The development of public policies for elderly care in Brazil

Abstracts

O presente estudo trata-se de análise documental que objetivou discutir aspectos legais do desenvolvimento de políticas de atenção ao idoso no Brasil no contexto sociopolítico e histórico, com vistas aos aspectos que delineiam o bem-estar para pessoa idosa. A coleta de dados ocorreu de junho a setembro/2010 em sites governamentais. Foram incluídos os documentos que tiveram aderência ao objetivo proposto; os que continham articulação com as políticas de atenção ao idoso situadas entre os marcos legais de políticas para a população idosa de 2006 e a Lei Elói Chaves de 1923. Esta análise indicou que o bem-estar dos idosos depende significativamente da alocação de recursos em setores além do setor de saúde, destacando o idoso no mercado de trabalho e a feminização da velhice. Espera-se da população e dos gestores a discussão de necessidades dessa população de idosos e a integração das redes de atenção para a pessoa idosa que ainda se mostram insipientes para a heterogeneidade.

Idoso; Políticas Públicas de Saúde; Serviços de Saúde para Idosos

CRITICAL REVIEW

The development of public policies for elderly care in Brazil

Desarrollo de políticas públicas de atención al anciano en Brasil

Maria Teresinha de Oliveira Fernandes^I; Sônia Maria Soares^II

^IRN. M.Sc. in Nursing. Ph.D. candidate, School of Nursing, Universidade Federal de Minas Gerais. Nurse, Belo Horizonte Municipal Health Secretary. Fixed member, Study and Research Group on Care and Human Development, School of Nursing, Universidade Federal de Minas Gerais. Belo Horizonte, MG, Brazil. [e-mail]

^IIRN. Ph.D. in Public Health. Professor, School of Nursing, Universidade Federal de Minas. Coordinator, Study and Research Group on Care and Human Development. Belo Horizonte, MG, Brazil. [e-mail]

^{Correspondence}

ABSTRACT

The objective of this documental analysis is to discuss the legal aspects involved in the development of elderly care policies in Brazil, considering the socio-historical-political context, and in view of the aspects that outline the wellbeing of an aged individual. Data collection was performed between June and September of 2010 via governmental websites. Documents were included if they complied with the proposed objective; were connected with elderly care policies, and lay within the legal accomplishments regarding elderly care policies in 2006 and the Elói Chaves Law of 1923. This analysis indicated that elderly wellbeing depends significantly on resource allocation in sectors other than the healthcare area, with emphasis on the elderly in the labor market and the feminization of old age. It is expected that the community and administrators will discuss the needs of the elderly population and the integration of care networks that remain necessary for the heterogeneity of this population.

Descriptors: Aged; Health Public Policy; Health Services for the Aged

RESUMEN

Análisis documental objetivando discutir aspectos legales del desarrollo de políticas de atención al anciano en Brasil, en el contexto socio-histórico-político, apuntando a los aspectos que delinean el bienestar de una persona anciana. Datos recolectados de junio a setiembre de 2010, en webs gubernamentales. Fueron incluidos documentos con vinculación al objetivo propuesto; los que contenían articulación con políticas de atención al anciano insertas en las políticas para la ancianidad en 2006 y la ley Elói Chaves de 1923. Este análisis indicó que el bienestar de los ancianos depende significativamente de destinar recursos a sectores que van más allá de lo estrictamente sanitario, destacando al anciano en el mercado laboral y la feminización de la vejez. Se espera de la población y gobernantes la discusión sobre necesidades de esta población la integración de redes de atención para la persona anciana que aún expresa escasez de conocimientos para la heterogeneidad de esta población.

Descriptores: Anciano; Políticas Públicas de Salud; Servicios de Salud para Ancianos

INTRODUCTION

The development of public policies for the elderly has been a highlight on the agenda of international health organizations, in the attempt to propose guidelines for nations that still need to set up social and care programs to respond to this population group's emerging needs.

In Brazil, although the Federal Government took initiatives on behalf of elderly people in the 1970's, it was only in 1994 that a national policy was established for this group. Before, government actions were charitable and protective. In the 1970's, the creation of non-contributive benefits like retirement benefits for rural workers stood out, as well the life-long monthly income for the urban and rural poor over 70 years of age who did not receive any Social Security benefit⁽¹⁾.

It is known that governmental actions in public health policies study basic health programs, observing their organization and professional practices in the community and their professional intervention to guarantee human rights⁽¹⁾. Therefore, public health policies' goals need to be constantly revised, with a view to seeking institutional strategies aimed at social promotion, health prevention and the guarantee of human rights in the most vulnerable population segments.

Based on this perspective, this article is based on the conception of public policy defined as: elaboration and implementation process; results; ways to practice political power involving power distribution and redistribution; role of social conflict in decision processes; and division of costs and social benefits⁽¹⁾.

In public health care policies however, the impacts caused by social pressure stand out, such as: accelerated urbanization, return of typical illnesses that were considered eradicated, and mainly population aging, which demand specific health policy programs to cope with social programs in different Brazilian regions^(2-3).

Brazil has organized itself in the attempt to respond to the growing demands of the aging population, getting prepared to cope with issues related to elderly people's health and wellbeing⁽²⁾, a rapidly emerging group in the vulnerability context, at the same time as regulations are developed for the Unified Health System (SUS).

In that sense, the National Policy for the Elderly (PNI), launched in 1994 and regulated through Decree No. 1948, issued on June 03^rd 1996, guarantees social rights to elderly people, by creating conditions to promote their autonomy, integration and effective participation in society and reaffirm their right to health at the different care levels of the SUS⁽³⁾.

Based on this context and the demographic and epidemiological transition, which public policies were implanted in the country to enhance the wellbeing of elderly people, considering their socio-historical and sociopolitical axes?

This theme implies getting to know the particularities of the object in order to understand it, which does not invalidate the attempt to seek relations that broaden and complement the comprehension of the interface between politics and care delivery to elderly people today.

This research is based on two interdependent premises: regulation and the implementation of the National Health Policy for Elderly People in Primary Health Care. This regulation process should adequately respond to the growing demand and needs of the aging population, whose proposed elderly care policy should address its particularities. Hence, although Brazilian elderly health care legislation is quite advanced, practice remains unsatisfactory⁽²⁾.

As observed, both primary health care and the family health strategy appoint that elderly care is not specific, which influences their wellbeing. Thus, a new professional look is needed, no longer focused on the disease but on functionality. For the elderly population, health is not restricted to the control and prevention of non-transmissible chronic illnesses, but also to the interaction between physical and mental health, financial independence, functional ability and social support⁽³⁾.

The importance of this study is focused on elderly care. Little research and knowledge on this area has been produced in primary health care; the approach is centered on the socio-political interface with health care, with isolated research development. It is one of the theme areas that most arouse interest, besides the fact that the Ministry of Health included elderly health research as a priority.

Thus, the aim in this study is to discuss the legal aspects of elderly care policy developments in Brazil, within the socio-historical-political context, based on articulated documents in the legal framework of the national health policy for elderly people.

METHOD

A qualitative, documentary research was developed, which is a study design based on documents that are contemporary or not. The aim in this kind of research is to identify, in primary documents, information that provides support to answer some research question. As they represent a natural knowledge source, documents are not just a contextualized knowledge base, but also emerge in a given context and provide information on the same context⁽⁴⁾.

Data were collected between June and September 2010. Menus about legislation were consulted on the following Brazilian governmental websites: Portal da Saúde do SUS^(2,5-6), Planalto^(3,7-8), Virtual Health Library of the Ministry of Health⁽⁹⁾, Federal Senate⁽¹⁰⁾, Ministry of Social Development⁽¹¹⁾, Secretary of Human Rights⁽¹²⁾, and the Ministry of Social Security and Assistance⁽¹³⁾, where information and publications were available to the general public. The search was based on the following descriptors: governmental health plans, public policies, public policies for the elderly, elderly health, assemblies/conferences about aging, legislation for the elderly. Inclusion of the documents was based on the following criteria: pertinence of the contents for the study objective and articulation with elderly care policies.

In legislation, we looked for the legal framework of public policies for elderly people with a view to guaranteeing representativeness through different kinds of documents, including decrees, decree-laws and resolutions, which were part of a socio-historical context, and others whose contents could be analyzed in a sociopolitical perspective.

The analysis of the references found was based on the documents that contained the set of policies for the elderly population based on PNSPI Decree No. 2.528, issued in 2006⁽⁹⁾. Starting from that point, a retrospective was developed, going back until 1923, with the Law Elói Chaves as a landmark, issued in 1923⁽¹⁴⁾. For the first time in history, the social security rights of elderly people were mentioned in that law.

In this study, for the hermeneutical reading of the documents to represent an important operation in the research process, the crossing and confrontation of the sources was fundamental, as it permitted reading the information in the documents not just literally, but with a view to an actual understanding, in the context of complementary sources in explanatory terms.

The data were evaluated through content analysis⁽⁴⁾, as a part of documentary analysis. This content analysis is a category of explicit textual analysis procedures for the sake of social research, it is a technique to objectively produce inferences from a focal text to its social context⁽¹⁵⁾.

The first reading of the documents was aimed at checking whether the documents complied with the inclusion criteria. Out of 24 references found on the governmental websites, only 16 were pertinent for the research objective. The choice of the documents was random, according to the investigated sites. Repeated documents were eliminated in the order of their appearance.

It should be mentioned that the standardized format of the study documents facilitated the analysis process because it implied a more stable relation between the terms used in each document's written language and its meanings, ranked according to the object and setting of each document analyzed.

After complying with the inclusion criteria, the material was read completely and exhaustively, with a view to the pre-analysis and exploration of the data, giving rise to two contextual units: 1) socio-historical, with a view to dimensioning the development of public elderly care policies in time; and 2) socio-political, with a view to addressing the aspects that support policies for the elderly in Brazil. Thus, determinations related to elderly health for health services, families and governmental spheres were contextualized.

To discuss the data, references from public policies were used, whose proposals and contemporary thoughts permitted dialoging and reflecting on the relations between the established and its actual repercussions in society, and specifically for elderly people.

The approach of the theme was based on a theoretical-methodological analysis dialogue, as textual aspects of the public policy documents on elderly health were observed, but broadened to their wellbeing.

RESULTS AND DISCUSSION

Socio-Historical Context of Public Elderly Care Policy Development in Brazil

The deployment of a public policy for elderly people in Brazil is recent, as it dates back to January 1994. In the same period, the implementation of the neoliberal model stands out in the same country, which led to the adherence to the Washington Consensus, when the globalized economy was inaugurated⁽¹⁶⁾.

The same period was marked by the hyperinflation crisis and its mitigation through the real plan, by the first years of the implementation of the Unified Health System (SUS) and by the universalization of primary education, despite the alignment of the neoliberal model⁽¹⁷⁾.

In terms of protection of this population segment – elderly people -, in 1923, the legal framework was established, called Law Eloy Chaves⁽¹⁴⁾, about the social security system; other references are found in some articles of the Civil Code (1916), the Penal Code (1940) and the Electoral Code (1965)⁽¹⁸⁾. Between 1923 and 1965, the two mandates of Getúlio Vargas stand out, which marked the start of concerns with the development of public policies for economic development in Brazil, essentially to respond to the anxieties of the Brazilian industrial class, without considering the population's basic needs, but with the State acting as the main funder of this industrialization, powerless to invest in such an undertaking⁽¹⁷⁾. In addition, the resulting policies are fragmented and, invariably, instead of minimizing, they tend to deepen processes of exclusion by continuing to guarantee services and benefits for the few.

As a result of the existing gap, developmental policies in that period favored but a small part of the population, which had access to the representatives of the State, who were responsible for elaborating economic development policies⁽¹⁷⁾.

Although public health policies were directed at a young population, the demographic base pointed towards social-health policies oriented towards the maternal-infant population. In the 1970's, the sociopolitical process started to operate changes in view of the new population profile, thus consecrating some historical landmarks (Chart 1).

In recent years, despite further discussions on the ageing process, its intrinsic changes still do not seem to be clear to society, nor to its institutions.

From a legal standardization perspective, ageing is protected in Brazil. Although guidelines exist and discussions have been undertaken, they have not been fully put in practice yet. The public authorities and society in general are responsible for applying this policy, respecting economic, social and regional differences^(12).

SOCIOPOLITICAL CONTEXT OF THE ELDERLY CARE POLICY IN BRAZIL

Many policies exist with a focus on elderly people. Difficulties to put them in practice range from precarious funding to the fragile information system for the analysis of life and health conditions, as well as inappropriate human resource training.

The ageing process relates to society in general and the elderly should not be discriminated against, but should be the main agent and addressee of the transformations indicated in the policies for the elderly⁽²⁰⁾.

Next, excerpts are presented from the main regulations focusing on the socio-political context.

Organic Health Law

In its principles, the preservation of people's autonomy, physical and moral integrity stands out, as well as comprehensive care and the establishment of epidemiology-based priorities.

In Brazil, society conquered the universal and comprehensive right to health in the 1988 Constitution, reaffirmed through the creation of the Unified Health System (SUS) in Organic Health Law 8.080/90⁽⁶⁾.

The understanding of this right involves universal and equalitarian access to health promotion, protection and recovery services and actions, guaranteeing holistic care, in view of the population's different realities and health needs. These constitutional premises are reaffirmed in Law 8.142, issued on December 28^th 1990, which rules on community participation in the management of the SUS and intergovernmental financial resource transfers in health and in the Basic Operational Standards (NOB), issued in 1991, 1993 and 1996, which in turn regulate and define the strategies and tactic movements that guide the operation of the System.

At the same time as SUS regulations, Brazil gets organized to respond to its ageing population's increasing demands and guarantee the social rights of elderly people, creating conditions to promote their autonomy, integration and effective participation in society, reaffirming the right to health at the different SUS care levels⁽³⁾.

The subsequent phase in the development of the PNI is the Integrated Governmental Action Plan⁽¹³⁾. This action plan involved nine entities: Ministry of Social Security and Services; Education and Sports; Justice; Culture; Work and Employment; Health; Sports and Tourism; Planning, Budget and Management; and the Urban Development Secretary, with a view to guiding integrated actions to put the PNI in practice. In that sense, it defines the actions and strategies for each sectoral entity, negotiates on financial resources among the three governmental spheres – federal, state and municipal – and monitors, controls and evaluates actions to guarantee all citizenship rights to the elderly, making the family, society and the State responsible for guaranteeing their community participation, defending their dignity, wellbeing and right to life. Thus, this plan addresses prevention, cure and promotion actions, with a view to enhancing the elderly's quality of life.

Statute of the Elderly

In 2003, the Statute of the Elderly⁽⁸⁾ was approved and, together with the PNI, these important documents broadened knowledge in the field of ageing and elderly health and were fundamental to affirm dynamic and consistent actions.

The Statute underlines the principles that guided discussions on the human rights of elderly people. The document represents a conquest to put these rights in practice, particularly because it tries to protect and lay the base to require everyone's (family, society and State) involvement with a view to supporting and respecting the elderly⁽²⁰⁾.

The Statute of the Elderly prioritized both attendance in general and clients who already suffer some level of dependence. Through these fundamental secondary prevention, rehabilitation, health promotion, care and treatment actions, a better quality of life can be guaranteed for the elderly, living with their family and in society.

The statute emphasizes the interface between intersectoral work and the right to health:

• Incorporates the holistic care concept, affirming that the elderly is entitled to all fundamental rights inherent in human beings, without infringing on the complete protection this Law addresses, guaranteeing (...) all opportunities and facilities to preserve their physical and mental health and improve their moral, intellectual, spiritual and social status, in conditions of freedom and dignity (Art. 2).

• Holistic health care is guaranteed to the elderly, through the Unified Health System – SUS, guaranteeing universal and equalitarian access, in an articulated and continuous set of actions and services, with a view to health prevention, promotion, protection and recovery (Art.15).

•The document coherently addresses the human resource problem: health institutions have to attend to minimal criteria for care delivery to the elderly's needs, offering professional training and education, as well as orientations to family caregivers and self-help groups (Art.18).

• Demands the inclusion, in the curricula of different formal education levels, of contents on the ageing process, the elimination of prejudices and the social valuation of elderly people (Art. 22).

The National Elderly Health Policy

The National Elderly Health Policy - PNSPI⁽⁹⁾, established in administrative rule 2528/GM, issued on October 19^th 2006, aims to guarantee appropriate and dignified care to the Brazilian elderly population, with a view to its integration.

In this policy, the guidelines have been defined that drive all health actions and institutional responsibilities have been indicated to achieve the proposal. In addition, the policy orients the continuous evaluation process that should accompany its development, taking into account possible adjustments practice may determine. Its implementation comprises the definition and/or re-adaptation of health sector plans, programs, projects and activities, directly or indirectly related to its object.

The aim of the PNSPI is to permit healthy ageing, which means preserving these people's functional ability, autonomy and maintain their quality of life⁽⁹⁾, in accordance with the principles and guidelines of the SUS, which drive individual and group measures at all health care levels.

Thus, this policy defines guidelines for all actions in the health sector, indicating responsibilities to achieve the proposal, which are:

• promotion of active and healthy ageing;

• comprehensive and integrated elderly health care;

• stimulation of intersectoral actions, with a view to holistic care;

• set-up of home care services;

• preferential reception at health services, respecting the risk criterion;

• provision of resources capable of guaranteeing high-quality health care to the elderly;

• strengthening of social participation;

• education and continuing education for SUS health professionals in elderly health care;

• dissemination and information on the National Elderly Health Policy for SUS health professional, managers and users;

• promotion of national and international cooperation for elderly healthcare experiences;

• support for study and research development.

• The PNSPI also indicates strategies for: implementation of the Elderly Health Card;

• issuing and distribution of the Primary Health Care Card – Ageing and Health of the Elderly, No. 19;

• organization of Distance Education Course on Ageing and Elderly Health – DE;

• elaboration of the Integrated Plan of Protective Actions for the Elderly SUAS-SUS;

• issuing and distribution of the Practical Guide for Caregivers;

• creation and implementation of the National Education Plan for Caregivers to Dependent ELDERLY in the Network of Technical Schools of the SUS (RET-SUS);

• publication of the decree on Prevention and Care Delivery to osteoporosis and falls (Decree No. 3.213/GM, issued on December 20^th 2007);

• expanded access to consultations in the Olhar Brasil Program for the identification of vision problems in young and elderly people (Decree n/33/SAS, issued on January 23^rd 2008);

• stimulation of research development on Ageing and Elderly Health;

• implementation of the Home Hospitalization Program;

• encouragement of medication access and rational use (Decree 2.529/GM, issued on October 19^th 2006).

With a view to presenting the guidelines and strategies and addressing National Elderly Health Policy issues, the essential goals proposed for Brazilian population ageing could be specified.

Although quite advanced, in practice, Brazilian legislation on elderly health care is still incipient. After the enactment of the Statute of the Elderly, the continuing search to guarantee the rights of elderly people and the expansion of the Family Health Strategy revealed the presence of elderly people in weakened families, in critical social vulnerability situations, pointing towards the fundamental need to readapt the PNSPI⁽⁹⁾. This policy, however, represented an important step for the health of more than 18 million elderly people in the country, corresponding to approximately 10.5% of the Brazilian population⁽²²⁾.

Despite the organization of the SUS network, however, it is fundamental for the guidelines of the PNSPI to be fully achieved. Hence, the revision of Decree 702/GM is fundamental, issued on April 12^th 2002, which creates the mechanisms for the organization and implementation of State Elderly Health Care Networks; as well as the revision of Decree 249/SAS, issued on April 16^th 2002, and the pact agreed in the Tripartite Inter-Management Committee.

Some subtle movements should be highlighted, like the experiences of local managers, States and Cities who, by organizing services for this population, permitted the review of the 1999 decree (PNI) that revoked it and gave origin, in 2006, to decree 2.528, and the guidelines of this process provided the foundations for an important document – the Pact for Health⁽²³⁾, signed by the Ministry of Health, the Councils of State and Municipal Health Secretaries (Conass and Conasems), and approved in the Plenary Meeting of the National Health Council.

The policy under discussion assumes active ageing, in line with the World Health Organization – WHO, which focuses on elderly people and acknowledges them as active participants who conduct their own lives with regard to family and community issues. This is an optimization process of opportunities for health, participation and security, with a view to improving quality of life as people get older. Public policies are involved which promote healthier and safer ways of life in all lifecycles.

It is important to highlight that approximately 75% of the elderly are living independently and do not need help for their daily activities. For this population, it is fundamental to maintain promotion and prevention activities, so as to continue living independent and autonomously and maintain their citizenship⁽²²⁾.

On the other hand, about 20 to 25% of the elderly have already developed some degree of dependence, and these people need distinguished care in health and other sectors⁽²²⁾.

