Auswahl der wissenschaftlichen Literatur zum Thema „Brazil's Health System“

ABSTRACT Introduction: Several studies have reported on the epidemiology of Anterior Cruciate Ligament Reconstruction (ACLR) in Europe and North America; however, there is currently no data relating to Brazil. Objective: To describe the incidence of ACLR in Brazil and investigate temporal trends and differences between age and sex groups. Methods: All reported ACLR cases in the public hospital system between January 2008 and December 2014 were extracted from the Information Technology Department of the Brazilian Ministry of Health. Linear regression analysis was used to assess changes in ACLR incidence in the overall population and among sex and age groups, hospitalization time, and health care costs. Results: A total of 48,241 ACLR were reported from 2008-2014 with an overall incidence of 3.49 per 100,000 persons/year. Males accounted for 82% of the procedures. The incidence of ACLR increased by 56% among males (p=0.01) and by 112% among females (p=0.001). The mean hospitalization time decreased from 2.4 days in 2008 to 1.8 day in 2014 (R2 = 0.883, p= 0.002). The total cost across all years was US$56 million, with a mean of US$1,145 per ACLR. Conclusion: Although the total incidence of ACLR in Brazil is lower compared to other countries, it has increased over the years, especially in females. The creation of an ACLR registry is necessary in the future, for more accurate control and new investigations.

The Health Economic-Industrial Complex (HEIC) is recognized as a fundamental pillar for the Welfare State, essential for ensuring universal health access and reducing the vulnerability of Brazil's Unified Health System. This paper argues that the HEIC must be positioned as a key vector in the national development strategy, linking the reconstruction of Brazil's economy with social development, science, technology, innovation, and environmental sustainability. These strategies collectively work towards building a dynamic, just, and democratic Brazil. Furthermore, it presents how Brazil, under Lula Presidency, incorporated HEIC in a set of public policies aiming to strengthen the production and innovation in health to increase the Brazilian Health System resilience and increase health access to Brazilian population. Furthermore, the paper explores how the principles of the HEIC can be adapted to the BRICS context. By leveraging this model, BRICS nations can address global health disparities and enhance their capacity to produce vaccines, treatments, diagnostics, and other critical health technologies. Ultimately, this paper advocates for the bold reimagining of the HEIC as a transformative force in BRICS countries capable of driving structural changes in both national and global health landscapes, promoting a healthier, more equitable, and sustainable society.

Le système public de santé brésilien couvre plus de 150 millions de personnes sur le plus grand territoire d’Amérique du Sud, ce qui en fait l’un des plus grands systèmes universels au monde. La compréhension de ce processus peut fournir des enseignements précieux sur la manière de mettre en place un système de santé universel et décentralisé, notamment dans un pays autrefois considéré comme l’un des plus inégalitaires de la planète. Cette thèse examine le rôle des gestionnaires publics fédéraux, en particulier au sein du Ministère de la Santé, ainsi que celui des spécialistes de la santé publique, les sanitaristas, qui ont constamment œuvré au sein de l’État pour construire et consolider le Système Unique de Santé (SUS). La recherche adopte une étude de cas retraçant le parcours de l’universalisation de la santé depuis les années 1970, lorsque le processus de réforme a commencé à prendre de l’ampleur, jusqu’à la crise politique de 2016. L’approche théorique s’appuie sur les théories du changement institutionnel et sur un cadre analytique centré sur les acteurs dans l'analyse des politiques publiques, dans le contexte plus large des débats sur le développement de la protection sociale en Amérique latine. Cela remet en question (i) la vision sceptique selon laquelle des changements significatifs dans les régimes de politiques sociales sont improbables sans un large soutien politique populaire ou des mouvements sociaux de grande envergure, et (ii) l’hypothèse selon laquelle les bureaucrates progressistes sont impuissants dans des systèmes paralysés par l’inertie de l’État, le clientélisme enraciné et le patronage généralisé – caractéristiques souvent attribuées au Brésil. Cette recherche soutient au contraire que l’intervention stratégique des sanitaristas, tant avant qu’après la modification constitutionnelle de 1988, a été cruciale pour le développement de la capacité d’agir collective et de la capacité institutionnelle dans le secteur. Ces professionnels, loin d’être de simples bureaucrates, ont conçu des instruments de politique innovants pour améliorer le système, en mobilisant des ressources telles que l’expertise technique, les compétences managériales, le sens politique et des liens étroits avec la communauté de la santé publique. L’étude montre également comment les spécialistes de la santé publique se sont adaptés à des environnements politiques en mutation, en naviguant à travers la transition démocratique et trois cycles gouvernementaux distincts. En plus de contribuer à la conception de politiques qui ont façonné la décentralisation et le financement de la santé, les sanitaristas ont veillé à ce que les soins primaires demeurent l'épine dorsale du système de santé brésilien. Leurs compétences ont été essentielles pour relever les défis et soutenir l’agenda expansionniste de la réforme de la santé au fil des décennies. En soulignant leur influence sous différentes administrations, la recherche met également en lumière le rôle croissant du Ministère de la Santé dans les négociations politiques et les coalitions, notamment grâce à son contrôle sur des politiques qui touchent directement toutes les municipalités du pays
The Brazilian universal health system provides comprehensive healthcare services to over 150 million people across South America's largest territorial area, making it one of the largest in the world. Understanding how this was accomplished offers insight into the process through which a universal and decentralized health system was established in a country once labeled as the most unequal in the world. This dissertation examines the role of the federal bureaucracy within the Ministry of Health and the public health experts (sanitaristas) who have consistently operated within the state to build and consolidate the Unified Health System (SUS). To address this, the study conducts a case analysis tracing the trajectory of healthcare universalization from the 1970s – when the gradual reform process began to gain momentum – through the political crisis of 2016. Building on theories of institutional change and an agency-based framework for public policies, and set against the backdrop of discussions on welfare development in Latin America, this research challenges (i) skeptical views suggesting that significant changes in social policy regimes are unlikely without broad mass political support or large-scale social movements, and (ii) assumptions that progressive bureaucrats are powerless in systems undermined by state inertia, entrenched patronage, and pervasive clientelism, as seen in Brazil. Instead, it argues that the strategic intervention of the public health experts, both before and after the 1988 reform, was crucial in developing collective agency and institutional capacity within the sector. Far from being mere bureaucrats, they crafted innovative policy instruments to improve the system, leveraging resources such as technical expertise, managerial skill, political acumen, and strong ties to the public health community. The study also demonstrates how public health experts adapted to shifting political environments, navigating a democratic transition and three different governmental cycles. These professionals not only contributed to the design of policy instruments that shaped decentralization and health financing but also ensured that primary care remained the backbone of Brazil’s health system. Their capacities were essential for addressing challenges and sustaining the expansionist agenda of health reform over decades. By highlighting their influence across different administrations, the research also underscores the Ministry of Health's increasing importance in coalition negotiations, particularly given its oversight of policies that impact every municipality in the country
O sistema público de saúde brasileiro oferece cobertura a mais de 150 milhões de pessoas no maior território da América do Sul, o que o torna um dos maiores sistemas universais do mundo. A compreensão desse processo pode oferecer valiosos insights sobre como estabelecer um sistema de saúde universal e descentralizado, especialmente em um país outrora considerado um dos mais desiguais do planeta. Esta dissertação examina o papel da burocracia federal, especificamente no âmbito do Ministério da Saúde, e dos especialistas em saúde pública, os sanitaristas, que consistentemente atuaram dentro do Estado para construir e consolidar o Sistema Único de Saúde (SUS). A pesquisa adota um estudo de caso que traça a trajetória da universalização da saúde desde os anos 1970 – quando o processo de reforma começou a ganhar força – até a crise política de 2016. A abordagem teórica está ancorada em teorias de mudança institucional e em um arcabouço analítico centrado na agência para análise das políticas públicas, situando-se no contexto mais amplo dos debates sobre o desenvolvimento do bem-estar social na América Latina. Esta pesquisa desafia (i) visões céticas sugerindo que mudanças significativas nos regimes de políticas sociais são improváveis sem amplo apoio político de massas ou movimentos sociais em grande escala, e (ii) suposições de que burocratas progressistas são impotentes em sistemas comprometidos pela inércia estatal, pelo clientelismo enraizado e pela patronagem generalizada –características frequentemente atribuídas ao caso brasileiro. Ao contrário, a pesquisa sustenta que a intervenção estratégica dos sanitaristas, tanto antes quanto depois da mudança constitucional promovida em 1988, foi crucial para o desenvolvimento da agência coletiva e da capacidade institucional dentro do setor. Estes profissionais, longe de serem meros burocratas, elaboraram instrumentos de política inovadores para aprimorar o sistema, dispondo de recursos como expertise técnica, habilidades gerenciais, astúcia política e fortes laços com a comunidade de saúde pública. O estudo também demonstra como os especialistas em saúde pública se adaptaram a ambientes políticos em transformação, navegando pela transição democrática e por três ciclos governamentais distintos. Além de contribuir para o desenho de políticas que moldaram a descentralização e o financiamento da saúde, os sanitaristas garantiram que a atenção primária permanecesse o alicerce do sistema de saúde brasileiro. Suas capacidades foram essenciais para enfrentar desafios e sustentar a agenda expansionista da reforma da saúde ao longo de décadas. Ao destacar sua influência nas diferentes gestões governamentais, a pesquisa sublinha o crescente papel do Ministério da Saúde nas negociações políticas e de coalizão, especialmente por meio do controle sobre políticas que afetam diretamente todos os municípios do país

