TRIPS, Public Health Systems and Free Access
Edited by Benjamin Coriat
Chapter 4: The Brazilian Experience of ‘Scaling-up’: A Public Policy Approach
Guillaume Le Loup, Andreia Pereira de Assis, Maria Helena Costa-Couto, Sonia Fleury, Kenneth Rochel de Camargo and Jean-Claude Thoenig
4. The Brazilian experience of ‘scalingup’: a public policy approach Guillaume Le Loup, Andreia Pereira de Assis, Maria Helena Costa-Couto, Jean-Claude Thoenig, Sonia Fleury, Kenneth Rochel de Camargo Jr and Bernard Larouzé INTRODUCTION In 2000, Hans P. Binswanger, from the World Bank, wrote: ‘The most important issue in the ﬁght against HIV/AIDS is how to scale up existing programmes that are only reaching small numbers of people to the national level’ (Binswanger, 2000). Subsequently, the scaling-up of the HIV/AIDS programmes of low- and middle-income countries rapidly became a new priority of the international community of scientists and health professionals. In this perspective, Brazil was recognized as a model: in 1996, it was the ﬁrst and only emerging country to implement free and universal access to highly active antiretroviral therapy (HAART). It was an example of successful scaling-up. Whatever the content of the policy may be, the scalingup process implies (a) the mobilization of ﬁnancial and human resources, and (b) the extension of programmes (prevention, diagnosis, care) and structures allowing a policy to be implemented throughout a whole country. The Brazilian response to the HIV/AIDS epidemic originated at the local level, in the south-east of the country, the wealthiest part of Brazil, with the best health indicators (Castilho and Chequer, 1997). At the end of the 1980s, the national IST/AIDS programme initiated and managed, with other public and non-governmental actors, a scaling-up process (Teixeira, 1997). The process has been both long and complex, due to the size of the country and...
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