Aging in Brazil

Aging in Brazil Abstract The population in Brazil is aging at a fast pace and in a context of historical socioeconomic and regional disparities. In the last decades, the country has developed important policies and legal mechanisms to guarantee older adults’ right to age well and with dignity. The implementation of these policies and laws, however, has been slow and hampered by lack of coordination and resources. With an estimate of 64 million seniors living in the country by 2050, Brazil has important public policy issues to address, such as the poor implementation of the National Policy of the Elderly, the urgency of Social Security Reform, and the need for a comprehensive long-term care policy for older adults. Demography, Public policy, Research on aging, International spotlight, Brazil Out of the estimated 2 billion older adults who will represent 22% of the global population in 2050, 80% will be living in developing countries. And although in most developed countries the aging of the population has been a gradual process consequent to substantial social and economic growth, populations in many developing countries are aging before having had the chance to increase wealth and reduce social disparities (World Health Organization, 2012). This is the case of Brazil, the largest country in South America, with the fifth largest population in the world, and with great social and economic disparities. Its population, currently over 200 million people, is aging at a rapid rate, and despite some recent improvements in socioeconomic status and health indicators, recent studies show that health disparities in old age have not changed in the last 10 years (Braga, Lima-Costa, César, & Macinko, 2015). The population growth of people aged 60 and older from 10% to 20%, which took France about 150 years to complete, is happening in Brazil in less than 20 years (World Health Organization, 2015). The fast aging of the population in Brazil increases the pressure for governments to address historical challenges in areas such as social security, health, education, housing, employment, and urban development. A combination of greater societal awareness, community support, effective public policies, and legislation is needed to ensure people age with dignity and high quality of life, maintaining their active role as citizens and their importance to the society (Braga, Del Maestro Filho, Silveira, & Guimaraes, 2008). This article aims to give a brief overview of aging in Brazil by presenting some of the demographics and characteristics of the older adult population, the principles and innovative processes used in developing the main legislation for the rights of older people, a bit of the history and current research agenda on aging, and finally some of the key policy issues in the country. The Demographics of Aging in Brazil Under Brazilian law, “older adults” are 60 years of age or older, a group that represented 9.7% of the population in 2004, 13.7% in 2014, and is estimated to represent 18.6% in 2030 and 33.7% in 2060 (Figure 1). (Instituto Brasileiro de Geografia e Estatística, 2015). Women represent the majority of older adults in the country and have a higher life expectancy at age 60 and 80 (Instituto Brasileiro de Geografia e Estatística, 2009). Recently, the racial composition of the older adult population has changed in the country, with the proportion of whites decreasing from 61.7% in 2000 to 56.8% in 2010, and the proportion of blacks and browns increasing in the same period from 6.9% to 7.7% and from 29.5% to 33.8%, respectively (Oliveira, Thomaz, & Silva, 2014). (Data on color/race are originally from the National Household Sample Survey (PNAD) where respondents self-classify themselves and are encouraged to refer to their color skin as a race proxy. This procedure is based on the assumption that the combination of color and race better describes with which racial group individuals identify themselves [Oliveira et al., 2014].) Figure 1. View largeDownload slide Distribution of Brazil’s population by age groups, from 2004 to 2060. Reprinted from Instituto Brasileiro de Geografia e Estatística (2015, p. 14). Figure 1. View largeDownload slide Distribution of Brazil’s population by age groups, from 2004 to 2060. Reprinted from Instituto Brasileiro de Geografia e Estatística (2015, p. 14). As demonstrated in Figure 2, in the last 30 years, literacy among older adults has increased, from 51.9% in 1983 to 77.2% in 2014, a change that has been even greater for older women. Nevertheless, the average number of school years for the older adult population, despite having doubled in the last three decades, was still very low in 2014 (5.1 years for men and 4.9 years for women; Camarano, Kanso, & Fernandes, 2016). Figure 2. View largeDownload slide Literacy and school years for the older adult population by gender (1983, 1993, and 2004). Reprinted from Camarano et al. (2016, p. 85). Figure 2. View largeDownload slide Literacy and school years for the older adult population by gender (1983, 1993, and 2004). Reprinted from Camarano et al. (2016, p. 85). According to the 2015 World Report on Aging and Health, a child born in Brazil in 2015 can expect to live 20 years longer than one born 50 years ago. In the last few decades, the country has gone through an important epidemiologic transition, and although deaths by infectious diseases decreased from 40% of the total registered deaths in 1950 to less than 10% by 2000, deaths from cardiovascular diseases increased from 12% to over 40% in the same period (Instituto Brasileiro de Geografia e Estatística, 2009). Studies investigating the impact of race on the health of the older adult population in Brazil have had mixed results. Although some scholars argue that inequalities in health cannot be attributed to a race apart from socioeconomic contexts, others state that black and brown older adults form a more vulnerable group due to a lifetime of unequal exposure to health risks (Oliveira et al., 2014). The proportion of households with seniors increased from 22.3% in 1983 to 31.2% in 2014. Among these households, 85.2% have access to water and 83.9% access to garbage collection. Nevertheless, only half of these homes are connected to the sewage system, which continues to be one of the biggest sanitary deficiencies in the country (Camarano et al., 2016). The first census of nursing care facilities identified 84,000 institutionalized seniors, which represents less than 1% of the older adult population (Camarano & Kanso, 2010). In the last few decades, demographic, economic, and social changes have substantially transformed family arrangements in Brazil. Although in 1980 most seniors were living with a spouse and children (43.7%), in 2014 only 25.5% had this residential arrangement, and most households (36%) involved older women living by themselves or with their children. The proportion of seniors living with children or relatives, which is considered an indicator of physical, mental, financial, or social fragility, had a significant drop, especially among women (from 26.7% in 1983 to 13.7% in 2014). Conversely, the proportion of older women as the “chief of the house” (chefe da casa) has increased from 33.4% to 51.9% in the same period (Camarano et al., 2016). Older adults have increasingly become an important source of income for families. Data from the Brazilian Institute of Geography and Statistics (IBGE) show that in 2013, 76.1% of older adults in Brazil were retired or pensioners, and among those, 15.6% were still working to supplement their income. Also, of the older adult population, 64.4% were the main source of income for their families (Ribas, 2016). Brazil is one of the few countries with no restrictions for retirees to continue working, and therefore, older adults are able to combine income from pensions and salaries. As a result, by 2014 retired men and women represented 51.6% and 55.5% of older workers, respectively (Camarano et al., 2016; Gugel, 2016). The Brazilian pension system is formed by three pillars. The largest pillar is the General Social Security Regime (Regime Geral da Previdência Social—RGPS), a mandatory pay-as-you-go system managed by the National Social Security Institute (Instituto Nacional do Seguro Social—INSS), which covers employed private-sector workers as well as self-employed professionals and elected civil servants. Public-sector employees are under a separate pension system, the Pension Regimes for Government Workers (Regime Próprio de Previdência Social—RPPS). As each federal unit can have its own system, there are more than 2,400 specific pension regimes for public servants, which are managed by the federal government, states, and municipalities with specific financing rules. The third pillar is the relatively new Private Pension Regime (Regime de Previdência Complementar—RPC), which offers occupational and individual plans on a voluntary basis (Associação Brasileira das Entidades Fechadas de Previdência Complementar, 2014; Caetano, 2015; Rangel & Saboia, 2015). The total number of pensions paid by the RGPS increased 2.8-fold from 1988 to 2013, which is attributed to a combination of greater social security coverage and the aging of the population. In 2013, women received 59% of the RGPS benefits. However, they received the vast majority (81%) of the “survivor benefits,” a category that pays less than the “time per contribution” category, where men were 71% of the beneficiaries, which indicates clear income inequality among seniors based on gender (Camarano & Fernandes, 2016). Social security benefits have been an important strategy to reduce poverty and inequalities in old age. In 2014, about 75% of the whole older adult population in the country received some social security benefit, including RGPS, RPPS, and welfare benefits (Camarano & Fernandes, 2016). The proportion of old women with no income has dropped from 34.3% in 1983 to 12.4% in 2014, which was even lower (about 5%) among those aged 80 years or