The central tenets of both the National Health Services of Scotland (NHS) and the Unified Health System of Brazil (SUS) are universality and equity of access to services on the basis of need, free at the point of delivery. Redistribution is designed into the Scottish system. This study uses a mixed methods approach to analyse access to health care and the influence of socioeconomic factors using hip arthroplasty as a proxy measure for equity in the public health care systems of Brazil and Scotland. Methods Three studies were conducted to establish the extent to which equity is achieved in each system and the extent to which inequalities in socioeconomic status and health service supply affect equity. First, an ecological study using routine data of hip arthroplasty rates in the public sector by country and geographic region (2009/10 to 2012/13) complemented by an analysis of supply, specifically per capita distribution of beds and staff nationally and by area. Second, inequalities in access due to socioeconomic status were analysed for Scotland using the Scottish Index of Multideprivation (SIMD) in association with standardised rates; in Brazil two socioeconomic indicators (Gini and Human Development Index - HDI) were modelled (Zero Inflated Poisson - ZIP) with standardised municipal rates of arthroplasties (5,565 municipalities); and a Pearson's correlation. Finally, qualitative interviews were undertaken in both countries with civil servants, health workers and policy makers who were invited to comment on the quantitative results from stages I and II based on a script of open ended questions. Results There is an almost eight fold difference in treatment rates between Brazil (7.8-8.3/100,000) and Scotland between 2009/10 to 2012/13 (57.7-61.1/100,000). There are geographic differences within both countries. The health board areas with the lowest and highest regional rates in Scotland were Glasgow & Clyde with rates of 29.2-40.2/100,000 and Ayrshire & Arran with a rate of 60.2-88.5/100,000 respectively; in Brazil the lowest and highest regions were the North Region (2.3-4/100,000) and South Region (15.4-17.9/100,000) respectively. The two least deprived quintiles (4 and 5) in the Scottish population had both a higher utilisation (42.6%) and proportional growth in number of procedures than the two more deprived (1 and 2); quintile 3 had no consistent changes. In Brazil municipal rates showed a negative correlation with Gini (r=- .226) and a positive correlation with HDI (r=.396); the ZIP model demonstrated that for every standard deviation (SD) change in Gini, rates would be 23% higher or lower, for HDI each SD would lower or increase rates by 56%. Three major areas were identified by interviewees as explanatory factors for these quantitative results: equity of access, health systems, evidence based actions/policies. Crucially the interviewees identified GDP spend on public health care, the ability of governments to redistribute and reallocate resources on the basis of need and the distorting effect of the market and private providers including physicians as key factors; and the need for better data collection from the private sector. Conclusion Although both countries aspire to universal health care, Brazil is very far from reaching that goal due to the widespread socioeconomic differences and that the health system does not redistribute resources, staff and beds according to need. Scotland appears to be achieving universal access on the basis of need, nevertheless there are geographic and socioeconomic differences in access that need to be carefully monitored and understood. In Brazil there should be better planning and resource allocation so that public resources are redirected towards those most in need of the North and Northeast regions.

