Health & Social Policy

Why Does a No Excuses Health Policy Lead to No Results in Brazil?

Brazilian poverty is a familiar subject to many of us. Images of the favelas or massive slums surrounding Brazil’s major cities have reached us one way or the other, whether through movies, newspapers or some other route. According to the World Development Indicators, the top 10% of Brazilians hold 43% of the income, while the bottom 10% only hold 1%. Poverty alleviation strategies have long been a focus in Brazilian policymaking, and with good reason.

In 2003, newly-elected president Lula da Silva announced a new program of social policy, called Fome Zero or Bolsa Familia. This program would combine 13 government agencies in a national fight against both the symptoms of poverty as well as its roots. Bolsa Familia would eliminate the redundancies and gaps of previous social policy, and work to make all programs reinforce each other, regardless of what aspect of poverty each program targeted.

The crown jewel of the program were conditional cash transfers for the poor, which could be spent on anything but were only given to those families fulfilling certain conditions relating to child health and education, among other objectives. Money lost by allowing children to attend school and make visits to the doctor rather than work would be made up by the transfer received for fulfilling the conditions. This eliminates one of the main reasons that the poor avoid this sort of social investment that could help them rise out of poverty.

Bolsa Familia has been largely successful. The program has kept costs down, managing to reach 11.1 million families while only costing between 0.5 to 0.8% of Brazil’s GDP. The number of people living under the poverty line decreased by 19.31% by 2009, which studies attribute to Bolsa Familia’s effects. School attendance is up 3.6% among beneficiary families, and nutrition indicators for infants show significant improvement.

The program was well-received internationally, and has been commended by multiple international agencies, such as the U.N. Food and Agriculture Organization and the International Poverty Centre, for both its unique planning as well as its effectiveness in the years since its inception. The World Bank in particular believes in Bolsa Familia as an answer to poverty that could be effectively implemented in other countries.

And effectively implemented internationally it has been. Mexico, Chile, and Guatemala have all implemented Bolsa Familia-style programs. While Guatemala’s program is still very new, Mexico and Chile’s programs have  been around nearly as long as that of Brazil, and have also enjoyed great success in the fight against poverty. Bolsa Familia is obviously something we should pay attention to.

However successful some parts of Bolsa Familia were, some programs did not yield the results that were anticipated, especially the programs targeting child health and immunizations. One of the conditions the poor had to fulfill to receive a Bolsa Familia cash transfer from the government was that children 6 or younger, pregnant women and nursing mothers had to have a record of routine health clinic visits and vaccinations. Missing work and by extension the chance for a paycheck would be balanced by the earnings from the cash transfers. The government hoped this trade-off would eliminate any excuse to avoid clinics.

Unfortunately, health policy of Bolsa Familia was one of the least successful parts of the program. Since 2003, there has been no increase in child vaccinations. Many indicators of health for children under 6 have likewise remained unchanged. What went wrong?

Studies indicate that while Brazilian policy targeted demand-side issues with health through conditional cash transfers, they neglected to bolster the supply-side of healthcare. Issues with availability of vaccinations, number of clinics, and amount of staff at health clinics made it difficult for the poor to make the required visits. This oversight vastly limits what Bolsa Familia is capable of accomplishing.

Here in the U.S., we could be facing a similar problem. The New York Times published an article on September 6, questioning whether our health care system is prepared for the influx of the 32 million people who were previously uninsured. We should learn from Brazil’s oversight and target issues with the supply of health care before we begin spending money in earnest to bolster access to the system for the uninsured, lest we limit the effectiveness of the money being spent.

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