older. In 2014, about 80% of older women’s income was provided by social benefits (Camarano et al., 2016). Social security policies have also had an important role in pulling many seniors out of poverty and in reducing racial disparities among the older adult population. A recent study showed that a greater proportion of the black population leaves poverty when aged, and black older adult population receive higher returns from their contributions when compared with white seniors of the same cohort (Zorzin, Wajnman, & Turra, 2016). Public Policies and Legislation for the Rights of the Older Adult Population In Brazil, aging with dignity is considered a fundamental human right, protected and promoted under the principles of a Social State of Democratic Rights. Article 230 of the 1988 Constitution states that “the family, society and the State have the duty to support the elderly, ensuring their participation in the community, defending their dignity and well-being, and guaranteeing them the right to life” (Giacomin & Gama Maio, 2016, p. 137). There are currently three major legal instruments establishing and protecting elder rights in the country: the Constitution, the National Policy for the Elderly, and the Statute for the Elderly (Gugel, 2016). The initial movement for a national policy for the older adult population began in the 1970s, when the country was still under military dictatorship, in a joint effort of nongovernmental organizations, professionals, and volunteers working with seniors. In 1976, the first Social Policy for the Elderly proposed the engagement of communities to help seniors stay with their families and a review of the criteria for licensing new long-term care institutions for seniors. The policy also called for the creation of specialized medical services for seniors (including home care), the review of the social security system and programs for retirement preparation, professional training for senior care, and the systematic collection of data about the country’s older adult population (Oliveira Alcântara, Camarano, & Giacomin, 2016). With re-establishment of democracy, aging became part of the political debate and was included in the 1988 Constitution. The so-called “citizen constitution” introduced the concept of social security as a citizen’s right, making Brazil one of the pioneers in Latin America in Social Security Policy. Also, health care, education, and social assistance were made available to the entire population (Oliveira Alcântara et al., 2016). The National Policy for the Elderly (Política Nacional do Idoso—PNI), created in 1994, lists a set of actions to be implemented by governments to ensure seniors’ social rights, autonomy, integration, and effective participation in society. Among the key stakeholders engaged in the process of designing this law were the Brazilian Bar Association (OAB), the National Confederation of Bishops of Brazil (CNBB), the National Gerontology Association (ANG), and the Brazilian Geriatrics and Gerontology Society (SBGG; Braga et al., 2008; Camarano, 2016; Oliveira Alcântara, 2016). As part of the implementation of the National Policy, the Statute for the Elderly (Estatuto do Idoso) was published in 2003 and has been considered not only an important policy enforcement instrument but also an innovative way to promote elder rights. The statute, which was the result of more than 7 years of discussion involving legislators and representatives from various public-interest organizations, states that the family, community, society, and government are responsible for assuring seniors’ rights to life, freedom, respect, dignity, food, health, family, and community support. It also determines that every individual at age 65 and older who cannot provide for their own livelihood is eligible to a noncontributory lifelong pension of 1 minimum wage per month (R$954 or about U.S.$300) paid by the Federal Government (Brasil. Câmara dos Deputados, 2013; Müller, 2014; Nobrega, Faleiros, & Telles, 2009). Seniors’ participation in the planning, implementation, and evaluation of policies, plans, and programs is one of the guidelines of the National Policy for the Elderly. To that end, the policy establishes national, state, and municipal Boards for the Elderly (Conselho Nacional, Estaduais e Municipais do Idoso), which are permanent and deliberative bodies formed by an equal number of representatives from governmental and nongovernmental organizations (Couto, 2016a; Oliveira Alcântara, 2016). Research on Aging: An Overview For most of its history, Brazil was considered “a young country,” a country formed by young people, and this is still the belief of many of its citizens. It required the visionary leadership of researchers and professionals to build awareness in government and society of demographic changes and the need for policies and legislation that support healthy and active aging (Barros & Junior, 2015; Rauth & Py, 2016). The 1987 article, “Aging: A Brazilian Reality,” presented trends in mortality, fertility, and life expectancy from the early 20th century to 2015 and showed that Brazil would go through an aging process comparable to developed countries (Veras, Ramos, & Kalache, 1987). Two years later, the National Association of Gerontology published the report, “Policy Recommendations for the Third Age in the 90s,” urging governments to prioritize issues related to aging. The report argued that the value of social problems should not be measured only by a particular group’s percentage of the total population but rather by the living conditions of that group. The report also stated that the country did not have accurate and specific data about the older adult population (Associação Nacional de Gerontologia, 1989; Rauth & Py, 2016). It was only in 1988 that the aging of the Brazilian population was included in the research agenda of the National Association of Population Studies (ABEP), which brings together scholars for scientific exchange and analysis of national demographic trends (Bezerra, de Almeida, & Nóbrega-Therrien, 2012). Since then, the number of researchers, studies, and publications on aging has increased exponentially (Bezerra et al., 2012; Donizete Prado & Dutra Sayd, 2004). Some of the early population studies on aging conducted in Brazil are still frequently cited and considered fundamental to the development of the research agenda in the country, such as Projeto Epidoso (1991), Projeto Bambuí (1997), and Estudo SABE (1999). Table 1 presents some of the key studies on aging currently active in Brazil. Table 1. Key Research Studies Currently Active in Brazil Study Primary Investigator Research characteristics and objectives Projeto EPIDOSO II Incidência de Perda Funcional (PF) em idosos e efetividade de ações de promoção da saúde na prevenção da PF (Incidence of Functional Loss in the elderly and effectiveness of actions of health promotion in the prevention of functional loss) (active since 2007) Luiz Roberto Ramos Urban cohort study that aims to identify avoidable risk factors for functional loss and to assess the effectiveness of health promotion interventions aimed at preserving and restoring the functional capacity of the older adults and social inclusion of the older adults. ELSI-Brasil: Estudo Longitudinal de Saúde e Bem-Estar dos Idosos Brasileiros (Longitudinal Study of Health and Welfare of the Brazilian Elderly) (active since 2012) Maria Fernanda Lima-Costa Elsi-Brasil is part of an international consortium of longitudinal studies, conducted on national representative samples of the population aged 50 and over. In Brazil, this population-based cohort study is based on a national probabilistic sample of 10,000 adults. The study uses the conceptual framework of other “Health and Retirement Studies” to allow for comparisons between countries. The main objective is to investigate the evolution and determinants of health conditions, functional capacity, and use of health services among older adults. The study adopts a population health multidisciplinary approach that combines economics, epidemiology, health planning, biostatistics, geriatrics, gerontology, and demography, among other perspectives. Fibra 80 +: Fragilidade nos Idosos Brasileiros (Fragility in Elderly Brazilians) (active since 2016) Anita Liberalesso Neri The study aims to determine the prevalence, risk and protective factors for frailty, cognition, and mortality, considering sociodemographic indicators, health conditions, independence, lifestyle, sociability, depression, subjective well-being, personality, and sense of psychological adjustment in people aged 80 and over. Padrões de envelhecimento físico, cognitivo e psicossocial em idosos longevos que vivem em diferentes contextos (Patterns of physical, cognitive and psychosocial aging in older adults living in different contexts) (active since 2015) Anita Liberalesso Neri A descriptive, comparative, and cross-sectional study with people aged 80 years and over, with the aim of identifying the correlation between demographic and socioeconomic risk variables, stressful events experienced in childhood and old age, indicators of cognitive reserve, physical health, social resources, and elements of psychological resilience. A participatory approach to the needs of dependent older people: barriers, facilitators, and sustainable solutions (active since 2016) Renato Peixoto Veras The study aims to identify the main challenges and unmet needs of dependent older adults in four areas: environment (their family environment and external environment), physical, psychological, and social. Research findings will be used to assess the need for better public policies for older dependents and their caregivers, as well as to identify low-cost solutions for immediate needs. Modelo de Hierarquização da Atenção ao Idoso com base na complexidade dos cuidados: Proposta de monitoramento dos três níveis de cuidado na assistencia suplementar (Hierarchical Model of Healthcare for the Elderly based on the complexity of care: Monitoring