Achieving a gender-responsive universal health system in Brazil: the role of Women in Global Health

23 September 2024

According to the World Health Organization (WHO), Universal Health Coverage (UHC) means that all people have access to the full range of quality health services they need, whenever they need. The WHO highlights that every country has a different path to achieving UHC and to decide what to cover based on the needs of their populations and the resources at hand. 

The policy framework for UHC

Brazil’s path towards health for all has been legally guaranteed in the federal constitution since 1988, as a right for all and a duty of the state. In 1990, the 8080/90 and 8142/90 Federal laws embedded the Unified Health System (SUS), aiming to provide universal and equitable health services. Community participation in the management of the SUS was also introduced. 

Despite this progressive framework, Brazil faces significant challenges in fully realizing these principles, due to historical funding challenges that intensify social and regional inequalities in access and health outcomes, as well as affecting service quality and efficiency. Documents such as the Ministry of Health’s Strategic Planning (2020-2023), the National Health Plan (2020-2023), the National Integral Health Policy for the Black Population (2009), the National Policy for the Health Care of Indigenous Peoples (2002, actualized in 2022), or the National LGBT Integral Health Policy (2011), underscore ongoing efforts to enhance health service delivery and access to health services for all social groups.

Shifting demography

Social protection policies aimed at ensuring basic human rights and respecting differences have a direct impact on the patterns of illness and mortality among Brazilians. Although Brazil has made significant strides in the health sector, the journey towards  social protection continues. When it comes to poverty, 1.7% of the population lives below the international poverty line of US$1.90 daily. According to the Brazilian Institute of Geography and Statistics, in 2018, 8.8% of people living below the poverty line on less than US$1.90 were black or brown, while 3.6% were white. The Gini Index of 0,52 in 2023, historically above 0,5, highlights the significant income inequality within the country.

The demographic and epidemiological landscape has shifted notably in Brazil, with population growth from 175.87 million in 2000 to 203.1 million in 2022. Non-communicable diseases are leading the burden of diseases and deaths. The population is aging, with people over 65 years old now comprising 10.9% of the total population, an increase of 4.7 percentage points compared to 2000. This demographic shift, coupled with a life expectancy of 76.2 years in 2020 — 6.4 years higher than in 2000 — illustrates the ongoing transformations within Brazil’s societal structure. However, significant inequality in Brazilian society is reflected in differences in life expectancy between its Federal Units. For example, in Santa Catarina in the South, life expectancy is 79 years, while states in the North and Northeast, such as Maranhão and Piauí, have significantly lower life expectancies, sometimes falling below 72 years. It is important to note that the Brazilian population is predominantly white in the south and black and brown in the north and northeast.

Inequality as a social determinant of health

These inequalities result in growing disparities in health outcomes and disease prevalence between different regions, social groups or populations, especially those who are more vulnerable, such as black, indigenous and LGBTQIA+ people. For example, black pregnant women are most at risk, accounting for 60% of all maternal deaths in the last 10 years.

Structural problems such as racial discrimination and gender inequality are often invisible but latent and deeply rooted in society. In Brazil, the more significant female presence is still evident in sectors such as education, social services, commerce, domestic services, and health, which are often low-wage, unstable, and precarious. These conditions negatively impact the health and safety of these workers. In the health sector specifically, the trend towards feminization of the workforce continues, with female predominance increasing from 64.5% to 68.3% between 2010 and 2022, above that observed in the Brazilian population, while white men still dominate leadership.

Since 2023, intensified federal efforts have been made to promote and maintain gender, race, and ethnic equity in Brazil, including in the health sector. For example, it is possible to mention the National Program for Gender, Race, Ethnicity and Valuation of Female Workers in the Unified Health System. Moreover, this year (2024), the Ministry of Management and Innovation in Public Services assumed the ministry’s adherence to the Gender Equality seal of the United Nations Development Program.

Efforts to reduce health inequalities are integral to Brazil’s public health strategy. Conditional income transfer programs such as Programa Bolsa Família aim to alleviate poverty and promote social equity through direct income support and integrated public policies. These initiatives and, along with a participatory governance model, are essential for addressing Brazil’s complex health challenges. 