O Sistema de InformaÃÃo Hospitalar do SUS (SIH/SUS) cobre a produÃÃo hospitalar de todos os serviÃos financiados pelo setor pÃblico no paÃs, constituindo uma fonte de dados extremamente relevante para estudos epidemiolÃgicos, sendo ainda, a Ãnica fonte de dados de internaÃÃo hospitalar no Brasil. A utilizaÃÃo de dados de morbidade torna-se cada vez mais importante como indicador do nÃvel de saÃde da populaÃÃo. Com o objetivo de caracterizar os padrÃes de morbidade hospitalar na rede do Sistema Ãnico de SaÃde (SUS), foram analisadas as internaÃÃes realizadas em hospitais pÃblicos e privados conveniados ao SUS, no municÃpio de Fortaleza, capital do estado do CearÃ, no perÃodo de 2001 a 2005, segundo as variÃveis: sexo, idade, diagnÃstico principal de internaÃÃo, segundo os capÃtulos da ClassificaÃÃo EstatÃstica Internacional de DoenÃas e Problemas relacionados à SaÃde (CID-10), e ano de internaÃÃo. Foram calculados coeficientes e proporÃÃes de internaÃÃo por sexo e faixa etÃria, proporÃÃes e Ãndice de dissimilitude (ID) de internaÃÃo por esfera administrativa e grupos diagnÃsticos. Para o cÃlculo de coeficientes aproximou-se o nÃmero de internaÃÃes ao nÃmero de pacientes, por meio da aplicaÃÃo de algoritmo proposto em estudo anterior, obtendo-se uma reduÃÃo de 5,42% no nÃmero de eventos, no perÃodo. Realizada distribuiÃÃo espacial dos coeficientes de internaÃÃo, utilizando o software GeoDA versÃo 0.9.5-1(BETA). Os hospitais pÃblicos responderam por 53% das internaÃÃes, com mÃdia de 83.539 hospitalizaÃÃes e a rede contratada conveniada por 46,2% das mesmas, com mÃdia de 72.923 atendimentos. Hospitais localizados no interior do estado foram responsÃveis por 0,8% das hospitalizaÃÃes de residentes no municÃpio de Fortaleza. A assistÃncia hospitalar pÃblica nÃo atingiu o parÃmetro de 8 a 10% da populaÃÃo/ano, permanecendo com uma mÃdia de 7%. O coeficiente geral de internaÃÃo passou de 70,7 internaÃÃes por mil habitantes, para 68,7 internaÃÃes por mil habitantes ao final. ExcluÃdas as internaÃÃes pelos capÃtulos XV. Gravidez, parto e puerpÃrio, as do capÃtulo XX. Causas externas de morbidade e de mortalidade (diagnÃstico secundÃrio), e XXI, Fatores que influenciam o estado de saÃde e o contato com os serviÃos de saÃde, os coeficientes de morbidade hospitalar variaram de 48,6/1000 habitantes, em 2001, para 51,3 internaÃÃes/1000 habitantes, em 2005, com variaÃÃo de 5,6%, menor que o crescimento populacional. Os principais diagnÃsticos, por ordem de grandeza de suas proporÃÃes, excetuado as internaÃÃes por complicaÃÃes da gravidez, parto e puerpÃrio foram: doenÃas do aparelho respiratÃrio, algumas doenÃas infecciosas e parasitÃrias, lesÃes, envenenamentos e algumas outras conseqÃÃncias de causas externas, doenÃas do aparelho digestivo, doenÃas do aparelho circulatÃrio e Neoplasias [tumores]. A distribuiÃÃo espacial das internaÃÃes, segundo o bairro apresentou pequenas variaÃÃes no tocante ao coeficiente de internaÃÃo/1000 habitantes.
O Sistema de InformaÃÃo Hospitalar do SUS (SIH/SUS) cobre a produÃÃo hospitalar de todos os serviÃos financiados pelo setor pÃblico no paÃs, constituindo uma fonte de dados extremamente relevante para estudos epidemiolÃgicos, sendo ainda, a Ãnica fonte de dados de internaÃÃo hospitalar no Brasil. A utilizaÃÃo de dados de morbidade torna-se cada vez mais importante como indicador do nÃvel de saÃde da populaÃÃo. Com o objetivo de caracterizar os padrÃes de morbidade hospitalar na rede do Sistema Ãnico de SaÃde (SUS), foram analisadas as internaÃÃes realizadas em hospitais pÃblicos e privados conveniados ao SUS, no municÃpio de Fortaleza, capital do estado do CearÃ, no perÃodo de 2001 a 2005, segundo as variÃveis: sexo, idade, diagnÃstico principal de internaÃÃo, segundo os capÃtulos da ClassificaÃÃo EstatÃstica Internacional de DoenÃas e Problemas relacionados à SaÃde (CID-10), e ano de internaÃÃo. Foram calculados coeficientes e proporÃÃes de internaÃÃo por sexo e faixa etÃria, proporÃÃes e Ãndice de dissimilitude (ID) de internaÃÃo por esfera administrativa e grupos diagnÃsticos. Para o cÃlculo de coeficientes aproximou-se o nÃmero de internaÃÃes ao nÃmero de pacientes, por meio da aplicaÃÃo de algoritmo proposto em estudo anterior, obtendo-se uma reduÃÃo de 5,42% no nÃmero de eventos, no perÃodo. Realizada distribuiÃÃo espacial dos coeficientes de internaÃÃo, utilizando o software GeoDA versÃo 0.9.5-1(BETA). Os hospitais pÃblicos responderam por 53% das internaÃÃes, com mÃdia de 83.539 hospitalizaÃÃes e a rede contratada conveniada por 46,2% das mesmas, com mÃdia de 72.923 atendimentos. Hospitais localizados no interior do estado foram responsÃveis por 0,8% das hospitalizaÃÃes de residentes no municÃpio de Fortaleza. A assistÃncia hospitalar pÃblica nÃo atingiu o parÃmetro de 8 a 10% da populaÃÃo/ano, permanecendo com uma mÃdia de 7%. O coeficiente geral de internaÃÃo passou de 70,7 internaÃÃes por mil habitantes, para 68,7 internaÃÃes por mil habitantes ao final. ExcluÃdas as internaÃÃes pelos capÃtulos XV. Gravidez, parto e puerpÃrio, as do capÃtulo XX. Causas externas de morbidade e de mortalidade (diagnÃstico secundÃrio), e XXI, Fatores que influenciam o estado de saÃde e o contato com os serviÃos de saÃde, os coeficientes de morbidade hospitalar variaram de 48,6/1000 habitantes, em 2001, para 51,3 internaÃÃes/1000 habitantes, em 2005, com variaÃÃo de 5,6%, menor que o crescimento populacional. Os principais diagnÃsticos, por ordem de grandeza de suas proporÃÃes, excetuado as internaÃÃes por complicaÃÃes da gravidez, parto e puerpÃrio foram: doenÃas do aparelho respiratÃrio, algumas doenÃas infecciosas e parasitÃrias, lesÃes, envenenamentos e algumas outras conseqÃÃncias de causas externas, doenÃas do aparelho digestivo, doenÃas do aparelho circulatÃrio e Neoplasias [tumores]. A distribuiÃÃo espacial das internaÃÃes, segundo o bairro apresentou pequenas variaÃÃes no tocante ao coeficiente de internaÃÃo/1000 habitantes.

Background and objectives. Studies and international agencies’ policy documents, while acknowledging the potential of Community Health Worker (CHW) programs in improving reproductive maternal newborn and child health (RMNCH) outcomes, underline the scarcity of strong evidence of effectiveness and solicit more in-depth investigations on the implementation process of such programs. Recent developments about how to improve service quality in RMNCH emphasize the need of a system approach, according to which any attempt to evaluate and improve the overall system, or part of it, should take into account the overall complexity and interdependency across actors and components. Moving from the intersection between the current debate on CHWs, the emphasis on quality improvement and system approaches to health systems, the research is aimed at developing analytical and policy tools that may be used to improve the performance of CHWs in Brazil, a country whose CHW program is considered among the most valuable models globally. Methods. A three step process has been envisaged. The first step, through a systematic review of qualitative studies conducted in Brazil on CHWs and building on concepts driven from the international literature, develops a logic model to describe factors influencing CHWs’ performance in Brazil and their underlying mechanisms. The second step, moving from a case study built around the impact evaluation of an intervention trial targeting CHWs in the city of Recife and aimed at supporting quality home visits to pregnant women and mothers, is aimed at providing further insights on barriers and facilitators to interventions designed to improve CHWs’ performance, and at further validating the model. The third step uses the logic model to identify and systematize policy options, contextualized to the Brazilian system, to improve the performance of CHWs across all their attributions and tasks as well as in a specific area such as RMNCH. Results. The systematic review, confirming the findings of international literature, showed that, although the main factors influencing CHWs’ performance reside in the formal health system components and in the sub-system elements of the CHW program, the community system is a powerful source of complex interactions that may act either as facilitators or as barriers of CHWs’ performance. A logic model was developed to facilitate the identification, analysis and visualization of these factors and their dynamics. The case study confirmed the validity of the model for analyzing and interpreting the results of the intervention and, by explaining the reasons for its partial failure, provided hints about how interventions and policies aimed at improving CHWs’ performances should be conceived. Using the model as the reference framework, policy options were systematized according to the health and community system components and proposed as a comprehensive compendium and as policy packages according to the various levels of responsibility regarding CHW program in the Brazilian health system. A model for prioritization criteria was also proposed. Conclusions. The analytical and policy tools that were developed may be useful for a more systematic and evidence-based approach to improving the performance of CHWs in Brazil. The systematization of influencers of CHWs’ performance and their mediators can be used to describe the institutional and stakeholders’ response to CHW program. The logical model, populated with institutional and behavioral facilitators and barriers, can serve to identify areas that requires action for program strengthening. The policy compendium can facilitate, at various levels of the system, the development and prioritization of policy packages aimed at improving RMNCH-related tasks of CHWs in a broader systemic perspective, recognizing that most factors influencing specific tasks of CHWs are cross-cutting and need to be addressed as such.

Orientador: Eduardo Fagnani
Dissertação (mestrado) - Universidade Estadual de Campinas, Instituto de Economia
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Resumo: Esta dissertação tem por objetivo delinear as relações entre os setores público e privado no que diz respeito à assistência à saúde no Brasil, destacando que os avanços formais da Constituição Federal de 1988 foram sobrepostos por um contexto político e econômico hostil que se abre a partir de 1990, que limitou o fortalecimento do setor público em favor da contínua expansão do setor privado. Este trabalho está dividido em duas partes, a primeira destaca os determinantes históricos e as relações entre Estado e mercado na saúde no período anterior à Constituição de 1988. Sublinha a forte predominância do setor privado no país desde os primórdios da formação do sistema de saúde brasileiro num contexto marcado pelo vigoroso viés conservador da sociedade e suas rígidas estruturas de um capitalismo tardio e dependente, marcado pela segregação social e dependência externa. Ressalta-se também o movimento de modernização conservadora dos bens e serviços públicos durante os 21 anos de governo militar, bem como os avanços sociais da Constituição de 1988. Na segunda parte discute-se a introdução do neoliberalismo no Brasil a partir dos anos de 1990, após ganhar força nos países centrais e subdesenvolvidos durante as décadas de 1970 e 1980. O trabalho sublinha o antagonismo desta corrente com os princípios do Sistema Unico de Saúde recém-implantado em 1988, com destaque para as diretrizes e orientações políticas do Banco Mundial no incentivo à expansão da iniciativa privada na oferta de serviços de saúde. Esse movimento político e econômico mais amplo era antagônico aos princípios estabelecidos pela Carta de 1988 e contribuíram, em grande medida, para que o processo de consolidação do SUS fosse permeado por diversas contramarchas que abriram novas brechas para a expansão do setor privado na saúde
Abstract: This paper aims to outline the relationships between the public and private sectors in health care on Brazil, noting that the formal advances of the Federal Constitution of 1988 were superimposed by a hostile political and economic context that was imposed in the 90's, that limited the strength of the public sector in favor of continued expansion of the private sector. This work is divided into two parts, the first shows the historical determinants and the relationship between state and market in health in the period prior to the 1988 Constitution. This part underlines the strong predominance of the private sector in the country since the beginning of formation of the Brazilian health system in a context characterized by strong conservative bias of society and its rigid structures of late and dependent capitalism. Also points up the conservative modernization movement of goods and public services during the 21 years of military government and the social advances of the 1988 Constitution. The second part discusses the introduction of neoliberalism in Brazil from the 90's, after gaining strength in the central and developing countries during the 70's and 80's. This work emphasizes the antagonism of this current with the principles of the Unified Health System (SUS) recently implemented in 1988, highlighting the guidelines and political directives of the World Bank encouraging the expansion of the private sector in the supply of health services. This broader political and economic movement was antagonic to the principles established by the 1988 constitution and contributed largely to the SUS consolidation process was impeded by several setbacks that have opened new spaces for the expansion of the private sector in health
Mestrado
Economia Social e do Trabalho
Mestra em Desenvolvimento Econômico

