Intended for healthcare professionals


Health equity in Brazil

BMJ 2010; 341 doi: (Published 29 November 2010) Cite this as: BMJ 2010;341:c6542
  1. Frederico C Guanais, health senior specialist
  1. 1Inter-American Development Bank, 1300 New York Avenue, NW, Washington, DC, 20577, USA
  1. fredericog{at}

Although Brazil has made important progress towards removing inequality, Frederico C Guanais finds much is still to be done

Vimicius Lima, 6, plays in the Jardin Edite favela in Sao Paulo, Brazil


When Brazil emerged from nearly 20 years of military dictatorship in 1988 it was a very unequal society: the wealthiest 10% of Brazilians held 49.5% of the national income; the poorest 10% were left with just 0.7%. One of the pillars of redemocratisation was a new federal constitution that for the first time in Brazilian history obliged the state to provide universal and equitable access to health services. An integrated health system was established, coordinating health services at all levels of government, following principles of decentralisation, and giving priority to prevention.

Today, the unified health system (known as SUS) offers comprehensive coverage to all, but it is mostly used by people on lower incomes. Despite the achievements of the past two decades, gradients in health status and access to health services persist along the lines of income, educational background, race, and region.1 2 This article considers progress and continued challenges towards health equity in Brazil.

State of the nation

Brazil has 185.7 million residents, 84% of whom live in urban areas. Between 1990 and 2009, poverty rates fell from 41.9% to 21.4% but 40 million people are still considered to be poor, and 13 million people extremely poor.3 Major challenges still lie ahead: in 2009, the national household sampling survey found that 40% of households are not connected to a sewage network and 10% of the adult population is illiterate.4

Health outcomes have improved, but sizeable disparities persist. Ministry of Health data show that state averages for postneonatal mortality ranged from 6.0 to 40.1 in 1997 and from 2.9 to 14.7 in 2007.5 Moreover, Brazil’s current demographic and …

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