Public health spending constituted 4.62% of GDP in 2020 of a 10,1% GDP total health spending, with out-of-pocket expenses accounting for 22.39% of total health spending in the first pandemic year. Historically, the country has never had a public health spending over 4% of GDP, highlighting the large participation of the private sector on health spending and the inequalities in health access. 

As the country continues to navigate the complexities of public health, the commitment to universal health coverage remains a guiding principle. The experiences and lessons learned from Brazil’s Women in Global Health Chapter for the inclusion of gender equality, women’s leadership, and the essential role of women in the health workforce in the UHC implementation in the country are essential. 

Achieving Gender-Responsive Universal Health Coverage in Brazil – the role of WGH Brazil

UHC means that all individuals and communities receive the health services they need without financial hardship. This includes a full range of essential health services, from health promotion to prevention, treatment, rehabilitation, and palliative care.

Aligning global and national movements

One of the primary goals of WGH Brazil is to align global and national efforts on gender equity in health leadership. By synchronizing these movements, we reaffirm the need to recognize the potential of women’s work at all levels of health work. This alignment is critical in fostering a cohesive approach that integrates gender perspectives at all levels of health leadership.

1. Since the WGH Brazil chapter was founded in 2020, we have contributed to the cause by participating in important national and international activities such as actively participating in high-profile global health events. The chapter was represented at the 76th and 77th World Health Assembly in Geneva, Switzerland, by Isabela Barjon, the Director of Inclusion and Chapter Diversity, and Laurenice Pires, the Director of Advocacy and Strategy. 
2. We also participated in the 17th World Public Health Congress in Rome, Italy. Flávia Virginio, represented the chapter in the round table discussion titled “Gender, Power and Privilege: Opportunities and Challenges for Women Leading in a World of Turmoil.” This platform provided an opportunity to discuss the significant challenges and opportunities for women leaders in public health, particularly in times of global instability.
3. We attended the 78th United Nations General Assembly in New York, where Gabriela Borin, former WGH Brazil President, was a WGH delegate. 
4. We co-organized the event “12/12 Time for Action: Bridging the Gap for Gender Responsive Universal Health Coverage” and participated in the panel “Feminist Solutions to Addressing Inequities & Discrimination for Enhanced Health Outcomes.” This event, co-hosted by WGH India, WGH Nigeria, WGH Burkina Faso, WGH Kenya, and WGH Brazil, was an important platform for sharing feminist perspectives on health inequities. Gisela Foz, an associate member of WGH-BR, represented the chapter at this online event.
5. We participated online in the Women Deliver Conference in 2023, represented by Gisela Foz.
6. We participated of the Working Groups in C20 Brazil, representing the chapter in the groups of Philanthropy, Health, Gender, and Environment contributing to the recommendations for G20.
7. We have been actively involved in the Alliance for Gender Equality and UHC monthly meetings, which Gisela Foz attends on behalf of the Chapter. These meetings are essential for coordinating efforts and sharing strategies to achieve gender equality in universal health coverage.

Cultivating women leaders

To overcome the challenges posed by regressive social and gender norms, WGH Brazil is dedicated to fostering a new generation of women leaders with the skills, experience, and confidence to advocate effectively for change. By providing leadership training and development opportunities, we empower women to take on decision-making roles within the health sector. Cultivating women leaders is essential for ensuring that gender perspectives are represented at all levels of health governance.

By bridging global advocacy with local action, we aim to contribute to a health system that is equitable, inclusive, and responsive to the needs of all individuals, particularly women and girls. The active participation of our chapter members and the collaboration with local and global partners will be essential in turning our vision into reality. Together, we can move towards a healthier and more equitable world.

The Brazilian chapter of Women in Global Health (WGH-BR) has contributed to a short video titled “Why We Fight for Gender Equality.” This video is intended to be part of an end-of-year compilation that highlights the passion and commitment of its members.