The study covers fertility, birth and death rates from 1960 to 2005, and deals with health, functional capacity, senior citizens’ access to health insurance plans, and the supply and the use of medical imaging equipment. The Indigenous population is also studied, according to the demographic censuses of 1991 and 2000. 

 

The Brazilian demographic pattern was, until the middle of the 20^th century, quite stable, with high gross birth rates (between 45 and 50 births per 1 thousand inhabitants) and total fertility rates between seven and nine children, on average, by woman, reflecting the conception of a numerous family, typical of farming societies. Transformations began in the 1940’s, with a constant decrease of general mortality levels, although not concurrently with the decline of birth rates, which only intensified in the 1980’s.

Thus, Brazilian life expectancy at birth¹ have slowly increasing, what points to population aging and requires new priorities from public policies, such as the formation of human resources for geriatrics and gerontology care, and measures related to social security.

 

Regional inequalities of mortality rates decreased a lot between 1960 and 2005

The increase in life expectancy reflects, however, striking regional differences. In 1940, the Northeast already presented the lowest amount: 36.7 years, versus 49.2 years in the South; 47.9 years in the Central-West Region; and 43.5 years in the Southeast. Until the middle of the 1950 decade, life expectancy increased approximately 10 years for the country as a whole (from 41.5 years to 51.6 years), whereas in the Northeast the increase was of just four years, and in the Central-South Regions, the gains reached 14 years (in the Southeast).

It was only from the middle of the 1970 decade, with the enlargement of the health care network, basic sanitation infrastructure, and schooling, a significant decrease begins in the patterns of regional inequality in relation to death rates, with the Northeast presenting the largest increases in life expectancy. Differences between the Northeast and the South, of 19 years in the decades 1960/70, reduced to five years in 2005.

 

Differences in life expectancy between sexes accentuated in the 1980’s

Differences by sex for this indicator became relevant from the 1980’s in nearly all Brazilian regions, because of the upward trend of violent causes, which began affecting especially men. In 1980, female survival was six years. This difference increases to 7.6 years in 2000; in the Southeast men live, on average, almost nine years less than women.

The improvement of women’s schooling has contributed to reduce the number of children. Up to 1960, the total fertility rate (TFT)² was lightly superior to six children per woman, falling to 5.8 children in 1970, because of the Southeast. In the South and in the Central-West regions, fertility transition begins in the early 70’s, whereas in the North and in the Northeast, it happens only in the beginning of the 80’s. The decline remained in the next decades, reaching the figure of 1.99 child in 2006 – a vertiginous fall in 30 years in relation to developed countries, which waited for more than a century to reach similar levels.

 

Fertility differentials decrease between groups of better and poorer schooling

There is an association between social economic status of the population and fertility levels: poor schooling groups still present the highest fertility rates. This difference, however, has been reduced during the last three decades in all regions. The differential, which in 1970 was 4.5 children by woman, declines to 1.6 child in 2005, mainly because of decrease in total fertility rate of women with up to three years of schooling, which goes from 7.2 children to 3.0 children. The results of the federation units reproduce regional specificities. Yet, in all states, women with more than eight years of schooling (at least complete primary education) have total fertility rates below replacement level (two children).

 

Chronic diseases strike 75.5% of the elderly

In less than 40 years, Brazil changed from a mortality profile typical of a young population to one characterized by more complex and costly diseases, distinctive of older age groups. The remarkable fact regarding chronic diseases is that they grow importantly as years go by: among those 0-14 years old, just 9.3% chronic diseases were reported, but among the elderly, this figure reaches 75.5% (69.3% among men, and 80.2% among women).

The 20% poorest senior citizens presented not so high statistically significant prevalence (69.9%) of chronic diseases. The others declared similar proportions (of approximately 75%).

Brazil rapidly grows old, but main urban centers, although already presenting a demographic profile similar to that of more developed countries, still need to improve infrastructure of services to meet the demands from demographic transformations.

 

Senior citizens in the Northeast have reduced mobility

The elderly of the Northeast are in serious disadvantage regarding functional condition, when compared to those of the other regions of the country. Functional incapacity is assessed by means of mobility difficulty, to carry out basic activities, such as personal care, and in more complex actions, necessary to live independently.

The elderly of many areas of the North and Central West Regions, where farming activities and lower urbanization rates predominate, have relative advantage. The case of Rio Grande do Sul, a federation unit that presents the second life expectancy of the country, also stands out because of the varied conditions of the elderly, with a quite differentiated prevalence of incapacity in its areas.