Orientador: Sergio Resende Carvalho
Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas
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Resumo: Este trabalho procura analisar as Redes de Atenção à Saúde do ponto de vista da sua constituição. Tomando o método da Cartografia, tal como proposto por Gilles Deleuze & Félix Guattari, busca nas linhas de força, que vão dando forma tanto aos seus processos organizativos quanto às suas funções existenciais, os regimes aos quais, cada um a seu modo, se envolve a este fluxo de acontecimentos. Apoiando-se no conceitos de Implicação e o aproximando aos da filosofia da pragmática, toma-se esta ligação à Rede de Atenção à Saúde como envolvimento no Agenciamento Coletivo. O texto procura analisar a evolução dos processos de constituição das Redes de Atenção à Saúde, observando seu componente mais tradicional - o Hospital - desde a antiguidade até a organização atual, identifica seus arranjos físicos e também seus enunciados próprios, depreendendo daí os regimes que constituem os Agenciamentos que dão conta destes complexos. A análise destes regimes, tanto enunciativos como físicos, nos permite entender a ligação que cada elemento desta rede faz com um outro constituinte
Abstract: This work analyzes the Networks of Health Care in terms of its constitution. Taking the method of cartography, as proposed by Gilles Deleuze & Félix Guattari, search the lines of force, ranging shaping both their organizational processes and functions to their existential, s schemes to which, each in its own way, if this involves the flow of events. Relying on the concepts of No Involvement and closer to the philosophy of pragmatic one takes this connection to the Network for Health Care and involvement in collective agency. The paper seeks to analyze the changes in the constitution of the Network for Health Care, noting its more traditional component - the hospital - from antiquity to the present organization, identify their physical arrangements as well as their own statements, it appears that there are schemes the assemblages that account for these complexes. The analysis of these schemes, both are listed as people, helps us understand the connection that each element of the network makes with another constituent
Mestrado
Saude Coletiva
Mestre em Saude Coletiva

This book has examined some of the key issues shaping efforts to achieve gender and racial health equity in Brazil. While Brazil continues to face a number of challenges in fully achieving health equity, it is important to recognize areas in which substantial progress has been achieved. During the 1990s, Brazil’s public health policies and the establishment of the Unified Health System (SUS) placed the country far ahead of many of its Latin American neighbors, as well as more economically developed countries, such as the United States. In addition, Brazil’s pioneering HIV/AIDS prevention and treatment initiatives and notable successes in curbing the HIV/AIDS epidemic have served as important models globally....

This book identifies 2 polarising concepts used by Brazilian mainstream sociology to explain the formation and identity of Brazil as a society: corruption and human rights. As the 1988 Constitution is a milestone in the Brazilian transition to democracy and part of a broader movement of Brazil's integration into international law, the impact of international legal regimes on the attainment of human rights and the fight against corruption is analysed to evaluate the state of Brazilian democracy. The book examines the outcomes of 4 specific international human rights regimes in Brazil, involving rights and policies related to: – the right to food, the fight against hunger, and conditional cash transfer programmes; – the right to health and the public healthcare system; – the right to racial equality and affirmative action in superior education; and – the right to recognition and the protection of Indigenous populations. This approach is then applied to the examination of the international anti-corruption agenda. It focuses on Brazil’s determination to deal with corruption against the backdrop of its worst democratic crisis of the last 35 years using meticulously researched case studies on the most prominent investigations, includingMensalãoandLava Jato (Car Wash). The book traces back to the origins of the international anti-corruption agenda and key legitimising efforts aimed at aligning the discourses with the developmental, good-governance trends, and delves into its repercussions within the Brazilian context, with a glance at their collateral effects in other parts of the world. Thus, the core focus of the work revolves around human rights and the fight against corruption, shedding light on how democracy evolves or recedes over time under their influence.

AbstractThis chapter identifies the overall trends in Japan’s official development assistance (ODA) policies for the health sector in developing countries from 1990 to 2020 and its future post-COVID-19 prospects. Since the end of the Cold War, watershed events have repeatedly changed the landscape of international cooperation in the health sector. Like other international aid donors, Japan has devised priorities and strategies for ODA based on a set of international and domestic factors in a constantly changing world. Numerous studies on Japan’s ODA have examined international and domestic factors that impact the formulation of the country’s aid policy. This chapter aims to add to those studies by combining recent debates on international cooperation and foreign aid, the right to health, and world health system reforms to explore and analyze Japan’s ODA for health in developing countries. The guiding research questions were as follows: What were the major trends in Japan’s ODA policies in the health sector from 1990 to 2020? Which international health debates and international cooperation factors exerted influence on those trends? What are the prospects of Japan’s ODA given the COVID-19 pandemic and its impacts? The research relied on primary sources, specifically Japan’s ODA official documents and the Organization for Economic Cooperation and Development’s (OECD) ODA quantitative databases, as well as secondary sources, such as academic literature on international cooperation and foreign aid for health. Our preliminary findings revealed that Japan’s ODA in the health sector from 1990 to 2020 centered on two main axes: infectious diseases and maternal and child health, both of which are oriented toward strengthening the healthcare system. Given this goal, it seems relevant to consider that Japan’s health system is based on the assumption of the need to provide universal health coverage, a concept currently supported by the World Health Organization (WHO), in contrast to the universal health system, and that the implications of this choice on Japan’s ODA and developing countries’ health policies are yet to be fully understood. The COVID-19 pandemic has put substantial pressure on health systems globally and international cooperation for health; thus, it has the potential to affect and even change Japan’s ODA for the health sector in developing countries.

AbstractMaternal health care continues to be excessively medicalised in many national health systems. Global, national, and local level policy initiatives seek to normalise low-risk birth and optimise the use of clinical interventions, informed by strong evidence supporting care that is centred on women’s preferences and needs. Challenges remain in translating evidence into practice in settings where care is primarily clinician-led and hospital-based, such as in Brazil.I conducted an ethnography of the movement for humanised care in childbirth in São Paulo between 2015 and 2018. I draw on interviews and focus groups with movement members (including mothers, doulas, midwives, obstetricians, politicians, programme leads, and researchers), and observations in health facilities implementing humanised protocols, state health council meetings, and key policy fora (including conferences, campaigning events, and social media). Key actors in this movement have been involved in the development and implementation of evidence-based policy programmes to “humanise” childbirth. Scientific evidence is used strategically alongside rights-based language, such as “obstetric violence”, to legitimise moral and ideological aims. When faced with resistance from pro-c-section doctors, movement members make use of other strategies to improve access to quality care, such as stimulating demand for humanised birth in the private health sector. In Brazil, this has led to a greater public awareness of the risks of the excessive medicalisation of birth but can reinforce existing inequalities in access to high-quality maternity care. Lessons might be drawn that have wider relevance in settings where policymakers are trying to reduce iatrogenic harm from unnecessary interventions in childbirth and for supporters of normal birth working to reduce barriers to access to midwifery-led, woman-centred care.

