摘要：We analyzed Brazil's efforts in reducing child mortality, improving maternal and child health, and reducing socioeconomic and regional inequalities from 1990 through 2007. We compiled and reanalyzed data from several sources, including vital statistics and population-based surveys. We also explored the roles of broad socioeconomic and demographic changes and the introduction of health sector and other reform measures in explaining the improvements observed. Our findings provide compelling evidence that proactive measures to reduce health disparities accompanied by socioeconomic progress can result in measurable improvements in the health of children and mothers in a relatively short interval. Our analysis of Brazil's successes and remaining challenges to reach and surpass Millennium Development Goals 4 and 5 can provide important lessons for other low- and middle-income countries. The world is now well past the midpoint for the achievement of the Millennium Development Goals (MDGs), a set of internationally agreed upon development aspirations to be achieved by 2015. Maternal, newborn, and child health are an integral part of these goals, yet global progress toward MDG 4 (reducing child mortality) has been uneven, and MDG 5 (improving maternal health) exhibits the least progress worldwide of all health MGDs. 1 – 3 The global economic crisis is also negatively affecting the most vulnerable women and children and threatens to undermine efforts to reduce persisting inequities in service delivery and health care outcomes. 1 , 4 In this context, it is becoming increasingly urgent to document and widely disseminate country success stories in improving maternal, newborn, and child survival so that they may be replicated elsewhere. Studies examining the success of low- and middle-income countries in increasing coverage of essential maternal, newborn, and child health services and narrowing the gaps between the richest and poorest population groups have attributed these accomplishments to health care reform measures and simultaneous improvements in women's access to education and income earning opportunities. 5 – 8 These studies have shown that significant reductions in maternal, newborn, and child health inequities can be achieved under diverse political and economic conditions. Key to the success of countries' efforts to progress toward MDGs 4 and 5 have been political commitment to universal access to services across the continuum of care 9 and the adoption of specific measures (e.g., implementation of a coherent mix of financial protection schemes) aimed at ensuring that no population groups are excluded. 10 , 11 Brazil, the nation with the largest economy in Latin America and a country historically characterized by substantial health and wealth inequities, has made rapid strides in improving maternal, newborn, and child health. In 2005, because of its high absolute number of child deaths, Brazil was included among the 60 priority countries (i.e., countries accountable for 94% of all child mortality) in the countdown to the 2015 deadline for achieving all MDGs. 12 The latest estimates show, however, that Brazil is on track for MDG 4 and is making good progress in increasing coverage for interventions relevant to MDG 5. 13 Also, Brazil is unique among low- and middle-income countries because of its tax-based unified health service, introduced in 1988, that offers free and comprehensive health care to all Brazilian citizens regardless of employment status or contributions to Social Security. Brazil has 1 federal district (Brasilia) and 26 states (we refer to 27 states throughout for the sake of simplicity) divided into 5 regions: North, Northeast, Southeast, South, and West–Central. The Southeast and South regions are the most developed; the North and Northeast regions are the poorest. The North region, dominated by the Amazon area, is the largest, with 45.2% of the land area, but it comprises only 8.1% of the population. The West–Central region has the second largest area, but the population corresponds to only 7.1% of the country. Most of the population is concentrated in the Southeast (42%), and an additional 14.5% of the country's residents live in the South, which has a subtropical climate. The Northeast region has a population of nearly 54 million, corresponding to 28.2% of the country's residents. 14 Our goals were to investigate trends in maternal, neonatal, infant, and child mortality in Brazil from 1990 to 2007 and interpret these trends in the light of health sector reforms, the introduction of pro-poor policies and programs, and broad socioeconomic and demographic changes. To determine whether and how inequities in these mortality indices changed, we examined trends in child and infant mortality across wealth quintiles and regions. We also documented changes in the cause distribution of infant deaths nationally and by region and examined available maternal mortality estimates from 1990 to 2006. To identify possible reasons for the downward mortality trends and improvements in mortality differentials among children younger than 5 years, we assessed broad health sector changes, the introduction of specific programs and policies targeted at women and children, and coverage trends associated with proven maternal, newborn, and child health interventions during the study period. Changes in key socioeconomic, child nutritional status, and demographic factors known to influence maternal, newborn, and child health outcomes were also reviewed.