the three levels of private healthcare services) (active since 2015) Renato Peixoto Veras The objective of the study is to improve the hierarchical model of health care for older adults, focusing on the three initial levels of care, which concentrates 90% of older adults, by monitoring and evaluating the systems’ structure, processes, and results. Study Primary Investigator Research characteristics and objectives Projeto EPIDOSO II Incidência de Perda Funcional (PF) em idosos e efetividade de ações de promoção da saúde na prevenção da PF (Incidence of Functional Loss in the elderly and effectiveness of actions of health promotion in the prevention of functional loss) (active since 2007) Luiz Roberto Ramos Urban cohort study that aims to identify avoidable risk factors for functional loss and to assess the effectiveness of health promotion interventions aimed at preserving and restoring the functional capacity of the older adults and social inclusion of the older adults. ELSI-Brasil: Estudo Longitudinal de Saúde e Bem-Estar dos Idosos Brasileiros (Longitudinal Study of Health and Welfare of the Brazilian Elderly) (active since 2012) Maria Fernanda Lima-Costa Elsi-Brasil is part of an international consortium of longitudinal studies, conducted on national representative samples of the population aged 50 and over. In Brazil, this population-based cohort study is based on a national probabilistic sample of 10,000 adults. The study uses the conceptual framework of other “Health and Retirement Studies” to allow for comparisons between countries. The main objective is to investigate the evolution and determinants of health conditions, functional capacity, and use of health services among older adults. The study adopts a population health multidisciplinary approach that combines economics, epidemiology, health planning, biostatistics, geriatrics, gerontology, and demography, among other perspectives. Fibra 80 +: Fragilidade nos Idosos Brasileiros (Fragility in Elderly Brazilians) (active since 2016) Anita Liberalesso Neri The study aims to determine the prevalence, risk and protective factors for frailty, cognition, and mortality, considering sociodemographic indicators, health conditions, independence, lifestyle, sociability, depression, subjective well-being, personality, and sense of psychological adjustment in people aged 80 and over. Padrões de envelhecimento físico, cognitivo e psicossocial em idosos longevos que vivem em diferentes contextos (Patterns of physical, cognitive and psychosocial aging in older adults living in different contexts) (active since 2015) Anita Liberalesso Neri A descriptive, comparative, and cross-sectional study with people aged 80 years and over, with the aim of identifying the correlation between demographic and socioeconomic risk variables, stressful events experienced in childhood and old age, indicators of cognitive reserve, physical health, social resources, and elements of psychological resilience. A participatory approach to the needs of dependent older people: barriers, facilitators, and sustainable solutions (active since 2016) Renato Peixoto Veras The study aims to identify the main challenges and unmet needs of dependent older adults in four areas: environment (their family environment and external environment), physical, psychological, and social. Research findings will be used to assess the need for better public policies for older dependents and their caregivers, as well as to identify low-cost solutions for immediate needs. Modelo de Hierarquização da Atenção ao Idoso com base na complexidade dos cuidados: Proposta de monitoramento dos três níveis de cuidado na assistencia suplementar (Hierarchical Model of Healthcare for the Elderly based on the complexity of care: Monitoring the three levels of private healthcare services) (active since 2015) Renato Peixoto Veras The objective of the study is to improve the hierarchical model of health care for older adults, focusing on the three initial levels of care, which concentrates 90% of older adults, by monitoring and evaluating the systems’ structure, processes, and results. Note: The information presented in this table is from Plataforma Lattes, a virtual platform created and maintained by CNPq, which integrates the databases of curricula, research groups and institutions in the areas of Science and Technology operating in Brazil. View Large Table 1. Key Research Studies Currently Active in Brazil Study Primary Investigator Research characteristics and objectives Projeto EPIDOSO II Incidência de Perda Funcional (PF) em idosos e efetividade de ações de promoção da saúde na prevenção da PF (Incidence of Functional Loss in the elderly and effectiveness of actions of health promotion in the prevention of functional loss) (active since 2007) Luiz Roberto Ramos Urban cohort study that aims to identify avoidable risk factors for functional loss and to assess the effectiveness of health promotion interventions aimed at preserving and restoring the functional capacity of the older adults and social inclusion of the older adults. ELSI-Brasil: Estudo Longitudinal de Saúde e Bem-Estar dos Idosos Brasileiros (Longitudinal Study of Health and Welfare of the Brazilian Elderly) (active since 2012) Maria Fernanda Lima-Costa Elsi-Brasil is part of an international consortium of longitudinal studies, conducted on national representative samples of the population aged 50 and over. In Brazil, this population-based cohort study is based on a national probabilistic sample of 10,000 adults. The study uses the conceptual framework of other “Health and Retirement Studies” to allow for comparisons between countries. The main objective is to investigate the evolution and determinants of health conditions, functional capacity, and use of health services among older adults. The study adopts a population health multidisciplinary approach that combines economics, epidemiology, health planning, biostatistics, geriatrics, gerontology, and demography, among other perspectives. Fibra 80 +: Fragilidade nos Idosos Brasileiros (Fragility in Elderly Brazilians) (active since 2016) Anita Liberalesso Neri The study aims to determine the prevalence, risk and protective factors for frailty, cognition, and mortality, considering sociodemographic indicators, health conditions, independence, lifestyle, sociability, depression, subjective well-being, personality, and sense of psychological adjustment in people aged 80 and over. Padrões de envelhecimento físico, cognitivo e psicossocial em idosos longevos que vivem em diferentes contextos (Patterns of physical, cognitive and psychosocial aging in older adults living in different contexts) (active since 2015) Anita Liberalesso Neri A descriptive, comparative, and cross-sectional study with people aged 80 years and over, with the aim of identifying the correlation between demographic and socioeconomic risk variables, stressful events experienced in childhood and old age, indicators of cognitive reserve, physical health, social resources, and elements of psychological resilience. A participatory approach to the needs of dependent older people: barriers, facilitators, and sustainable solutions (active since 2016) Renato Peixoto Veras The study aims to identify the main challenges and unmet needs of dependent older adults in four areas: environment (their family environment and external environment), physical, psychological, and social. Research findings will be used to assess the need for better public policies for older dependents and their caregivers, as well as to identify low-cost solutions for immediate needs. Modelo de Hierarquização da Atenção ao Idoso com base na complexidade dos cuidados: Proposta de monitoramento dos três níveis de cuidado na assistencia suplementar (Hierarchical Model of Healthcare for the Elderly based on the complexity of care: Monitoring the three levels of private healthcare services) (active since 2015) Renato Peixoto Veras The objective of the study is to improve the hierarchical model of health care for older adults, focusing on the three initial levels of care, which concentrates 90% of older adults, by monitoring and evaluating the systems’ structure, processes, and results. Study Primary Investigator Research characteristics and objectives Projeto EPIDOSO II Incidência de Perda Funcional (PF) em idosos e efetividade de ações de promoção da saúde na prevenção da PF (Incidence of Functional Loss in the elderly and effectiveness of actions of health promotion in the prevention of functional loss) (active since 2007) Luiz Roberto Ramos Urban cohort study that aims to identify avoidable risk factors for functional loss and to assess the effectiveness of health promotion interventions aimed at preserving and restoring the functional capacity of the older adults and social inclusion of the older adults. ELSI-Brasil: Estudo Longitudinal de Saúde e Bem-Estar dos Idosos Brasileiros (Longitudinal Study of Health and Welfare of the Brazilian Elderly) (active since 2012) Maria Fernanda Lima-Costa Elsi-Brasil is part of an international consortium of longitudinal studies, conducted on national representative samples of the population aged 50 and over. In Brazil, this population-based cohort study is based on a national probabilistic sample of 10,000 adults. The study uses the conceptual framework of other “Health and Retirement Studies” to allow for comparisons between countries. The main objective is to investigate the evolution and determinants of health conditions, functional capacity, and use of health services among older adults. The study adopts a population health multidisciplinary approach that combines economics, epidemiology, health planning, biostatistics, geriatrics, gerontology, and demography, among other perspectives. Fibra 80 +: Fragilidade nos Idosos Brasileiros (Fragility in Elderly Brazilians) (active since 2016) Anita Liberalesso Neri The study aims to determine the prevalence, risk and protective factors for frailty, cognition, and mortality, considering