The risk of functional incapacity in mobility was bigger among the elderly of urban areas than those of rural areas, according to studies about the subject. Women declared functional incapacity in a greater proportion than men, also taking into consideration the progressive character of functional incapacity among the elderly as age advances.

 

São Paulo has the lowest rates of functional incapacity

The municipality of São Paulo presents the lowest prevalence of functional incapacity: 20.1% for women and 15.8% for men; rates are also lower according to age groups: 12.3% for the elderly between 60 and 69 years; 21.5% for those between 70 and 79; and 38.4% for those who are 80 or over.

Palmas, for women (38.5%), and Maceió (28.2%), for men, have the highest rates of functional incapacity. The elderly in the municipalities of Regions South and Southeast capitals present better functional condition, although Cuiabá (26.6%), Porto Velho (27.2%), and Campo Grande (27.3%), for women; and Palmas (29%), for men, figure among the seven first, above Porto Alegre.

The analysis in a more disaggregate level showed heterogeneity of functional decline in the Brazilian older population, associated to diverse factors, and in large part, to social demographic inequalities present in society.

 

Hospitalization at SUS of elderly aged 80 or older cost, on average, R$ 179 per elderly

The elderly make more use of health services, hospital stays are more frequent, and the time of bed occupation is longer due to multiple pathologies, when compared to other age groups.

Among the elderly, the cost of hospitalization per capita tends to increase as age advances, going from R$ 93 per elderly between ages 60 and 69 to R$ 179 among those who are 80 or older. Older men presented, in 2006, a per capita cost (R$ 100) lower than that of women (R$ 135).

 

Around 29% of the elderly in Brazil have a health insurance plan

Health insurance plans among the elderly cover approximately 5 million people aged 60 or older, representing 29.4% of total population in this age group. Users of such plans encompass chiefly people of higher income, the opposite happening among the elderly who just have SUS coverage. Among the elderly who are SUS users, only 5.8% presented a household income of more than three minimum wages per capita, whereas among the elderly who had private insurance plans, this proportion reached 42.8%.

 

 

 

Number of births reduced between 2000 and 2006

The number of births in the country, according to information supplied by SINASC (System of Live Births) of the Ministry of Health, decreased from 3.2 million, in 2000, to 2.9 million, in 2006. Regionally, the reduction was more significant in the South and Southeast regions, whereas the North and Central-West presented an almost stable volume of births. The increase of births in the North region, in this period, derives from the improvement in data capture.

Between 2000 and 2006, births to mothers aged 15 to 19, and 20 to 24 declined. In the group of mothers between 10 and 14 there was stability; among mothers over 24, a small decrease in the percentages of births occurred.

In 2006, 51.4% (1,512,374) of live children were born to mothers aged up to 24, being 27,610 (0.9%) to mothers aged between 10 and 14; 605,270 (20.6%) to mothers between 15 and 19, and 879,493 (29.9%), to mothers aged between 20 and 24. In 2000, those age groups corresponded, respectively, to 0.9% (28,973), 22.5% (721,564), and 31.1% (998.523).

In the Federal District, São Paulo, Rio Grande do Sul, Santa Catarina, Rio de Janeiro, Minas Gerais, and Paraná, the proportions of births to mothers up to 24 were smaller than 50%. In the other states, most births resulted from the segments of younger women, but with reductions in all federation units, in relation to 2000. Maranhão recorded, in 2006, the greater share of births to mothers aged up to 24 (66.2%).

 

Increase in the share of mothers who had prenatal visits

In relation to prenatal care, between 2000 and 2006, there was increase in the proportion of live births whose mothers had seven or more visits, changing from 43.7% to 54.5%, whereas the proportion of mothers who had no visits decreased from 4.7% to 2.1%.

From the state point of view, whereas in São Paulo and Paraná the percentage of live births whose mothers had seven visits or more was greater than 70%, in Amapá this proportion was just 23.6%. The greatest percentages of live births whose mothers had no prenatal visits were observed in the states of Acre (11.1%) and Amapá (9.6%).

 

Roraima and Acre presented the largest proportions of live births in households

In 2000, the percentage of births in hospitals was 96.6%, changing to 97.2% in 2006 for the country as a whole. In 2006, just Roraima and Acre still had not reached hospital coverage equal to or greater than 90%, despite being close to this figure, with 12.7% and 9.8% of live births in households, respectively.

