World Health Survey in Brazil, 2003
The report of the World Health Organization (WHO) in the year 2000 (World Health Report 2000) had the objective to propose a methodology for health system performance assessment of member countries. Despite its laudable goals of evaluating the health system responsiveness and of monitoring inequalities in health financing and in health state, the proposal received numerous criticisms, both because of the lack of the instrument's usefulness to back health policy-making and the methodology it employed, which mathematically combined distinct aspects in a single performance measure, devoid of conceptual meaning.
In 2001, during a reformulation phase, the WHO proposed the application of the World Health Survey (WHS), a population-based survey aimed at evaluation of health systems performance in member countries. The questionnaire included modules related to coverage of health programs, access and utilization of health services. As part of this initiative, the Brazilian government signed an agreement with the WHO to conduct the survey in Brazil, under the responsibility of the Oswaldo Cruz Foundation and our coordination. The questionnaire originally proposed by the WHO was entirely reviewed and modified, and the necessary adaptations were made to the Brazilian context. From January to September 2003, a nationwide population survey was held in 5 thousand households selected by probabilistic sampling.
The current supplement of Cadernos de Saúde Pública combines the main results obtained in the data analysis from the Brazilian WHS. In addition to articles on various performance aspects of the national health system, the publication includes a report on the field experience, and three studies presenting innovative methodological procedures in Brazil: the description of the household selection process by an inverse sampling scheme; the construction of healthy life expectancy, a measure that combines mortality and morbidity indicators in a single index; and the vignettes methodology, using hypothetical stories that describe third-party problems, tested as to its possible utilization in the calibration of the ordinal scale for self-evaluation by socioeconomic level.
In relation to health state evaluation, the two studies on self-perception of health in its various domains indicated sharp socioeconomic inequalities, as well as the influence of the adverse social context on Brazilian citizens' health. In relation to healthy practices, one of the articles focused on fruit and vegetable consumption by the general Brazilian population, and another study among females established the socio-demographic profile of women displaying adequate care for their own health.
The supplement also presents themes related to health care: diagnostic and therapeutic coverage of six chronic diseases; characteristics of utilization of medicines by the Brazilian population; private health plan coverage in relation to services utilization; and degree of satisfaction with the care provided, from the user's perspective.
The results provide relevant information for the improvement of the methodology for health system performance assessment, contributing to the international debate launched in 2000. The in-depth investigation of each aspect speaks clearly in favor of maintaining a multidimensional approach, not only to allow an evaluation that is more consistent with the object's complexity, but especially to back decisions aimed at meeting the population's needs.
Célia Landmann Szwarcwald; Francisco Viacava
Centro de Informação Científica e Tecnológica, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil.