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são paulo - a tale of two cities

interesting results are evident when comparing vulnerable households and non-vulnerable households. The distinction between vulnerable and non-vulnerable is based on education and income; the data reveals that only 34 per cent of the vulnerable households have access to medical establishments in their proximate areas, while 65 per cent of non-vulnerable households said they had hospitals and clinics in their neighbourhoods. Coverage of health posts appears to be much more equitable: 78 per cent of vulnerable households live close to a health post, compared with 81.9 per cent of non-vulnerable households. Despite these differences, the overall level of access to medical assistance and treatment in the MRSP is high. Health posts, clinics and hospitals are generally available in most neighbourhoods, clearly illustrating the urban advantage: a concentration of population close to a concentration of resources and services. In Brazil, approximately one-quarter of the total population benefits from private insurance schemes — the highest proportion in the region. This type of ‘double-citizenship’ separates and privileges those with private health care insurance, who receive better treatment and services than those who rely on the public system. Brazil’s two-tier health care system also provides limited fiscal relief for the public system, and creates equity issues arising from the reduction of political pressure to improve the quality of public services once higher-income people opt for private health insurance and services. Most of the private health care provision is concentrated in the southeast region of the country, especially in the São Paulo Metropolitan Region (MRSP). São Paulo has the biggest and richest consumer markets, which led to a concentration of high-end treatment resources in the city (doctors, hospitals, laboratories, and the like). People from all over Brazil, and even from other countries, go to São Paulo for medical treatment.82 MRSP’s high subscription rates to private schemes (45 per cent in 2004) mirrors the nation’s rapid rise in private health-care coverage, which analysts identify as a lack of faith in the quality of the public system. The regression results of a recent economic study show a negative association between the decision to purchase private

health insurance and being satisfied with public health services.83 Since the implementation of the SUS, the relationship between the private and public health sectors has posed challenges for equity in the access and provision of health services. The impact of inequity in São Paulo and its relation to health in terms of access and outcomes has been extensively researched.84 Analyses overwhelmingly point to clear differences based on social equity, income, education and age. Whether analysed in terms of rates of mortality85 or disease, care of the elderly,86 disabled or mentally ill, or simple access to health care for average citizens, studies in the MRSP and the municipality of São Paulo agree on the fact that inequality remains a major challenge to the implementation and success of the pub-

...inequality remains a major challenge to the implementation and success of the public healthcare system. lic health-care system. One analysis conducted in São Paulo concluded, ‘Epidemiological studies have consistently demonstrated social inequality to be an important factor in the distribution of illness and death in society… These data support the contention that mortality for Brazilian adults is inextricably bound to the issue of social equity’.87 São Paulo’s health sector clearly illustrates the extent of the urban divide. Disaggregation of health outcome data in one study in São Paulo dramatically contrasted district-level outcomes with an aggregate view of the city on four survival indicators.88 Examining the conditions at the extremes revealed a distribution of health outcomes that exposed considerable inequality. Among the 12 urban districts studied (six wealthy and six poor), adverse health outcomes were between three and 24 times higher in the poorest districts than in the richest. While infant mortality rates were three to four times higher in poor districts than rich ones, it is rates of death among young men that point to the greatest disparities: mortality among men age 15 to

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Profile for UN-Habitat

Sao Paulo; A tale of two cities  

UN-HABITAT’s new Cities and Citizens series examines urban inequality in the developing world through in-depth analysis of intracity data de...

Sao Paulo; A tale of two cities  

UN-HABITAT’s new Cities and Citizens series examines urban inequality in the developing world through in-depth analysis of intracity data de...

Profile for unhabitat
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