This paper presents OntoDrug, an ontology designed to enhance medicine management in Brazil by integrating regulatory frameworks and standardizing terminologies. OntoDrug improves patient safety and treatment efficacy by accurately identifying and classifying medications and supporting interoperability with health information systems. A proof-of-concept application integrated into the Hospital das Clínicas de Marília’s hospital EHR system demonstrated OntoDrug’s utility, achieving high precision and recall. An experimental study using large language models grounded on the ontology achieved, using GPT-4 turbo, 0.97 precision, 1.0 recall and an F1-score of 0.99. We also evaluated open-source models llama3-8b, llama3-70b, and gemma-7b-it. Their performance was close to GPT-4’s. The significant effectiveness is primarily due to the utilization of large language models (LLMs). While using these large language models enhanced performance, challenges related to cost, privacy, and service availability were identified. OntoDrug represents a significant advancement in Brazil’s medication information standardization and optimization.

Abstract Health System (SUS) obtains from some policies that aim to ensure the best health condition for the population. In this perspective, when analyzing women in penitentiary situations, they tend to suffer from more injuries and in a certain way a vulnerability in their health due to the proportions to which they are submitted.

Brazil has seen an increase in the elderly population as a result of falling mortality rates. Associated with the ageing process, there is an increased risk of developing comorbidities, which is why the health system has found it difficult to keep up with the rapid demographic transition and support this more fragile section of the population. The aim of this study was to describe the epidemiological aspects of hospitalization of the elderly in Brazil. This is a retrospective epidemiological study, with a quantitative approach, which used data from the Hospital Information System and the Unified Health System, made available by the Department of Informatics of the Unified Health System, for the period 2019 to 2023. The variables analyzed were: type of care, gender, race, reason for hospitalization, cause of death and region with the highest incidence. 16,779,162 elderly people were admitted to hospital units: 78% (n= 16,069,729) were admitted as emergencies. Of these individuals, 51% (n= 8,595,199) were male and 41% (n= 6,892,500) were white. Initially, 21% (n= 3,485,803) were hospitalized for diseases related to the circulatory system, but the main cause of death was pneumonia, which accounted for 7% (n= 1,195,048) of these patients, and was most prevalent in the southeast region with 508,696 deaths. Hospitalizations of the elderly in Brazil are on the increase, considering epidemiological characteristics, a reduction in the number of investments in the elderly and the number of deaths. The main related diseases are those affecting the cardiovascular and respiratory systems, accounting for almost half of the deaths in this age group. The increase in the number of hospitalizations demonstrates the need to formulate public policies to improve the quality of life of the elderly population.

The study aims to analyze the working conditions of health professionals of Basic Health Units (BHU) of Fortaleza, Ceará, Brazil. BHUs are primary health care units that are the front door of the national public health system. The research analyzes working conditions of primary care auxiliary and/or technicians and their perceptions regarding working conditions and harassment. It is a cross-sectional survey of exploratory nature, using quantitative and qualitative methods. 120 mid-educational level background workers answered a questionnaire containing socio-economic information; an occupational stressors scale and the Negative Acts Questionnaire (NAQ). Nine technicians and auxiliaries participated in individual interviews. Observations of workplaces were also done. 2.5% of participants declared to have suffered workplace harassment. However, 11.7% reported negative acts towards them, weekly or daily in the last six months. The participants perceive their working conditions as precarious. They report employment instability, lack of equipment, low salaries, and long working journeys. They appear to worry about exercising their activities with prejudice to the services’ quality and to their health. The study points to the need for actions that bring egalitarian conditions in terms of employment to this category of workers, better working conditions, and financial and social recognition.

The lack of semantic information is a big challenge, even in context-driven areas like Healthcare, characterized by established terminologies. Here, semantic data integration is the solution to provide precise information and answers to questions like: What is the care pathway of newborns diagnosed with a congenital anomaly in consequence of congenital syphilis in the city of Sao Paulo? This project will use a semantic data integration technique, ontology based data integration, to integrate three health databases from the city of Sao Paulo - Brazil: mortality, live births and hospital information system. It is expected that the integration of public health databases will help to map patient care pathways, predict public resource needs and minimize unnecessary spending.

Objective: This study evaluated the number of breast reconstructive surgeries performed in the SUS, in the period from January 2019 to January 2023, making a comparative analysis between mastectomies and breast reconstructions performed in the same period, in addition to observing the impact of the COVID-19 pandemic on a possible reduction in the number of breast reconstructive surgeries in the SUS after the year 2020. Methodology: It is a retrospective, cross-sectional, and descriptive study of available records of Health Centers linked to the Unified Health System, including data collection regarding the number of mastectomies and reconstructive breast surgeries performed in Brazil. Data were extracted from DATASUS. Results: In the period observed, 13,609 breast reconstruction surgeries after mastectomy with breast implants were recorded; 59,325 were non-aesthetic female breast plastic surgeries and 54 were bilateral reconstructive breast plastic surgeries, including bilateral silicone breast implants and silicone breast implants. There were also 288,599 radical mastectomies with axillary lymphadenectomy in oncology; 24,591 radical mastectomies with lymphadenectomy and 50,524 simple mastectomies in oncology; and 17,119 simple mastectomies. Therefore, we found a total of 380,833 radical breast oncological surgeries. When we take into account the year in which the procedures were performed, we noticed a trend toward a lower number of surgeries between the years 2020 and 2021, which may be related to the period of the COVID-19 pandemic. In 2019, 103,802 radical breast surgeries were performed with 20,312 reconstructive surgeries in total, while in 2020 and 2021, 89,958 and 86,085 mastectomies were performed, with 13,730 and 15,389 reconstructive surgeries, respectively. Conclusion: We found a rate of 19% of reconstructive surgeries in relation to radical surgeries for breast cancer, which corroborates data from the national literature. We believe that better training of surgeons who provide care in the SUS, as well as a better subdivision of medical teams, forming groups responsible only for reconstructive surgeries, can increase the number of immediate reconstructions, without jeopardizing the treatment of less aggressive cases with surgery of less complexity.

Spread across Brazil and attaining an unparalleled political force, therapeutic communities are as inescapable in the debate on drug policy as they are complex to define. Although they are not a Brazilian creation, they have been operating in that country for decades, and their dissemination intensified in the 1990s. In 2011, they were officially incorporated into Brazil's Psychosocial Care Network (Rede de Atenção Psicossocial, or RAPS). Since then, therapeutic communities have been at the center of public debates about their regulation; about how they should—or even if they should—be a part of the healthcare system; about the level of supervision to which they should be submitted; about their sources of funding, particularly whether or not they should have access to public funding; and, most importantly, about the quality of the services they offer and the many reports of rights violation that have been made public. However, a well-informed public debate can only flourish if the available information is based on sound evidence. The SSRC’s Drugs, Security and Democracy Program is concerned with the policy relevance of the research projects it supports, and the debate around therapeutic communities in Brazil points to a clear need for impartial research that addresses different cross-cutting aspects of this topic in its various dimensions: legal, regulatory, health, and observance of human rights, among others. It is in this context that we publish this working paper series on therapeutic communities in Brazil. The eight articles that compose this series offer a multidisciplinary view of the topic, expanding and deepening the existing literature and offering powerful contributions to a substantive analysis of therapeutic communities as instruments of public policy. Although they can be read separately, it is as a whole that the strength of the eight articles that make up this series becomes more evident. Even though they offer different perspectives, they are complementary works in—and already essential for—delineating and understanding the phenomenon of therapeutic communities in Brazil.