sociodemographic indicators, health conditions, independence, lifestyle, sociability, depression, subjective well-being, personality, and sense of psychological adjustment in people aged 80 and over. Padrões de envelhecimento físico, cognitivo e psicossocial em idosos longevos que vivem em diferentes contextos (Patterns of physical, cognitive and psychosocial aging in older adults living in different contexts) (active since 2015) Anita Liberalesso Neri A descriptive, comparative, and cross-sectional study with people aged 80 years and over, with the aim of identifying the correlation between demographic and socioeconomic risk variables, stressful events experienced in childhood and old age, indicators of cognitive reserve, physical health, social resources, and elements of psychological resilience. A participatory approach to the needs of dependent older people: barriers, facilitators, and sustainable solutions (active since 2016) Renato Peixoto Veras The study aims to identify the main challenges and unmet needs of dependent older adults in four areas: environment (their family environment and external environment), physical, psychological, and social. Research findings will be used to assess the need for better public policies for older dependents and their caregivers, as well as to identify low-cost solutions for immediate needs. Modelo de Hierarquização da Atenção ao Idoso com base na complexidade dos cuidados: Proposta de monitoramento dos três níveis de cuidado na assistencia suplementar (Hierarchical Model of Healthcare for the Elderly based on the complexity of care: Monitoring the three levels of private healthcare services) (active since 2015) Renato Peixoto Veras The objective of the study is to improve the hierarchical model of health care for older adults, focusing on the three initial levels of care, which concentrates 90% of older adults, by monitoring and evaluating the systems’ structure, processes, and results. Note: The information presented in this table is from Plataforma Lattes, a virtual platform created and maintained by CNPq, which integrates the databases of curricula, research groups and institutions in the areas of Science and Technology operating in Brazil. View Large There are no publicly accessible secondary data sets specifically on aging in Brazil, but many researchers have been using the data from national household surveys produced by the IBGE, such as the Health National Survey (PNS) from 2013, and the National Household Sample Survey (PNAD), published most recently in 2015. Key Public Policy Issues As Brazil is experiencing one of the world’s most rapid rates of demographic aging, historical, social, and economic issues need to be addressed along with new emerging problems (Lima-Costa, Mambrini, Peixoto, Malta, & Macinko, 2016). Although there is great diversity among the older adult population based on socioeconomic status and regional differences, there are three key public policy issues that affect older adults in the whole country: the poor implementation of the National Policy of the Elderly, the urgency of social security reform, and the need for a comprehensive long-term care policy. The National Policy for the Elderly sets the direction for a country where people should be able to age well, with greater autonomy, better health, social engagement, participation in the job market, and quality of life. However, lack of coordination, political will, and budgetary provision have been critical barriers to its implementation (Couto, 2016b). According to Rauth and Py (2016), “with regard to national social policy for old age, this grew in discourse, but stalled in practice. …Recognizing rights is not enough as it is necessary to provide them” (p. 61). In practice, seniors still do not have the recommended priority in health and social services and their specific needs have not yet been properly addressed (e.g., regulation of long-term care facilities, integration of the three levels of health care, prevention and management of chronic illnesses). Besides the increasing needs for health and social services, the aging of the population also raises concerns about the negative impact on the workforce. The old-age dependency ratio was 15.6 in 2010 but is estimated to be 51.9 in 2050, a trend that raises a red flag for urgent social security reform in Brazil (Simões, 2016). Social security is considered a fundamental right in the 1988 Constitution, and the system is based on three pillars: health, pension, and welfare assistance. As explained earlier, the pension system is multipronged, with most beneficiaries covered by the RGPS system. Currently, RGPS spends almost R$34 billion (U.S.$10.8 billion) every month, which represents about 8% of the country’s GDP. This expense, however, is estimated to reach 18% of the GDP by 2060, threatening the sustainability of the entire social security system. In 2016, the RGPS deficit was about R$150 billion (U.S.$47.7 billion), which, added to the R$77 billion (U.S.$27.5 billion) deficit of the Federal Pension Regime for civil and military public servants, raises an alarming scenario for the Brazilian government and society (Brasil. Ministério da Previdência Social, 2017). In December 2016, President Michel Temer submitted a new pension bill to Congress with the purpose of ensuring the sustainability of the social security system and promoting equity between workers and public servants. The main changes include the required time of contribution, a minimum age for retirement (Brazil is one of the five countries that do not have a minimum age), and the proportional value of benefits based on time of contribution (Alves, 2016; Brasil. Ministério da Previdência Social, 2017; Camarano & Fernandes, 2016; Marchesan, Kaoru, & Abe, 2017). With the vast majority of the older population consisting of community-dwelling seniors, the demand for elder care increasing, and decreased availability of family members to care for dependent seniors, the country urgently needs long-term care policies. This topic is not addressed in the National Health Policy for the Elderly (Política Nacional de Saúde da Pessoal Idosa—PNSI), which sets national guidelines for active aging and management of frailty (Brasil. Ministério da Saúde, 2014; Duarte, Berzins, & Giacomin, 2016; Lima-Costa et al., 2016). A long-term care policy for older adults should guide the development of models of care that consider the continuum of support required by seniors with different levels of dependency. Care systems for older adults should include home- and community-based care (with coordinated social and health services) and services provided in assisted living and nursing facilities, as well as day care and palliative care. Also, acknowledging the value of family caregiving, greater instrumental, emotional, and financial support should be provided for those who assume this role. And finally, such a policy should include the regulation of caregiving as a profession, combined with comprehensive training and support, as the need for caregivers increases (Duarte et al., 2016; Gugel, 2016). Conclusion Brazil is aging at a rapid pace, whereas policies and legislation to address the needs and rights of older adults are still underdeveloped. Despite the engagement of important stakeholders in the development of the National Policy for the Elderly, its implementation has been hampered by the lack of political will, budgetary provision, and government coordination and leadership. Although the Constitution establishes a shared responsibility for the wellness of older adults among families, society, and the State, families have assumed most of the onus as a consequence of societal expectations and lack of long-term care policies and support. A country that still considers itself a “young country” needs to awaken to the urgency of greater investment in research on aging, workforce development, coordinated services and support, and age-friendly cities to better address the current and future needs of the older population. Funding None reported. Acknowledgments The authors thank Ana Maria Camarano, Áurea Soares Barroso, Holly Coryell Smith, Idenéia Silveira dos Santos, Ina Voelcker, Maria Fernanda Lima-Costa, and other researchers and professionals who contributed with information and ideas for this article. Conflict of Interest None reported. References Alves , L . ( 2016 ). Brazil announces new social security reform bill . The Rio Times . Retrieved March 8, 2018, from http://riotimesonline.com/brazil-news/rio-politics/brazil-announces-new-social-security-reform-bill/ Associação Brasileira das Entidades Fechadas de Previdência Complementar . ( 2014 ). The Brazilian pension system . Retrieved March 8, 2018, from http://www.abrapp.org.br/Paginas/Brazilian-Pension-System.aspx Associação Nacional de Gerontologia . ( 1989 ). Recomendações de políticas para a terceira idade nos anos 90 . Retrieved March 8, 2018, from Rio de Janeiro: http://angbrasil.blogspot.com/2015/06/politicas-para-3-idade-nos-anos-90.html Barros , R. H. 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Relações entre as alterações históricas na dinâmica demográfica brasileira e os impactos decorrentes do processo de envelhecimento da população . Rio de Janeiro, Brazil : IBGE . Veras , R. , Ramos , L. R. , & Kalache , A . ( 1987 ). Crescimento da população idosa no Brasil: Transformações e conseqüências na sociedade . Revista de Saúde Pública , 21 , 225 – 233 . doi: 10.1590/S0034-89101987000300007 Google Scholar CrossRef Search ADS PubMed World Health Organization . ( 2012 ). Active ageing: A policy framework . Madrid, Spain : Author . World Health Organization . ( 2015 ). World report on ageing and health . Luxembourg: Author . Zorzin , P. , Wajnman , S. , & Turra , C . ( 2016 ). Previdência social e desigualdade racial no Brasil . Anais , 1 – 28 . © The Author(s) 2018. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. 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Abstract