 

Cesarean sections are more common in women with higher schooling

According to the Ministry of Health, the Cesarean section already represents 43% of childbirths of public and private sectors in Brazil, when the United Nations Organization recommends that the rate of Cesarean sections should not exceed 15% of childbirths, being limited to risky situations to mother or child.

When taking private insurance health plans into account, this percentage is verified to be even larger, reaching 80%. In the Unified Health System, Cesarean sections account for 26% of total deliveries. Experts consider the safety of normal delivery both for the mother and for the baby³.

The study demonstrated growth in the proportion of births by Cesarean sections in all regions of Brazil. The largest percentages were observed, in 2006, in the Southeast and South regions. The North had the smallest percentage of Cesarean sections in that year.

According a report of the Interagency Information Net for Health in Brazil, of 2008, Cesarean sections are more common among women with higher schooling levels, reaching almost 70% for those with 12 years of schooling or more, and being less than 20% for those with lower schooling levels.

 

Child mortality keeps a downward trend

Mortality patterns of the Brazilian population went through deep transformations in the middle of the 1990 decade. There is a downward trend in the country, especially of child and infant mortality. Causes related to infectious and parasitic diseases and parasites lost relative importance in this age group. Perinatal conditions now predominate, as a possible reflection of the lack of health services to the whole population.

Prenatal care, for example, is still not enough in the North and Northeast. Those regions still fail to record deaths, especially of children; in Rio Grande do Norte, Alagoas, Paraíba, Maranhão, and Ceará, under-reporting is higher than 40%. Even for total deaths, under-reporting is extremely high (above 26%) in those places. The national average is 12%; and the average of Central South states is below 10%.

The elderly more frequently suffer from cardiovascular diseases. The number of neoplasm-related deaths also stands out.

The proportion of deaths reported as ill-defined causes is still significant, despite the improvement observed in the reporting of real death causes. Those comprise cases whose signs and symptoms were not objectively cleared, besides the abnormal findings of clinical examinations and laboratory tests.

 

Excess male mortality has increased since the 1980’s

In Brazil, excess male mortality in the years 1940/50 and 1950/60 was moderate, beginning to rise in 1970 and increasing along 1980, 1991, and 2000, especially among youngsters and young adults.

Between 2000 and 2005, whereas in the Southeast excess male mortality decreased in all age groups, except that between 15 and 25 years, in the Northeast it increased in all age groups. These results may reflect, on the one hand, a more intense violence control in regions of high incidence, such as the Southeast; on the other hand, its generalization to the Northeast and other regions of the country.

 

Violent deaths are more incident on poor youngsters

Young poor men, aged between 15 and 29, are at the same time the main victims and the main agents of the violence situation that has affected Brazilian population.

Information on deaths, from the database of the National System of Information on Mortality (SIM/DATASUS), of the Ministry of Health, follows a pattern and is published annually. SIM obeys the methodology of the World Health Organization (WHO), and is built based on death statements, which are obligatory⁴, and issued in the whole country.

The proportion of deaths by external causes increased principally at the end of the 1970’s, but violent deaths are not a determinant factor of death to women. Its percentages are low and remain stable: from 4.5% in 1980 to 4.9% in 2005. For the male population, percentages were 12.9% in 1980 and 18.3% in 2005.

 

Between 200 and 2005 the proportion of homicides in the Southeast decreases by seven percentage points

In 1980, homicides represented 22.4% of male deaths by external causes in the country. The percentage of male death by homicide from 1980 to 1990 increased significantly: 13 percentage points, reaching its highest point (41.8%) in 2000, and reducing a little in 2005.

From 1980 to 1990, percentages of male homicides increased more in the North (18 percentage points) and Southeast (14 percentage points). In the 1980 decade, with some variations, the situation of violence is deepened in all regions, and in the Southeast reaches its highest level in 2000, when almost half of male deaths by external causes were due to homicides.

Between 2000 and 2005, the percentage of male homicides grew in the South, North, and Northeast regions, where, in 2005, rates rose around 40%, and a little less in the South. But the percentage fall of homicides in the Southeast, between 2000 and 2005, from 48.0% to 41.6%, is still surprising.