This technical note presents a comparative analysis of Latin America's fragmented health systems. It provides a detailed account of health system fragmentation along six dimensions (organizations, risk pooling, eligibility, benefits, premium/contributions, payments) and the effects of historical reforms in Costa Rica, Colombia, Ecuador, Brazil, Mexico, and Chile, as well as examples of successful integration in Spain and Turkey. Additionally, it offers a set of policy options for promoting the integration of health systems and a series of practical steps for implementing health system reforms. It concludes that analyzing the fragmentation of various dimensions of health systems can be useful for developing policy, but further research is needed to determine the effect of fragmentation on health system performance.

This brief aims to provide an analysis of the Brazilian response to the COVID-19 pandemic regarding transnational migrants and to look forward on how to build epi/pandemic preparedness in a way that is considerate of migrants’ rights, cultures and political demands. Building on Leach et al., the objective of this brief is ‘to rethink preparedness more fundamentally as a dynamic social, cultural and political process’ and to shed light on how the country’s response to the pandemic failed to be inclusive. This brief details key policy and operational considerations for the Brazilian Unified Healthcare System (Sistema Único de Saúde, SUS) policymakers, health managers and public health authorities. It draws on ethnographic research from the main author’s doctoral research on the impact of the COVID-19 on racialised migrant and refugee communities in Brazil, on other academic and grey literature on the topic, and on guidelines and proposals for SUS produced in consultation processes organised by civil society.

This paper discusses Brazil's structural reforms since the 1990s and areas where work remains to be done. Reforms of the 1990s included the containment of inflation, the adoption of a comprehensive Fiscal Responsibility Law, a successful debt restructuring program for subnational governments, the reduction of trade barriers, a wave of privatizations, and the expansion of health and education programs. Reforms of the 2000s included strengthening welfare programs, rapidly increasing the minimum wage, and reforming the financial sector to increase access to credit among lower income groups. Political opposition and other factors, however, have prevented reforms in the tax and pension systems and in the labor market. Brazil's recent strong economic performance owes more to generally sound macroeconomic management, and to a favorable external environment, than to a comprehensive and sustained structural reform effort. Doubts remain about the country's ability to sustain high growth rates while keeping inflation low.

Hospitals are a critical component of health systems. This technical note proposes a policy-oriented framework for measuring hospital performance and provides a short list of indicators related to the efficiency and quality of hospital care in Latin America and the Caribbean. The note draws on international and country-specific experiences, including those of Brazil, Mexico, the OECD, the United Kingdoms National Health Service, and the United Statess Medicare program. The proposed indicators are feasible and relevant, and the list can be used immediately to inform hospital performance measurement efforts in the region.

In early 2020, once the severity was recognized on a global scale, the COVID-19 pandemic quickly became the most immediately pressing crisis. In addition to the general demands the pandemic created for strong and competent national and international response, it also raised numerous issues and generated tensions around the sharing of responsibilities and resources among levels of governments in many countries around the world. A number of comparable health and economic issues have emerged fairly universally, but they have manifested in different ways and the responses and results have been diverse across and within countries. This monograph summarizes available information about how the pandemic has affected fiscal decentralization around the world, focusing on five Latin American countries: Argentina, Brazil, Colombia, Mexico, and Peru. It briefly characterizes the intergovernmental fiscal systems in these countries, provides an overview of the known impacts of the pandemic and summarizes available information on government responses to the pandemic, both national and those undertaken by subnational governments with national support or more independently. The conclusions draw lessons from regional and global experiences about if and how post-pandemic policies might be developed to improve the intergovernmental fiscal system in particular countries.

Population aging and the growing burden of chronic disease are causing many countries to explore new options as they reorganize their health systems from acute care toward increased chronic care provision. There are several modalities to deliver recuperative intermediate care at a level between the hospital and primary care, but some patients will require a bed-based solution. For these individuals, inpatient non-acute facilities may provide superior outcomes at a lower cost than traditional care on a hospital ward. The international literature regarding this type of service reveals positive findings on provider and patient satisfaction, clinical outcomes, and cost-effectiveness. However, to achieve the best possible results, providers must establish and apply appropriate procedures for the identification of eligible patients, exercise rigorous protocols during their transfer, and ensure their comprehensive assessment and adhesion to a therapeutic plan managed by a multidisciplinary team. For developing countries considering the formulation of policies to promote the implementation of intermediate care facilities, Brazil's recent experience may offer a point of reference and some guidance, especially in terms of reconditioning small community hospitals with excess capacity for this purpose.

This report, commissioned by Bloomberg Philanthropies, finds that 42,000 lives could be saved and 150,000 serious injuries prevented by 2030 if all new cars in seven G20 countries were required to be equipped with an inexpensive crash avoidance technology starting in 2020. Thirteen G20 counties currently adhere to United Nations regulations on electronic stability control (ESC). If the seven remaining countries—Argentina, Brazil, China, India, Indonesia, Mexico and South Africa—also mandated ESC in 2020, the report estimates $21.5 billion in economic benefit to those countries from the prevention of deaths and serious injuries. Argentina and Brazil are due to start applying ESC regulations in 2020. The UK-based Transport Research Laboratory (TRL) conducted the independent study of costs and benefits of applying ESC regulation in G20 countries, which are responsible for 98% of the world’s passenger car production. This report comes before the 3rd Ministerial Conference on Road Safety in Stockholm, which is the largest gathering of governments and is a key opportunity for adoption of this UN-recommended standard. According to the World Health Organization’s Global Road Safety Report, the number of road traffic deaths reached 1.35 million in 2016. Of all vehicle safety features, electronic stability control is regarded as the most important one for crash avoidance since it is 38% effective in reducing the number of deaths in loss-of-control collisions. ESC tries to prevent skidding and loss of control in cases of over-steering and under-steering. The technology continuously monitors a vehicle’s direction of travel, steering wheel angle and the speed at which the individual wheels are rotating. If there is a mismatch between the intended direction of travel and the actual direction of travel, as indicated by the steering wheel position, ESC will selectively apply the brakes and modulate the engine power to keep the vehicle traveling along the intended path. The cost of implementing ESC on vehicles that already contain anti-lock braking systems is thought to be as little as $50 per car. And the report finds the benefits are significant: For every dollar spent by consumers in purchasing vehicles with these technologies, there is a US$2.80 return in economic benefit to society because of the deaths and serious injuries avoided. The analysis warns that without regulation of ESC, the seven remaining G20 countries will only reach 44% installation of ESC by 2030. However, if all seven countries implemented ESC regulations this year, 85% of the total car fleet in G20 countries will have ESC by 2030, a figure still below the United Nations target of 100% ESC fleet coverage by 2030.