Abstract The population in Brazil is aging at a fast pace and in a context of historical socioeconomic and regional disparities. In the last decades, the country has developed important policies and legal mechanisms to guarantee older adults’ right to age well and with dignity. The implementation of these policies and laws, however, has been slow and hampered by lack of coordination and resources. With an estimate of 64 million seniors living in the country by 2050, Brazil has important public policy issues to address, such as the poor implementation of the National Policy of the Elderly, the urgency of Social Security Reform, and the need for a comprehensive long-term care policy for older adults. Demography, Public policy, Research on aging, International spotlight, Brazil Out of the estimated 2 billion older adults who will represent 22% of the global population in 2050, 80% will be living in developing countries. And although in most developed countries the aging of the population has been a gradual process consequent to substantial social and economic growth, populations in many developing countries are aging before having had the chance to increase wealth and reduce social disparities (World Health Organization, 2012). This is the case of Brazil, the largest country in South America, with the fifth largest population in the world, and with great social and economic disparities. Its population, currently over 200 million people, is aging at a rapid rate, and despite some recent improvements in socioeconomic status and health indicators, recent studies show that health disparities in old age have not changed in the last 10 years (Braga, Lima-Costa, César, & Macinko, 2015). The population growth of people aged 60 and older from 10% to 20%, which took France about 150 years to complete, is happening in Brazil in less than 20 years (World Health Organization, 2015). The fast aging of the population in Brazil increases the pressure for governments to address historical challenges in areas such as social security, health, education, housing, employment, and urban development. A combination of greater societal awareness, community support, effective public policies, and legislation is needed to ensure people age with dignity and high quality of life, maintaining their active role as citizens and their importance to the society (Braga, Del Maestro Filho, Silveira, & Guimaraes, 2008). This article aims to give a brief overview of aging in Brazil by presenting some of the demographics and characteristics of the older adult population, the principles and innovative processes used in developing the main legislation for the rights of older people, a bit of the history and current research agenda on aging, and finally some of the key policy issues in the country. The Demographics of Aging in Brazil Under Brazilian law, “older adults” are 60 years of age or older, a group that represented 9.7% of the population in 2004, 13.7% in 2014, and is estimated to represent 18.6% in 2030 and 33.7% in 2060 (Figure 1). (Instituto Brasileiro de Geografia e Estatística, 2015). Women represent the majority of older adults in the country and have a higher life expectancy at age 60 and 80 (Instituto Brasileiro de Geografia e Estatística, 2009). Recently, the racial composition of the older adult population has changed in the country, with the proportion of whites decreasing from 61.7% in 2000 to 56.8% in 2010, and the proportion of blacks and browns increasing in the same period from 6.9% to 7.7% and from 29.5% to 33.8%, respectively (Oliveira, Thomaz, & Silva, 2014). (Data on color/race are originally from the National Household Sample Survey (PNAD) where respondents self-classify themselves and are encouraged to refer to their color skin as a race proxy. This procedure is based on the assumption that the combination of color and race better describes with which racial group individuals identify themselves [Oliveira et al., 2014].) Figure 1. View largeDownload slide Distribution of Brazil’s population by age groups, from 2004 to 2060. Reprinted from Instituto Brasileiro de Geografia e Estatística (2015, p. 14). Figure 1. View largeDownload slide Distribution of Brazil’s population by age groups, from 2004 to 2060. Reprinted from Instituto Brasileiro de Geografia e Estatística (2015, p. 14). As demonstrated in Figure 2, in the last 30 years, literacy among older adults has increased, from 51.9% in 1983 to 77.2% in 2014, a change that has been even greater for older women. Nevertheless, the average number of school years for the older adult population, despite having doubled in the last three decades, was still very low in 2014 (5.1 years for men and 4.9 years for women; Camarano, Kanso, & Fernandes, 2016). Figure 2. View largeDownload slide Literacy and school years for the older adult population by gender (1983, 1993, and 2004). Reprinted from Camarano et al. (2016, p. 85). Figure 2. View largeDownload slide Literacy and school years for the older adult population by gender (1983, 1993, and 2004). Reprinted from Camarano et al. (2016, p. 85). According to the 2015 World Report on Aging and Health, a child born in Brazil in 2015 can expect to live 20 years longer than one born 50 years ago. In the last few decades, the country has gone through an important epidemiologic transition, and although deaths by infectious diseases decreased from 40% of the total registered deaths in 1950 to less than 10% by 2000, deaths from cardiovascular diseases increased from 12% to over 40% in the same period (Instituto Brasileiro de Geografia e Estatística, 2009). Studies investigating the impact of race on the health of the older adult population in Brazil have had mixed results. Although some scholars argue that inequalities in health cannot be attributed to a race apart from socioeconomic contexts, others state that black and brown older adults form a more vulnerable group due to a lifetime of unequal exposure to health risks (Oliveira et al., 2014). The proportion of households with seniors increased from 22.3% in 1983 to 31.2% in 2014. Among these households, 85.2% have access to water and 83.9% access to garbage collection. Nevertheless, only half of these homes are connected to the sewage system, which continues to be one of the biggest sanitary deficiencies in the country (Camarano et al., 2016). The first census of nursing care facilities identified 84,000 institutionalized seniors, which represents less than 1% of the older adult population (Camarano & Kanso, 2010). In the last few decades, demographic, economic, and social changes have substantially transformed family arrangements in Brazil. Although in 1980 most seniors were living with a spouse and children (43.7%), in 2014 only 25.5% had this residential arrangement, and most households (36%) involved older women living by themselves or with their children. The proportion of seniors living with children or relatives, which is considered an indicator of physical, mental, financial, or social fragility, had a significant drop, especially among women (from 26.7% in 1983 to 13.7% in 2014). Conversely, the proportion of older women as the “chief of the house” (chefe da casa) has increased from 33.4% to 51.9% in the same period (Camarano et al., 2016). Older adults have increasingly become an important source of income for families. Data from the Brazilian Institute of Geography and Statistics (IBGE) show that in 2013, 76.1% of older adults in Brazil were retired or pensioners, and among those, 15.6% were still working to supplement their income. Also, of the older adult population, 64.4% were the main source of income for their families (Ribas, 2016). Brazil is one of the few countries with no restrictions for retirees to continue working, and therefore, older adults are able to combine income from pensions and salaries. As a result, by 2014 retired men and women represented 51.6% and 55.5% of older workers, respectively (Camarano et al., 2016; Gugel, 2016). The Brazilian pension system is formed by three pillars. The largest pillar is the General Social Security Regime (Regime Geral da Previdência Social—RGPS), a mandatory pay-as-you-go system managed by the National Social Security Institute (Instituto Nacional do Seguro Social—INSS), which covers employed private-sector workers as well as self-employed professionals and elected civil servants. Public-sector employees are under a separate pension system, the Pension Regimes for Government Workers (Regime Próprio de Previdência Social—RPPS). As each federal unit can have its own system, there are more than 2,400 specific pension regimes for public servants, which are managed by the federal government, states, and municipalities with specific financing rules. The third pillar is the relatively new Private Pension Regime (Regime de Previdência Complementar—RPC), which offers occupational and individual plans on a voluntary basis (Associação Brasileira das Entidades Fechadas de Previdência Complementar, 2014; Caetano, 2015; Rangel & Saboia, 2015). The total number of pensions paid by the RGPS increased 2.8-fold from 1988 to 2013, which is attributed to a combination of greater social security coverage and the aging of the population. In 2013, women received 59% of the RGPS benefits. However, they received the vast majority (81%) of the “survivor benefits,” a category that pays less than the “time per contribution” category, where men were 71% of the beneficiaries, which indicates clear income inequality among seniors based on gender (Camarano & Fernandes, 2016). Social security benefits have been an important strategy to reduce poverty and inequalities in old age. In 2014, about 75% of the whole older adult population in the country received some social security benefit, including RGPS, RPPS, and welfare benefits (Camarano & Fernandes, 2016). The proportion of old women with no income has dropped from 34.3% in 1983 to 12.4% in 2014, which was even lower (about 5%) among those aged 80 years or older. In 2014, about 80% of older women’s income was provided by social