease, diabetes, and cancer, is a growing challenge.

"We have progressed, but we have some challenges," Mendes said.

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