Under the United Nations Charter, the U.N. Security Council has several important functions and powers, not least with regard to taking binding actions to maintain international peace and security. The ten elected members have the opportunity to influence this area and others during their two-year terms on the Council. In this paper, we aim to illustrate some of these opportunities, identify potential guidance from prior elected members’ experiences, and outline the key procedures that incoming elected members should be aware of as they prepare to join the Council. In doing so, we seek in part to summarize the current state of scholarship and policy analysis in an effort to make this material more accessible to States and, particularly, to States’ legal advisers. We drafted this paper with a view towards States that have been elected and are preparing to join the Council, as well as for those States that are considering bidding for a seat on the Council. As a starting point, it may be warranted to dedicate resources for personnel at home in the capital and at the Mission in New York to become deeply familiar with the language, structure, and content of the relevant provisions of the U.N. Charter. That is because it is through those provisions that Council members engage in the diverse forms of political contestation and cooperation at the center of the Council’s work. In both the Charter itself and the Council’s practices and procedures, there are structural impediments that may hinder the influence of elected members on the Security Council. These include the permanent members’ veto power over decisions on matters not characterized as procedural and the short preparation time for newly elected members. Nevertheless, elected members have found creative ways to have an impact. Many of the Council’s “procedures” — such as the “penholder” system for drafting resolutions — are informal practices that can be navigated by resourceful and well-prepared elected members. Mechanisms through which elected members can exert influence include the following: Drafting resolutions; Drafting Presidential Statements, which might serve as a prelude to future resolutions; Drafting Notes by the President, which can be used, among other things, to change Council working methods; Chairing subsidiary bodies, such as sanctions committees; Chairing the Presidency; Introducing new substantive topics onto the Council’s agenda; and Undertaking “Arria-formula” meetings, which allow for broader participation from outside the Council. Case studies help illustrate the types and degrees of impact that elected members can have through their own initiative. Examples include the following undertakings: Canada’s emphasis in 1999–2000 on civilian protection, which led to numerous resolutions and the establishment of civilian protection as a topic on which the Council remains “seized” and continues to have regular debates; Belgium’s effort in 2007 to clarify the Council’s strategy around addressing natural resources and armed conflict, which resulted in a Presidential Statement; Australia’s efforts in 2014 resulting in the placing of the North Korean human rights situation on the Council’s agenda for the first time; and Brazil’s “Responsibility while Protecting” 2011 concept note, which helped shape debate around the Responsibility to Protect concept. Elected members have also influenced Council processes by working together in diverse coalitions. Examples include the following instances: Egypt, Japan, New Zealand, Spain, and Uruguay drafted a resolution that was adopted in 2016 on the protection of health-care workers in armed conflict; Cote d’Ivoire, Kuwait, the Netherlands, and Sweden drafted a resolution that was adopted in 2018 condemning the use of famine as an instrument of warfare; Malaysia, New Zealand, Senegal, and Venezuela tabled a 2016 resolution, which was ultimately adopted, condemning Israeli settlements in Palestinian territory; and A group of successive elected members helped reform the process around the imposition of sanctions against al-Qaeda and associated entities (later including the Islamic State of Iraq and the Levant), including by establishing an Ombudsperson. Past elected members’ experiences may offer some specific pieces of guidance for new members preparing to take their seats on the Council. For example, prospective, new, and current members might seek to take the following measures: Increase the size of and support for the staff of the Mission to the U.N., both in New York and in home capitals; Deploy high-level officials to help gain support for initiatives; Partner with members of the P5 who are the informal “penholder” on certain topics, as this may offer more opportunities to draft resolutions; Build support for initiatives from U.N. Member States that do not currently sit on the Council; and Leave enough time to see initiatives through to completion and continue to follow up after leaving the Council.