benefits (Camarano et al., 2016). Social security policies have also had an important role in pulling many seniors out of poverty and in reducing racial disparities among the older adult population. A recent study showed that a greater proportion of the black population leaves poverty when aged, and black older adult population receive higher returns from their contributions when compared with white seniors of the same cohort (Zorzin, Wajnman, & Turra, 2016). Public Policies and Legislation for the Rights of the Older Adult Population In Brazil, aging with dignity is considered a fundamental human right, protected and promoted under the principles of a Social State of Democratic Rights. Article 230 of the 1988 Constitution states that “the family, society and the State have the duty to support the elderly, ensuring their participation in the community, defending their dignity and well-being, and guaranteeing them the right to life” (Giacomin & Gama Maio, 2016, p. 137). There are currently three major legal instruments establishing and protecting elder rights in the country: the Constitution, the National Policy for the Elderly, and the Statute for the Elderly (Gugel, 2016). The initial movement for a national policy for the older adult population began in the 1970s, when the country was still under military dictatorship, in a joint effort of nongovernmental organizations, professionals, and volunteers working with seniors. In 1976, the first Social Policy for the Elderly proposed the engagement of communities to help seniors stay with their families and a review of the criteria for licensing new long-term care institutions for seniors. The policy also called for the creation of specialized medical services for seniors (including home care), the review of the social security system and programs for retirement preparation, professional training for senior care, and the systematic collection of data about the country’s older adult population (Oliveira Alcântara, Camarano, & Giacomin, 2016). With re-establishment of democracy, aging became part of the political debate and was included in the 1988 Constitution. The so-called “citizen constitution” introduced the concept of social security as a citizen’s right, making Brazil one of the pioneers in Latin America in Social Security Policy. Also, health care, education, and social assistance were made available to the entire population (Oliveira Alcântara et al., 2016). The National Policy for the Elderly (Política Nacional do Idoso—PNI), created in 1994, lists a set of actions to be implemented by governments to ensure seniors’ social rights, autonomy, integration, and effective participation in society. Among the key stakeholders engaged in the process of designing this law were the Brazilian Bar Association (OAB), the National Confederation of Bishops of Brazil (CNBB), the National Gerontology Association (ANG), and the Brazilian Geriatrics and Gerontology Society (SBGG; Braga et al., 2008; Camarano, 2016; Oliveira Alcântara, 2016). As part of the implementation of the National Policy, the Statute for the Elderly (Estatuto do Idoso) was published in 2003 and has been considered not only an important policy enforcement instrument but also an innovative way to promote elder rights. The statute, which was the result of more than 7 years of discussion involving legislators and representatives from various public-interest organizations, states that the family, community, society, and government are responsible for assuring seniors’ rights to life, freedom, respect, dignity, food, health, family, and community support. It also determines that every individual at age 65 and older who cannot provide for their own livelihood is eligible to a noncontributory lifelong pension of 1 minimum wage per month (R$954 or about U.S.$300) paid by the Federal Government (Brasil. Câmara dos Deputados, 2013; Müller, 2014; Nobrega, Faleiros, & Telles, 2009). Seniors’ participation in the planning, implementation, and evaluation of policies, plans, and programs is one of the guidelines of the National Policy for the Elderly. To that end, the policy establishes national, state, and municipal Boards for the Elderly (Conselho Nacional, Estaduais e Municipais do Idoso), which are permanent and deliberative bodies formed by an equal number of representatives from governmental and nongovernmental organizations (Couto, 2016a; Oliveira Alcântara, 2016). Research on Aging: An Overview For most of its history, Brazil was considered “a young country,” a country formed by young people, and this is still the belief of many of its citizens. It required the visionary leadership of researchers and professionals to build awareness in government and society of demographic changes and the need for policies and legislation that support healthy and active aging (Barros & Junior, 2015; Rauth & Py, 2016). The 1987 article, “Aging: A Brazilian Reality,” presented trends in mortality, fertility, and life expectancy from the early 20th century to 2015 and showed that Brazil would go through an aging process comparable to developed countries (Veras, Ramos, & Kalache, 1987). Two years later, the National Association of Gerontology published the report, “Policy Recommendations for the Third Age in the 90s,” urging governments to prioritize issues related to aging. The report argued that the value of social problems should not be measured only by a particular group’s percentage of the total population but rather by the living conditions of that group. The report also stated that the country did not have accurate and specific data about the older adult population (Associação Nacional de Gerontologia, 1989; Rauth & Py, 2016). It was only in 1988 that the aging of the Brazilian population was included in the research agenda of the National Association of Population Studies (ABEP), which brings together scholars for scientific exchange and analysis of national demographic trends (Bezerra, de Almeida, & Nóbrega-Therrien, 2012). Since then, the number of researchers, studies, and publications on aging has increased exponentially (Bezerra et al., 2012; Donizete Prado & Dutra Sayd, 2004). Some of the early population studies on aging conducted in Brazil are still frequently cited and considered fundamental to the development of the research agenda in the country, such as Projeto Epidoso (1991), Projeto Bambuí (1997), and Estudo SABE (1999). Table 1 presents some of the key studies on aging currently active in Brazil. Table 1. Key Research Studies Currently Active in Brazil Study Primary Investigator Research characteristics and objectives Projeto EPIDOSO II Incidência de Perda Funcional (PF) em idosos e efetividade de ações de promoção da saúde na prevenção da PF (Incidence of Functional Loss in the elderly and effectiveness of actions of health promotion in the prevention of functional loss) (active since 2007) Luiz Roberto Ramos Urban cohort study that aims to identify avoidable risk factors for functional loss and to assess the effectiveness of health promotion interventions aimed at preserving and restoring the functional capacity of the older adults and social inclusion of the older adults. ELSI-Brasil: Estudo Longitudinal de Saúde e Bem-Estar dos Idosos Brasileiros (Longitudinal Study of Health and Welfare of the Brazilian Elderly) (active since 2012) Maria Fernanda Lima-Costa Elsi-Brasil is part of an international consortium of longitudinal studies, conducted on national representative samples of the population aged 50 and over. In Brazil, this population-based cohort study is based on a national probabilistic sample of 10,000 adults. The study uses the conceptual framework of other “Health and Retirement Studies” to allow for comparisons between countries. The main objective is to investigate the evolution and determinants of health conditions, functional capacity, and use of health services among older adults. The study adopts a population health multidisciplinary approach that combines economics, epidemiology, health planning, biostatistics, geriatrics, gerontology, and demography, among other perspectives. Fibra 80 +: Fragilidade nos Idosos Brasileiros (Fragility in Elderly Brazilians) (active since 2016) Anita Liberalesso Neri The study aims to determine the prevalence, risk and protective factors for frailty, cognition, and mortality, considering sociodemographic indicators, health conditions, independence, lifestyle, sociability, depression, subjective well-being, personality, and sense of psychological adjustment in people aged 80 and over. Padrões de envelhecimento físico, cognitivo e psicossocial em idosos longevos que vivem em diferentes contextos (Patterns of physical, cognitive and psychosocial aging in older adults living in different contexts) (active since 2015) Anita Liberalesso Neri A descriptive, comparative, and cross-sectional study with people aged 80 years and over, with the aim of identifying the correlation between demographic and socioeconomic risk variables, stressful events experienced in childhood and old age, indicators of cognitive reserve, physical health, social resources, and elements of psychological resilience. A participatory approach to the needs of dependent older people: barriers, facilitators, and sustainable solutions (active since 2016) Renato Peixoto Veras The study aims to identify the main challenges and unmet needs of dependent older adults in four areas: environment (their family environment and external environment), physical, psychological, and social. Research findings will be used to assess the need for better public policies for older dependents and their caregivers, as well as to identify low-cost solutions for immediate needs. Modelo de Hierarquização da Atenção ao Idoso com base na complexidade dos cuidados: Proposta de monitoramento dos três níveis de cuidado na assistencia suplementar (Hierarchical Model of Healthcare for the Elderly based on the complexity of care: Monitoring the three levels of private healthcare services) (active since 