 

Between 2000 and 2005 the participation of homicides in male deaths decreased in São Paulo

In the State of São Paulo, homicides represented half of the male deaths by external causes in 2000, but reduced to approximately 35% in 2005. There were decreases in Mato Grosso, Mato Grosso do Sul, Roraima, and Tocantins too, and to a lesser extent, in Rio de Janeiro, Amazonas, and the Federal District.

In the Northeast the percentage of male deaths by homicide increased. In Bahia, the rise was around 19 percentage point, followed by Maranhão and Alagoas, and, in a very lower level, Rio Grande do Norte. It is important to highlight the seriousness of the violence situation in Pernambuco, with the highest percentages of male deaths by homicide in the country: 62%.

Lethal violence is the main cause of death for men between 15 and 29, representing more than half of deaths for this part of the Brazilian population between 2000 and 2005. In 2000, the mortality rate by homicide (per 100 thousand youngsters) in the male population aged between 15 and 29 was 98.3 in the country, reducing to 95.6 in 2005.

North, Northeast, and South had an expressive increase in mortality rates of youngsters by homicide. The Southeast, in this period, had an important reduction (from 142.2 to 102.6) possibly related to the efforts by state and municipal governments, and by civil society, especially in the axis Rio-São Paulo. An example is the Statute of Disarmament, created in December 2003, and the disarmament campaign, in 2004. Their effects, however, were more limited to major urban centers.

Maranhão, Bahia, and Minas Gerais, in the period, more than doubled their mortality rates by homicide of youngsters. In Alagoas, the rate changed from 89.7 to 151.9 homicides per 100 thousand youngsters. Pernambuco had the highest rates in the country: 204.8 in 2000, and 206.1 in 2005.

The main reduction of lethal violence against youngsters happened in São Paulo: from 168.5 in 2000 to 75.6 per 100 thousand youngsters in 2005.

 

In 2005 firearms victimized 74.5 youngsters per 100 thousand

The use of firearms in homicides is very high in the country. In 2000, the rate of male deaths by homicide with firearms was 72.4 (per 100 thousand youngsters), changing to 74.5 in 2005.

In the Northeast, Pernambuco presented, in 2000, the highest rate in the country, keeping it in 2005, in spite of a small reduction: from 183.7 to 177.7 per 100 thousand youngsters. In Piauí and Alagoas, rates nearly doubled, the latter presenting the fourth highest rate in the country in 2005. In some states, rates nearly tripled (Bahia) or increased by four times (Maranhão) in an interval of just five years.

In the Southeast, São Paulo presented the greater reduction in death rate by homicide with firearm among youngsters: from 112.6 per 100 thousand youngsters in 2000 to 57.2 in 2005. In Rio de Janeiro there was reduction too, but in a smaller extent.

In the North, in 2000, Pará had 25 out of 100 thousand youngsters murdered with firearms. Five years later, they were 64.6 youngsters per 100 thousand. This increase may be due to land conflicts in that state. In Roraima there was significant reduction in juvenile mortality rates by homicide with firearm: from 49.6 per 100 thousand youngsters in 2000 to 13.7 in 2005.

In the South the number of murders with firearm also grew. Highlights are the states of Santa Catarina, which in five years more than doubled its rate of juvenile homicide with firearm, and Paraná, which changes from 45.1 to 88.3 youngsters per 100 thousand along this period.

 

External causes make male life expectancy reduce by 3.2 years

Among the main causes of death over the male Brazilian population, violent causes were the chief responsible by the “years of life lost”: in they 1996 provoked decrease of 3.4 years in the life expectancy of Brazilian men, and in 2005 this indicator had a light reduction, changing to 3.2 years. For women, the number of “years of life lost” because of deaths by external causes is lower than that of men: 0.83 year in 1995, and 0.65 in 2005.

The participation of men aged between 15 and 39 in “years of life lost” is 64% in 2005, in Brazil as a whole. The Southeast region has the highest figure (67% in 2005), and the South, the lowest (60%). Women exhibit significantly smaller proportions (below 50%), despite the upward trend of these proportions in all regions, except the North.

In summary, despite the downward trend, violent deaths continue being responsible for significant loss of years of life for men, in the whole of the country. In some states important reductions are observed, as in Rio de Janeiro and São Paulo, in opposition to others, where there was growth in violence, mainly in Ceará, Rio Grande do Norte, Paraíba, and Alagoas, with indexes close to those of Pernambuco, one of the most violent in the country.

 

Number of machines of imaging diagnosis increases more sharply in the public sector

In 2005, Brazil had 39.254 machines of imaging diagnosis⁵, 20% more than in 1999. This change was bigger among magnetic resonance imaging instruments (93% rise), standard mammography machines (71%), color Doppler ultrasonography (58%), and X-ray for hemodynamics (51%). The growth of X-ray was below average (9%), as well as that of ultrasonic echographs (4%), what may show that the simplest devices, although in a higher number, have a lower growth compared to the more complex ones.

As to administrative spheres where those acquisitions occur, a greater variation is observed in the public sector (58.9% from 1999 to 2005) than in the private (11.4%). At the same time, a reduction is observed, from 1999 to 2002, in the proportion of private equipment available at SUS, changing from 42% to 35% of total, and becoming steady in this level since then.

Considering manufacturing time of equipment, between 50% and 60% of color Doppler ultrasonography, and 44% and 51% of magnetic resonance instruments are less than 5 years old. The others are in an intermediate position.

 

Supply of equipment at SUS and health insurance plans is unequal

The potential supply of those imaging machines varies as possibilities of universal (SUS) or private access are considered. In the overall equipment rate in 2005, only X-ray for bone density measurement was not within the parameters laid by the Ministry of Health decree (Pt 1101/02). For the others there was a small surplus, except mammography units, which outnumbered the laid parameters by four to one. But in the supply available to SUS, there was no lack f equipment only for mammography, whereas in the supply to patients of health insurance plans, there are plenty of all machines, as the following table:

 

Data from ECDE (Organization for Cooperation and Economical Development) of 2006⁶, considering equipment of computed tomography, show that in the total, Brazil, with 4.9 units per 1 million inhabitants, is below average of the analyzed countries (13.8 machines); private supply (30.8 per 1 million inhabitants) is similar to that of the United States (32.2 per 1 million inhabitants).

In the case of magnetic resonance, total supply (one machine per 1 million inhabitants) is even lower than average (6.6), but private supply (10.7 per 1 million) is also above that found in most of the studied countries.

Likewise there is inequality in the regional distribution of imaging equipment.

 

In the North and Northeast regions there is a smaller supply than recommended for the most complex and expensive machines, with a lower rate than in the other regions for all the machines. On the other hand, the Southeast, South, and Central-West regions show similar figures, with Central-West region surpassing the other two in X-ray for bone density measurement and in ultrasonography.

However, in the public sector, there are proportionally more new machines in the most destitute regions and in the Central-West region. In relation to private supply, there is not such a remarkable difference, but the Southeast, traditionally the most saturated with health services, and the North, with its long distances and low income and formality in labor market, have fewer machines with less than five years of use.

 

Mammography units are machines with a more egalitarian distribution

A better distribution of mammography units is observed in the national territory. Although concentration in the South and Southeast regions is kept, there was a wider distribution over the micro-regions of Central West, Northeast and North – even though there still are large areas in need of the equipment.

The number of micro-regions without mammography units decreased from 280 (50%) in 1999 to 178 (32%) in 2005. The micro-regions of São Paulo (353 mammography units in 2005), Rio de Janeiro (285), and Belo Horizonte (123), which concentrate 16% of national population, have the highest number of mammography units, comprising around 24% of those functioning in the country in 2005.

The micro-regions that presented the highest rates of mammography units per inhabitant are in the countryside. In 1999 rates higher than 40 mammography units per 1 million inhabitants were found in municipalities of the Southeast and South countryside. In 2005 micro-regions with such rates were also observed in Central West and in utmost points of the North region. The micro-regions of Guajaramirim (158), in Rondônia; Oiapoque (84), in Amapá; Barretos (75), in São Paulo; Pirapora (75), in Minas Gerais; and Amapá (53), in Amapá, presented the highest rates in 2005, for a national average of 18.

In the case of magnetic resonance, the spread throughout the territory is not so wide, with a heavier concentration in the Southeast (markedly in São Paulo) and South regions. In 1999, 88.7% of micro-regions did not have those devices, which existed just in 64 micro-regions. In 2005, that number rose to 104 micro-regions – even so, more than 80% did not possess the equipment. Among the micro-regions with the highest number of those machines were São Paulo (83), Rio de Janeiro (77), Belo Horizonte, Salvador, and Porto Alegre (22 each).

The micro-regions that presented the highest rates of magnetic resonance imaging instruments per 1 million inhabitants were also in the countryside, principally in the Southeast and the South.