Banco de la República is celebrating its 100th anniversary in 2023. This is a very significant anniversary and one that provides an opportunity to highlight the contribution the Bank has made to the country’s development. Its track record as guarantor of monetary stability has established it as the one independent state institution that generates the greatest confidence among Colombians due to its transparency, management capabilities, and effective compliance with the central banking and cultural responsibilities entrusted to it by the Constitution and the Law. On a date as important as this, the Board of Directors of Banco de la República (BDBR) pays tribute to the generations of governors and officers whose commitment and dedication have contributed to the growth of this institution.1 Banco de la República’s mandate was confirmed in the National Constitutional Assembly of 1991 where the citizens had the opportunity to elect the seventy people who would have the task of drafting a new constitution. The leaders of the three political movements with the most votes were elected as chairs to the Assembly, and this tripartite presidency reflected the plurality and the need for consensus among the different political groups to move the reform forward. Among the issues considered, the National Constitutional Assembly gave special importance to monetary stability. That is why they decided to include central banking and to provide Banco de la República with the necessary autonomy to use the instruments for which they are responsible without interference from other authorities. The constituent members understood that ensuring price stability is a state duty and that the entity responsible for this task must be enshrined in the Constitution and have the technical capability and institutional autonomy necessary to adopt the decisions they deem appropriate to achieve this fundamental objective in coordination with the general economic policy. In particular, Article 373 established that “the State, through Banco de la República, shall ensure the maintenance of the purchasing power of the currency,” a provision that coincided with the central banking system adopted by countries that have been successful in controlling inflation. In 1999, in Ruling 481, the Constitutional Court stated that “the duty to maintain the purchasing power of the currency applies to not only the monetary, credit, and exchange authority, i.e., the Board of Banco de la República, but also those who have responsibilities in the formulation and implementation of the general economic policy of the country” and that “the basic constitutional purpose of Banco de la República is the protection of a sound currency. However, this authority must take the other economic objectives of state intervention such as full employment into consideration in their decisions since these functions must be coordinated with the general economic policy.” The reforms to Banco de la República agreed upon in the Constitutional Assembly of 1991 and in Act 31/1992 can be summarized in the following aspects: i) the Bank was assigned a specific mandate: to maintain the purchasing power of the currency in coordination with the general economic policy; ii) the BDBR was designatedas the monetary, foreign exchange, and credit authority; iii) the Bank and its Board of Directors were granted a significant degree of independence from the government; iv) the Bank was prohibited from granting credit to the private sector except in the case of the financial sector; v) established that in order to grant credit to the government, the unanimous vote of its Board of Directors was required except in the case of open market transactions; vi) determined that the legislature may, in no case, order credit quotas in favor of the State or individuals; vii) Congress was appointed, on behalf of society, as the main addressee of the Bank’s reporting exercise; and viii) the responsibility for inspection, surveillance, and control over Banco de la República was delegated to the President of the Republic. The members of the National Constitutional Assembly clearly understood that the benefits of low and stable inflation extend to the whole of society and contribute mto the smooth functioning of the economic system. Among the most important of these is that low inflation promotes the efficient use of productive resources by allowing relative prices to better guide the allocation of resources since this promotes economic growth and increases the welfare of the population. Likewise, low inflation reduces uncertainty about the expected return on investment and future asset prices. This increases the confidence of economic agents, facilitates long-term financing, and stimulates investment. Since the low-income population is unable to protect itself from inflation by diversifying its assets, and a high proportion of its income is concentrated in the purchase of food and other basic goods that are generally the most affected by inflationary shocks, low inflation avoids arbitrary redistribution of income and wealth.2 Moreover, low inflation facilitates wage negotiations, creates a good labor climate, and reduces the volatility of employment levels. Finally, low inflation helps to make the tax system more transparent and equitable by avoiding the distortions that inflation introduces into the value of assets and income that make up the tax base. From the monetary authority’s point of view, one of the most relevant benefits of low inflation is the credibility that economic agents acquire in inflation targeting, which turns it into an effective nominal anchor on price levels. Upon receiving its mandate, and using its autonomy, Banco de la República began to announce specific annual inflation targets as of 1992. Although the proposed inflation targets were not met precisely during this first stage, a downward trend in inflation was achieved that took it from 32.4% in 1990 to 16.7% in 1998. At that time, the exchange rate was kept within a band. This limited the effectiveness of monetary policy, which simultaneously sought to meet an inflation target and an exchange rate target. The Asian crisis spread to emerging economies and significantly affected the Colombian economy. The exchange rate came under strong pressure to depreciate as access to foreign financing was cut off under conditions of a high foreign imbalance. This, together with the lack of exchange rate flexibility, prevented a countercyclical monetary policy and led to a 4.2% contraction in GDP that year. In this context of economic slowdown, annual inflation fell to 9.2% at the end of 1999, thus falling below the 15% target set for that year. This episode fully revealed how costly it could be, in terms of economic activity, to have inflation and exchange rate targets simultaneously. Towards the end of 1999, Banco de la República announced the adoption of a new monetary policy regime called the Inflation Targeting Plan. This regime, known internationally as ‘Inflation Targeting,’ has been gaining increasing acceptance in developed countries, having been adopted in 1991 by New Zealand, Canada, and England, among others, and has achieved significant advances in the management of inflation without incurring costs in terms of economic activity. In Latin America, Brazil and Chile also adopted it in 1999. In the case of Colombia, the last remaining requirement to be fulfilled in order to adopt said policy was exchange rate flexibility. This was realized around September 1999, when the BDBR decided to abandon the exchange-rate bands to allow the exchange rate to be freely determined in the market.Consistent with the constitutional mandate, the fundamental objective of this new policy approach was “the achievement of an inflation target that contributes to maintaining output growth around its potential.”3 This potential capacity was understood as the GDP growth that the economy can obtain if it fully utilizes its productive resources. To meet this objective, monetary policy must of necessity play a countercyclical role in the economy. This is because when economic activity is below its potential and there are idle resources, the monetary authority can reduce the interest rate in the absence of inflationary pressure to stimulate the economy and, when output exceeds its potential capacity, raise it. This policy principle, which is immersed in the models for guiding the monetary policy stance, makes the following two objectives fully compatible in the medium term: meeting the inflation target and achieving a level of economic activity that is consistent with its productive capacity. To achieve this purpose, the inflation targeting system uses the money market interest rate (at which the central bank supplies primary liquidity to commercial banks) as the primary policy instrument. This replaced the quantity of money as an intermediate monetary policy target that Banco de la República, like several other central banks, had used for a long time. In the case of Colombia, the objective of the new monetary policy approach implied, in practical terms, that the recovery of the economy after the 1999 contraction should be achieved while complying with the decreasing inflation targets established by the BDBR. The accomplishment of this purpose was remarkable. In the first half of the first decade of the 2000s, economic activity recovered significantly and reached a growth rate of 6.8% in 2006. Meanwhile, inflation gradually declined in line with inflation targets. That was how the inflation rate went from 9.2% in 1999 to 4.5% in 2006, thus meeting the inflation target established for that year while GDP reached its potential level. After this balance was achieved in 2006, inflation rebounded to 5.7% in 2007, above the 4.0% target for that year due to the fact that the 7.5% GDP growth exceeded the potential capacity of the economy.4 After proving the effectiveness of the inflation targeting system in its first years of operation, this policy regime continued to consolidate as the BDBR and the technical staff gained experience in its management and state-of-the-art economic models were incorporated to diagnose the present and future state of the economy and to assess the persistence of inflation deviations and expectations with respect to the inflation target. Beginning in 2010, the BDBR established the long-term 3.0% annual inflation target, which remains in effect today. Lower inflation has contributed to making the macroeconomic environment more stable, and this has favored sustained economic growth, financial stability, capital market development, and the functioning of payment systems. As a result, reductions in the inflationary risk premia and lower TES and credit interest rates were achieved. At the same time, the duration of public domestic debt increased significantly going from 2.27 years in December 2002 to 5.86 years in December 2022, and financial deepening, measured as the level of the portfolio as a percentage of GDP, went from around 20% in the mid-1990s to values above 45% in recent years in a healthy context for credit institutions.Having been granted autonomy by the Constitution to fulfill the mandate of preserving the purchasing power of the currency, the tangible achievements made by Banco de la República in managing inflation together with the significant benefits derived from the process of bringing inflation to its long-term target, make the BDBR’s current challenge to return inflation to the 3.0% target even more demanding and pressing. As is well known, starting in 2021, and especially in 2022, inflation in Colombia once again became a serious economic problem with high welfare costs. The inflationary phenomenon has not been exclusive to Colombia and many other developed and emerging countries have seen their inflation rates move away from the targets proposed by their central banks.5 The reasons for this phenomenon have been analyzed in recent Reports to Congress, and this new edition delves deeper into the subject with updated information. The solid institutional and technical base that supports the inflation targeting approach under which the monetary policy strategy operates gives the BDBR the necessary elements to face this difficult challenge with confidence. In this regard, the BDBR reiterated its commitment to the 3.0% inflation target in its November 25 communiqué and expects it to be reached by the end of 2024.6 Monetary policy will continue to focus on meeting this objective while ensuring the sustainability of economic activity, as mandated by the Constitution. Analyst surveys done in March showed a significant increase (from 32.3% in January to 48.5% in March) in the percentage of responses placing inflation expectations two years or more ahead in a range between 3.0% and 4.0%. This is a clear indication of the recovery of credibility in the medium-term inflation target and is consistent with the BDBR’s announcement made in November 2022. The moderation of the upward trend in inflation seen in January, and especially in February, will help to reinforce this revision of inflation expectations and will help to meet the proposed targets. After reaching 5.6% at the end of 2021, inflation maintained an upward trend throughout 2022 due to inflationary pressures from both external sources, associated with the aftermath of the pandemic and the consequences of the war in Ukraine, and domestic sources, resulting from: strengthening of local demand; price indexation processes stimulated by the increase in inflation expectations; the impact on food production caused by the mid-2021 strike; and the pass-through of depreciation to prices. The 10% increase in the minimum wage in 2021 and the 16% increase in 2022, both of which exceeded the actual inflation and the increase in productivity, accentuated the indexation processes by establishing a high nominal adjustment benchmark. Thus, total inflation went to 13.1% by the end of 2022. The annual change in food prices, which went from 17.2% to 27.8% between those two years, was the most influential factor in the surge in the Consumer Price Index (CPI). Another segment that contributed significantly to price increases was regulated products, which saw the annual change go from 7.1% in December 2021 to 11.8% by the end of 2022. The measure of core inflation excluding food and regulated items, in turn, went from 2.5% to 9.5% between the end of 2021 and the end of 2022. The substantial increase in core inflation shows that inflationary pressure has spread to most of the items in the household basket, which is characteristic of inflationary processes with generalized price indexation as is the case in Colombia. Monetary policy began to react early to this inflationary pressure. Thus, starting with its September 2021 session, the BDBR began a progressive change in the monetary policy stance moving away from the historical low of a 1.75% policy rate that had intended to stimulate the recovery of the economy. This adjustment process continued without interruption throughout 2022 and into the beginning of 2023 when the monetary policy rate reached 12.75% last January, thus accumulating an increase of 11 percentage points (pp). The public and the markets have been surprised that inflation continued to rise despite significant interest rate increases. However, as the BDBR has explained in its various communiqués, monetary policy works with a lag. Just as in 2022 economic activity recovered to a level above the pre-pandemic level, driven, along with other factors, by the monetary stimulus granted during the pandemic period and subsequent months, so too the effects of the current restrictive monetary policy will gradually take effect. This will allow us to expect the inflation rate to converge to 3.0% by the end of 2024 as is the BDBR’s purpose.Inflation results for January and February of this year showed declining marginal increases (13 bp and 3 bp respectively) compared to the change seen in December (59 bp). This suggests that a turning point in the inflation trend is approaching. In other Latin American countries such as Chile, Brazil, Perú, and Mexico, inflation has peaked and has begun to decline slowly, albeit with some ups and downs. It is to be expected that a similar process will take place in Colombia in the coming months. The expected decline in inflation in 2023 will be due, along with other factors, to lower cost pressure from abroad as a result of the gradual normalization of supply chains, the overcoming of supply shocks caused by the weather, and road blockades in previous years. This will be reflected in lower adjustments in food prices, as has already been seen in the first two months of the year and, of course, the lagged effect of monetary policy. The process of inflation convergence to the target will be gradual and will extend beyond 2023. This process will be facilitated if devaluation pressure is reversed. To this end, it is essential to continue consolidating fiscal sustainability and avoid messages on different public policy fronts that generate uncertainty and distrust. 1 This Report to Congress includes Box 1, which summarizes the trajectory of Banco de la República over the past 100 years. In addition, under the Bank’s auspices, several books that delve into various aspects of the history of this institution have been published in recent years. See, for example: Historia del Banco de la República 1923-2015; Tres banqueros centrales; Junta Directiva del Banco de la República: grandes episodios en 30 años de historia; Banco de la República: 90 años de la banca central en Colombia. 2 This is why lower inflation has been reflected in a reduction of income inequality as measured by the Gini coefficient that went from 58.7 in 1998 to 51.3 in the year prior to the pandemic. 3 See Gómez Javier, Uribe José Darío, Vargas Hernando (2002). “The Implementation of Inflation Targeting in Colombia”. Borradores de Economía, No. 202, March, available at: https://repositorio.banrep.gov.co/handle/20.500.12134/5220 4 See López-Enciso Enrique A.; Vargas-Herrera Hernando and Rodríguez-Niño Norberto (2016). “The inflation targeting strategy in Colombia. An historical view.” Borradores de Economía, No. 952. https://repositorio.banrep.gov.co/handle/20.500.12134/6263 5 According to the IMF, the percentage change in consumer prices between 2021 and 2022 went from 3.1% to 7.3% for advanced economies, and from 5.9% to 9.9% for emerging market and developing economies. 6 https://www.banrep.gov.co/es/noticias/junta-directiva-banco-republica-reitera-meta-inflacion-3