2015) Renato Peixoto Veras The objective of the study is to improve the hierarchical model of health care for older adults, focusing on the three initial levels of care, which concentrates 90% of older adults, by monitoring and evaluating the systems’ structure, processes, and results. Study Primary Investigator Research characteristics and objectives Projeto EPIDOSO II Incidência de Perda Funcional (PF) em idosos e efetividade de ações de promoção da saúde na prevenção da PF (Incidence of Functional Loss in the elderly and effectiveness of actions of health promotion in the prevention of functional loss) (active since 2007) Luiz Roberto Ramos Urban cohort study that aims to identify avoidable risk factors for functional loss and to assess the effectiveness of health promotion interventions aimed at preserving and restoring the functional capacity of the older adults and social inclusion of the older adults. ELSI-Brasil: Estudo Longitudinal de Saúde e Bem-Estar dos Idosos Brasileiros (Longitudinal Study of Health and Welfare of the Brazilian Elderly) (active since 2012) Maria Fernanda Lima-Costa Elsi-Brasil is part of an international consortium of longitudinal studies, conducted on national representative samples of the population aged 50 and over. In Brazil, this population-based cohort study is based on a national probabilistic sample of 10,000 adults. The study uses the conceptual framework of other “Health and Retirement Studies” to allow for comparisons between countries. The main objective is to investigate the evolution and determinants of health conditions, functional capacity, and use of health services among older adults. The study adopts a population health multidisciplinary approach that combines economics, epidemiology, health planning, biostatistics, geriatrics, gerontology, and demography, among other perspectives. Fibra 80 +: Fragilidade nos Idosos Brasileiros (Fragility in Elderly Brazilians) (active since 2016) Anita Liberalesso Neri The study aims to determine the prevalence, risk and protective factors for frailty, cognition, and mortality, considering sociodemographic indicators, health conditions, independence, lifestyle, sociability, depression, subjective well-being, personality, and sense of psychological adjustment in people aged 80 and over. Padrões de envelhecimento físico, cognitivo e psicossocial em idosos longevos que vivem em diferentes contextos (Patterns of physical, cognitive and psychosocial aging in older adults living in different contexts) (active since 2015) Anita Liberalesso Neri A descriptive, comparative, and cross-sectional study with people aged 80 years and over, with the aim of identifying the correlation between demographic and socioeconomic risk variables, stressful events experienced in childhood and old age, indicators of cognitive reserve, physical health, social resources, and elements of psychological resilience. A participatory approach to the needs of dependent older people: barriers, facilitators, and sustainable solutions (active since 2016) Renato Peixoto Veras The study aims to identify the main challenges and unmet needs of dependent older adults in four areas: environment (their family environment and external environment), physical, psychological, and social. Research findings will be used to assess the need for better public policies for older dependents and their caregivers, as well as to identify low-cost solutions for immediate needs. Modelo de Hierarquização da Atenção ao Idoso com base na complexidade dos cuidados: Proposta de monitoramento dos três níveis de cuidado na assistencia suplementar (Hierarchical Model of Healthcare for the Elderly based on the complexity of care: Monitoring the three levels of private healthcare services) (active since 2015) Renato Peixoto Veras The objective of the study is to improve the hierarchical model of health care for older adults, focusing on the three initial levels of care, which concentrates 90% of older adults, by monitoring and evaluating the systems’ structure, processes, and results. Note: The information presented in this table is from Plataforma Lattes, a virtual platform created and maintained by CNPq, which integrates the databases of curricula, research groups and institutions in the areas of Science and Technology operating in Brazil. View Large Table 1. Key Research Studies Currently Active in Brazil Study Primary Investigator Research characteristics and objectives Projeto EPIDOSO II Incidência de Perda Funcional (PF) em idosos e efetividade de ações de promoção da saúde na prevenção da PF (Incidence of Functional Loss in the elderly and effectiveness of actions of health promotion in the prevention of functional loss) (active since 2007) Luiz Roberto Ramos Urban cohort study that aims to identify avoidable risk factors for functional loss and to assess the effectiveness of health promotion interventions aimed at preserving and restoring the functional capacity of the older adults and social inclusion of the older adults. ELSI-Brasil: Estudo Longitudinal de Saúde e Bem-Estar dos Idosos Brasileiros (Longitudinal Study of Health and Welfare of the Brazilian Elderly) (active since 2012) Maria Fernanda Lima-Costa Elsi-Brasil is part of an international consortium of longitudinal studies, conducted on national representative samples of the population aged 50 and over. In Brazil, this population-based cohort study is based on a national probabilistic sample of 10,000 adults. The study uses the conceptual framework of other “Health and Retirement Studies” to allow for comparisons between countries. The main objective is to investigate the evolution and determinants of health conditions, functional capacity, and use of health services among older adults. The study adopts a population health multidisciplinary approach that combines economics, epidemiology, health planning, biostatistics, geriatrics, gerontology, and demography, among other perspectives. Fibra 80 +: Fragilidade nos Idosos Brasileiros (Fragility in Elderly Brazilians) (active since 2016) Anita Liberalesso Neri The study aims to determine the prevalence, risk and protective factors for frailty, cognition, and mortality, considering sociodemographic indicators, health conditions, independence, lifestyle, sociability, depression, subjective well-being, personality, and sense of psychological adjustment in people aged 80 and over. Padrões de envelhecimento físico, cognitivo e psicossocial em idosos longevos que vivem em diferentes contextos (Patterns of physical, cognitive and psychosocial aging in older adults living in different contexts) (active since 2015) Anita Liberalesso Neri A descriptive, comparative, and cross-sectional study with people aged 80 years and over, with the aim of identifying the correlation between demographic and socioeconomic risk variables, stressful events experienced in childhood and old age, indicators of cognitive reserve, physical health, social resources, and elements of psychological resilience. A participatory approach to the needs of dependent older people: barriers, facilitators, and sustainable solutions (active since 2016) Renato Peixoto Veras The study aims to identify the main challenges and unmet needs of dependent older adults in four areas: environment (their family environment and external environment), physical, psychological, and social. Research findings will be used to assess the need for better public policies for older dependents and their caregivers, as well as to identify low-cost solutions for immediate needs. Modelo de Hierarquização da Atenção ao Idoso com base na complexidade dos cuidados: Proposta de monitoramento dos três níveis de cuidado na assistencia suplementar (Hierarchical Model of Healthcare for the Elderly based on the complexity of care: Monitoring the three levels of private healthcare services) (active since 2015) Renato Peixoto Veras The objective of the study is to improve the hierarchical model of health care for older adults, focusing on the three initial levels of care, which concentrates 90% of older adults, by monitoring and evaluating the systems’ structure, processes, and results. Study Primary Investigator Research characteristics and objectives Projeto EPIDOSO II Incidência de Perda Funcional (PF) em idosos e efetividade de ações de promoção da saúde na prevenção da PF (Incidence of Functional Loss in the elderly and effectiveness of actions of health promotion in the prevention of functional loss) (active since 2007) Luiz Roberto Ramos Urban cohort study that aims to identify avoidable risk factors for functional loss and to assess the effectiveness of health promotion interventions aimed at preserving and restoring the functional capacity of the older adults and social inclusion of the older adults. ELSI-Brasil: Estudo Longitudinal de Saúde e Bem-Estar dos Idosos Brasileiros (Longitudinal Study of Health and Welfare of the Brazilian Elderly) (active since 2012) Maria Fernanda Lima-Costa Elsi-Brasil is part of an international consortium of longitudinal studies, conducted on national representative samples of the population aged 50 and over. In Brazil, this population-based cohort study is based on a national probabilistic sample of 10,000 adults. The study uses the conceptual framework of other “Health and Retirement Studies” to allow for comparisons between countries. The main objective is to investigate the evolution and determinants of health conditions, functional capacity, and use of health services among older adults. The study adopts a population health multidisciplinary approach that combines economics, epidemiology, health planning, biostatistics, geriatrics, gerontology, and demography, among other perspectives. Fibra 80 +: Fragilidade nos Idosos Brasileiros (Fragility in Elderly Brazilians) (active since 2016) Anita Liberalesso Neri The study aims to determine the prevalence, risk and protective factors for frailty, cognition, and mortality, considering sociodemographic indicators, health conditions, independence, lifestyle, sociability, depression, subjective