Social exclusion and health inequity: a case study based on a cash distribution program (Bolsa Familia) in Brazil

Objective. To understand the impact of Bolsa Familia (PBF), a federal cash transfer program, and to analyze its effects on social inclusion and exclusion processes experienced by low-income families in Brazil, with a focus on the program's potential to help overcome health inequity. Methods. This qualitative investigation used a case study methodology including observant participation, review of documents, and semi-structured interviews with current and former PBF beneficiaries, as well as with the program's local managers. The study was conducted in a small city in the state of Rio de Janeiro with a high social exclusion index and 100% coverage by the Family Health Strategy (Estrategia Saude da Familia, ESF) program. The economic, political, social, and cultural dimensions of social exclusion and inclusion processes were used to guide data collection and analysis. Results. The program facilitated social inclusion of low-income families, especially in the economic and social dimensions. Nevertheless, it did not produce the changes desired by the beneficiaries in the work dimension. The effects on the political dimension were limited by the insufficient social engagement of the PBF. The interviewees underscored the positive effects of the ESF, which allowed them to exercise their right to health by granting them wider access to primary health care services. However, these effects appeared to be unrelated to the PBF. Conclusions. The results reveal effects, limitations, and challenges of the PBF towards modifying the social determinants of health inequity, in order to promote more effective changes in the social exclusion/inclusion dynamics affecting low-income families.