It is calculated that between 70% and 80% of elderly people are solely and exclusively dependent on public health services, arousing reflections on the need for public health services to adapt to the population ageing, mainly in primary health care⁽²²⁾.

In that sense, one of the main objectives of this policy is to redirect Public Health Services in order to identify these people's level of dependence, providing them with a distinguished follow-up in each situation and promoting their quality of life in such heterogeneous and diverse contexts.

CONCLUSION

Public health, which was organized until then to attend to maternal-infant health demands, is now facing the reality of a rapidly ageing population, representing a concern for themselves, governments and society. Thus, population ageing is a phenomenon that entails repercussions for social and health policies, which need to be monitored and reviewed at every step of their implementation.

In developing countries, this phenomenon necessarily implies new directions for public policies, especially those focused on health aspects of the ageing population, also considering the minimization of costs in different social sectors.

It is highlighted that this documentary research did not respond to some contemporary problems and/or situations. First, the feminization of old age, a relevant factor whose public policies for Brazilian population ageing need to take into account and consider the significant repercussions of this event in gender relations. Second, it was observed that retirement-related financial rights are guaranteed, but indicate that public policies for elderly wellbeing are insufficient, considering the job market they have returned to in order to complement their income.

This study alerts to the fact that one cannot forget that the main challenge is to return to the struggle for the social and human rights of the elderly at all times, with a view to the construction of their citizenship, to the relativity of these policies for a population that depends on the SUS. This analysis also indicated that the health status of the elderly significantly depends on the allocation of resources to health as well as to other sectors, including: education, food, health infrastructure, housing, environment, work incentives, healthy lifestyle promotion in sports, culture, leisure and justice.

The areas and services listed in the Brazilian legal framework refer to ideal situations, but the incipient nature of networks and the fact that some care services are not offered to this population indicate gaps that call for reorganization. Once these are overcome, they will serve as indicators of wellbeing, the problem-solving ability of health services and the access to and comprehensive range of elderly care.

The elderly population, society and managers in different governmental spheres need to continuously discuss elderly health needs in various Brazilian regions, considering service supplies and including the organization and integration of care networks into health maintenance systems, but mainly their functioning.

In that sense, modifying fixed concepts is one of the challenges public policies face, mainly in elderly health. There is an obvious need to systematically and critically incorporate new technologies, to learn how to talk about financial resources, as well as to approximate collective health to elderly health (gerontology and geriatrics). In addition, an elderly care network needs to be built and policies need to be developed to respond to the growing and emerging demands deriving from population ageing in Brazil, interconnecting health and social services.

Based on the reality of the ageing population's growing need for care and treatment, policies should be devised that further health across the lifetime, including the promotion of healthy life, healthy environments, disease prevention and care technology developments. this also includes rehabilitation care and mental health services, which can minimize disability levels related to old age over time, considering their heavy weight in governmental budgets.

On the other hand, social protection policies are still restricted to the delivery of public health services and programs. The State serves as a punctual partner, with limited responsibilities, and attributes the main home care responsibilities for frail elderly to the family. In this study, observations revealed a lack of more vehement policies related to the roles attributed to families and the support responsibilities of a service network for dependent elderly people and their family caregivers, leading to informal support and an informal elderly support network.

The State no longer plays a preponderant role in elderly health promotion, protection and recovery at the three management levels of the SUS (federal, state and municipal), which could optimize family support.

The different proposals of the National Elderly Care Policy have been well designed and outline, but public service managers – not just in health – and the health team are responsible for debating on care priorities and furthering a network policy. In general, Brazilian elderly mostly live in the community and Primary Health Care is an important strategy the reduce care fragmentation and enhance the elderly care network through Family Health.

There is an urgent need to train the health team for this knowledge area though, due to the great and increasing elderly care demands in the health system.

REFERENCES

Received: 11/26/2011

Approved: 03/08/2012

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Correspondence addressed to:

Sônia Maria Soares

Escola de Enfermagem, Universidade Federal de Minas Gerais

Av. Professor Alfredo Balena, 190 - Bairro Santa Efigênia

CEP 30130-100 – Belo Horizonte, MG, Brazil

Publication Dates

• Publication in this collection
  30 Jan 2013
• Date of issue
  Dec 2012

History

• Received
  26 Nov 2011
• Accepted
  08 Mar 2012