well-being, personality, and sense of psychological adjustment in people aged 80 and over. Padrões de envelhecimento físico, cognitivo e psicossocial em idosos longevos que vivem em diferentes contextos (Patterns of physical, cognitive and psychosocial aging in older adults living in different contexts) (active since 2015) Anita Liberalesso Neri A descriptive, comparative, and cross-sectional study with people aged 80 years and over, with the aim of identifying the correlation between demographic and socioeconomic risk variables, stressful events experienced in childhood and old age, indicators of cognitive reserve, physical health, social resources, and elements of psychological resilience. A participatory approach to the needs of dependent older people: barriers, facilitators, and sustainable solutions (active since 2016) Renato Peixoto Veras The study aims to identify the main challenges and unmet needs of dependent older adults in four areas: environment (their family environment and external environment), physical, psychological, and social. Research findings will be used to assess the need for better public policies for older dependents and their caregivers, as well as to identify low-cost solutions for immediate needs. Modelo de Hierarquização da Atenção ao Idoso com base na complexidade dos cuidados: Proposta de monitoramento dos três níveis de cuidado na assistencia suplementar (Hierarchical Model of Healthcare for the Elderly based on the complexity of care: Monitoring the three levels of private healthcare services) (active since 2015) Renato Peixoto Veras The objective of the study is to improve the hierarchical model of health care for older adults, focusing on the three initial levels of care, which concentrates 90% of older adults, by monitoring and evaluating the systems’ structure, processes, and results. Note: The information presented in this table is from Plataforma Lattes, a virtual platform created and maintained by CNPq, which integrates the databases of curricula, research groups and institutions in the areas of Science and Technology operating in Brazil. View Large There are no publicly accessible secondary data sets specifically on aging in Brazil, but many researchers have been using the data from national household surveys produced by the IBGE, such as the Health National Survey (PNS) from 2013, and the National Household Sample Survey (PNAD), published most recently in 2015. Key Public Policy Issues As Brazil is experiencing one of the world’s most rapid rates of demographic aging, historical, social, and economic issues need to be addressed along with new emerging problems (Lima-Costa, Mambrini, Peixoto, Malta, & Macinko, 2016). Although there is great diversity among the older adult population based on socioeconomic status and regional differences, there are three key public policy issues that affect older adults in the whole country: the poor implementation of the National Policy of the Elderly, the urgency of social security reform, and the need for a comprehensive long-term care policy. The National Policy for the Elderly sets the direction for a country where people should be able to age well, with greater autonomy, better health, social engagement, participation in the job market, and quality of life. However, lack of coordination, political will, and budgetary provision have been critical barriers to its implementation (Couto, 2016b). According to Rauth and Py (2016), “with regard to national social policy for old age, this grew in discourse, but stalled in practice. …Recognizing rights is not enough as it is necessary to provide them” (p. 61). In practice, seniors still do not have the recommended priority in health and social services and their specific needs have not yet been properly addressed (e.g., regulation of long-term care facilities, integration of the three levels of health care, prevention and management of chronic illnesses). Besides the increasing needs for health and social services, the aging of the population also raises concerns about the negative impact on the workforce. The old-age dependency ratio was 15.6 in 2010 but is estimated to be 51.9 in 2050, a trend that raises a red flag for urgent social security reform in Brazil (Simões, 2016). Social security is considered a fundamental right in the 1988 Constitution, and the system is based on three pillars: health, pension, and welfare assistance. As explained earlier, the pension system is multipronged, with most beneficiaries covered by the RGPS system. Currently, RGPS spends almost R$34 billion (U.S.$10.8 billion) every month, which represents about 8% of the country’s GDP. This expense, however, is estimated to reach 18% of the GDP by 2060, threatening the sustainability of the entire social security system. In 2016, the RGPS deficit was about R$150 billion (U.S.$47.7 billion), which, added to the R$77 billion (U.S.$27.5 billion) deficit of the Federal Pension Regime for civil and military public servants, raises an alarming scenario for the Brazilian government and society (Brasil. Ministério da Previdência Social, 2017). In December 2016, President Michel Temer submitted a new pension bill to Congress with the purpose of ensuring the sustainability of the social security system and promoting equity between workers and public servants. The main changes include the required time of contribution, a minimum age for retirement (Brazil is one of the five countries that do not have a minimum age), and the proportional value of benefits based on time of contribution (Alves, 2016; Brasil. Ministério da Previdência Social, 2017; Camarano & Fernandes, 2016; Marchesan, Kaoru, & Abe, 2017). With the vast majority of the older population consisting of community-dwelling seniors, the demand for elder care increasing, and decreased availability of family members to care for dependent seniors, the country urgently needs long-term care policies. This topic is not addressed in the National Health Policy for the Elderly (Política Nacional de Saúde da Pessoal Idosa—PNSI), which sets national guidelines for active aging and management of frailty (Brasil. Ministério da Saúde, 2014; Duarte, Berzins, & Giacomin, 2016; Lima-Costa et al., 2016). A long-term care policy for older adults should guide the development of models of care that consider the continuum of support required by seniors with different levels of dependency. Care systems for older adults should include home- and community-based care (with coordinated social and health services) and services provided in assisted living and nursing facilities, as well as day care and palliative care. Also, acknowledging the value of family caregiving, greater instrumental, emotional, and financial support should be provided for those who assume this role. And finally, such a policy should include the regulation of caregiving as a profession, combined with comprehensive training and support, as the need for caregivers increases (Duarte et al., 2016; Gugel, 2016). Conclusion Brazil is aging at a rapid pace, whereas policies and legislation to address the needs and rights of older adults are still underdeveloped. Despite the engagement of important stakeholders in the development of the National Policy for the Elderly, its implementation has been hampered by the lack of political will, budgetary provision, and government coordination and leadership. Although the Constitution establishes a shared responsibility for the wellness of older adults among families, society, and the State, families have assumed most of the onus as a consequence of societal expectations and lack of long-term care policies and support. A country that still considers itself a “young country” needs to awaken to the urgency of greater investment in research on aging, workforce development, coordinated services and support, and age-friendly cities to better address the current and future needs of the older population. Funding None reported. Acknowledgments The authors thank Ana Maria Camarano, Áurea Soares Barroso, Holly Coryell Smith, Idenéia Silveira dos Santos, Ina Voelcker, Maria Fernanda Lima-Costa, and other researchers and professionals who contributed with information and ideas for this article. Conflict of Interest None reported. References Alves , L . ( 2016 ). Brazil announces new social security reform bill . The Rio Times . Retrieved March 8, 2018, from http://riotimesonline.com/brazil-news/rio-politics/brazil-announces-new-social-security-reform-bill/ Associação Brasileira das Entidades Fechadas de Previdência Complementar . ( 2014 ). The Brazilian pension system . Retrieved March 8, 2018, from http://www.abrapp.org.br/Paginas/Brazilian-Pension-System.aspx Associação Nacional de Gerontologia . ( 1989 ). Recomendações de políticas para a terceira idade nos anos 90 . Retrieved March 8, 2018, from Rio de Janeiro: http://angbrasil.blogspot.com/2015/06/politicas-para-3-idade-nos-anos-90.html Barros , R. H. 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Relações entre as alterações históricas na dinâmica demográfica brasileira e os impactos decorrentes do processo de envelhecimento da população . Rio de Janeiro, Brazil : IBGE . Veras , R. , Ramos , L. R. , & Kalache , A . ( 1987 ). Crescimento da população idosa no Brasil: Transformações e conseqüências na sociedade . Revista de Saúde Pública , 21 , 225 – 233 . doi: 10.1590/S0034-89101987000300007 Google Scholar CrossRef Search ADS PubMed World Health Organization . ( 2012 ). Active ageing: A policy framework . Madrid, Spain : Author . World Health Organization . ( 2015 ). World report on ageing and health . Luxembourg: Author . Zorzin , P. , Wajnman , S. , & Turra , C . ( 2016 ). Previdência social e desigualdade racial no Brasil . Anais , 1 – 28 . © The Author(s) 2018. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. 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The GerontologistOxford University Press

Published: Mar 21, 2018

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