By observing the color Doppler ultrasonography, the most concentrated equipment in the private network, one can note that from 1999 to 2005 there was an expansion in number to new micro-regions, in both the private and public sector.

 

Medical imaging exams increased by 38.45% from 2000 to 2005

Between 2000 and 2005 there was expansion in the number of imaging procedures approved in all analyzed segments. The group of radiodiagnosis presented an overall growth of 37.59%, much more accentuated in serving the public – a similar rate to that observed for the group of procedures (38.45%). The group has a bigger and increasing participation of procedures adopted in public establishments (51% of total in 2000, 54% in 2002, and 61% in 2005).

For the procedures of mammography and bone density measurement, the variation in the procedures approval is more accentuated between 2002 and 2005: for mammography, growth is similar between public and private sectors; for bone density measurement, the private stands out, whereas the public reduces the number of procedures. Participation by the public sector in mammography remained constant: 29%. In the case of bone density measurement, there is an important reduction of public procedures in the total, from 68% in 2000 to 28% in 2005.

Ultrasonography procedures increased by 50.67% between 2000 and 2005, with progression in the public sector from 48% of total in 2000 to 63% in 2005. Magnetic resonance procedures had the greatest expansion (176.3), with a small participation by the public sector, but with an upward trend (from 16% in 2000 to 29% of total in 2005). At last, the procedures of computed tomography presented a variation similar to that of radiodiagnosis group, with those carried out in public establishments also demonstrating a greater expansion.

 

Indigenous population experiences demographic recovery

The fifth chapter of “Demographic and Health Indicators in Brazil” highlights the importance of censuses to quantify the Indigenous population and its demographic aspects (mortality and fertility levels, among others). The category Indigenous was incorporated by IBGE to the Census questionnaire in 1991, joining the four ones existing so far (white, black, yellow, and brown) in the item “Color or Race”.

From 1991 to 2000, Demographic Censuses revealed that the percentage of Indigenous in the Brazilian population changed from 0.2% (294 thousand) to 0.4% (734 thousand), what represents an absolute growth of 440 thousand Indigenous persons, or an annual growth rate of 10.8% between both censuses. This may be explained not only by the demographic aspect, but also by the change in the self-identification of a contingent of people that in previous censuses probably declared themselves as browns.

Censuses revealed a new spatial distribution of population that declared themselves Indigenous: in the North region, this population represented 42.4% of total in 1991, and decreased to 29.1% in 2000. In the Southeast, between 1991 and 2000, the number of people who classified themselves as Indigenous changed from 30,586 to 156,134. In the Northeast this contingent went from 55,851 to 166,500 in the period.

The demographic growth of some remaining Indigenous peoples may be explained by factors as their increased resistance to infectious agents, health actions directed to those populations, and the organization of Indigenous peoples into institutions for their own defense.

The publication also highlights progress in average schooling of the Indigenous population, which nearly doubled in the last decade: in 1991, the average years of schooling among Indigenous aged 10 or more was 2.0 years, changing to 3.9 in 2000.

 

_______________________

¹ Mean number of years of life expected for a newborn, considering the existing mortality pattern.

² Mean number of live births to a woman at the end of her “child-bearing years”.

³ Information obtained at http://portal.saude.gov.br/portal/aplicacoes/campanhas_publicitarias/campanha.

⁴ According to Brazilian law, no burial can take place without a death certificate.

5 Data sources are the surveys of Medical-Sanitary Assistance of IBGE (AMS), from 1999, 2002, and 2005, and the Outpatient Information System of the Unified Health System (SIA-SUS). The analyzed instruments are: standard mammography unit, stereotactic mammographic machine, X-ray, X-ray for bone density measurement, X-ray for hemodynamics, magnetic resonance instrument, computed tomography, color Doppler ultrasonography, and ultrasonic echograph.

⁶ The rate was calculated by Rodrigues, R. M., in “Análise do mercado privado de diagnóstico por imagem do Município de Macaé e suas inter-relações com o processo regulatório local”. Dissertation (Master degree in Public Health) – Institute of Studies of Public Health, Universidade Federal do Rio de Janeiro, 2008. The following countries were considered in the comparison: Japan, United States, Korea, Austria, Italy, Switzerland, Germany, Denmark, Finland, Spain, Czech Republic, New Zealand, Canada, France, Poland, and Hungary.