On the occasion of the 30th anniversary of the unified healthcare system in Brazil, Prof Adriano Massuda and Ana Maria Malik of FGV-EAESP and their fellow researchers give an account of the nation’s journey on achieving nearly universal access to health, and the road ahead.
By CoBS Editor Guragam Singh. Related research: Brazil’s unified health system: the first 30 years and prospects for the future
Rights and duties
The seventh edition of the Brazilian Constitution recognised that the wealth of a nation was its people and made health not only a universal right but also a state responsibility. As such, it paved the way for the unified health system—or Sistema Único de Saúde (SUS)—which since 1990 has contributed to notably reducing the inequality in healthcare access and improving results for those who do.
The SUS targeted existing and new infectious diseases, high maternal and child mortality, and problems caused by major changes in society. These were urbanisation, the opening of the Amazon frontier, reduced female fertility, and a higher number of deaths from non-communicable diseases.
This success of the SUS was largely made possible by the decentralisation of power, for the local governments were given the authority and the funds to take decisions on public health. In what can only be a tribute to a sense of ownership towards public good, governments at three levels—federal, state, and municipal—also took part in joint commissions that took such decisions.
Step by step
Yet, this story of the SUS has not been without its challenges, for ever since its creation, the SUS has been underfunded. Steps to overcome this hurdle began in 1998 and real health expenditure per capita increased by almost 150% between 1989 and 2014. As such, this feather in Brazil’s cap also includes the development of a private healthcare system, which is used by people with high incomes either through their own pockets or via private health insurance.
Credit still must be given to the SUS for changing the landscape of healthcare in Brazil. This involved ‘rapid expansion of comprehensive primary healthcare (PHC) centres and the development of health networks for mental health services, emergency care, and specialised outpatient services’.
Further improvements were made through such programmes as those that delivered to the poorest areas in north-eastern Brazil and set standards for family health teams, which provided a wide array of health services including disease prevention and chronic disease management. And formed a core part of the SUS for PHC, despite staff shortages.
The programme for these teams became the Family Health Strategy (FHS) in 2006 as a mark of the crucial role it played in the public health system—teams covered 4% of the population in 1998 but a whopping 62% in 2018. As such, Brazil has witnessed a fall in infant mortality, avoidable hospitalisation and associated deaths, as well as decline in racial inequality in mortality. To cap it all, people satisfaction with the SUS has increased, as has accessibility to a level that is akin to high-income countries’.
This Brazilian legacy of thirty years still faces its share of problems—access to specialist care is characterised by long waiting times and delays, and the FHS still does not cover the country properly. These are being dealt by leveraging public-private partnerships (PPP) that are funded by the public but run privately.
According to the researchers, the SUS has also taken measures to ‘better regulate health products’ and to increase their availability and affordability. These measures also include a national immunisation programme, a policy on generic medicine, an essential drugs list, and promotion of locally produced health products.
The status accorded to health in the Brazilian legal setup is a double-edged sword, for people can go to court to ensure that the government provides better access to care. The caveat is that most of these cases are filed on behalf of those wanting to access high-cost treatment not covered by the SUS. Putting pressure on an overtaxed system. Though, there are regions where people from more humble backgrounds are in the majority of those seeking justice, and access to care. For now.
From hero to zero
All these achievements may turn to dust, given the major changes that Brazil is facing as a society today. One such change is austerity in public spending. The researchers showed that transfer of funds from the federal to municipal level was linked with lower infant mortality, increased FHS coverage, and a higher frequency of visits to care centres by expecting mothers; three parameters crucial to the United Nations’ Sustainable Development Goals.
The study also showed that the effect of changes in national funding was more strongly felt across each of these parameters in smaller municipalities. According to the researchers, this highlights that ‘federal subsidies are much more effective in smaller municipalities, which are more reliant on federal funds than are larger municipalities’.
Also prominent is the likely effect on amenable heart-related diseases, especially in municipal areas that manage resources better.
When politics trumped humanity
Other transformations include a political shift towards populism, ‘testing democracy and threatening human rights’. The new fiscal policy that ended targeted federal spending on health and education is still to be replaced by a proper health plan.
Medical cooperation with the Cuban government has also ended, resulting in a redistribution of SUS resources that could seriously affect the poor. In another blow to the progress of the SUS, the Brazilian government objected to including pro-reproductive and sexual healthcare terminology in its universal healthcare programme. Arguing that use of such words boosts policies that could promote abortion.
Graphic descriptions in booklets—distributed to adolescents—that give instructions on condom use have also been banned by the government. Plus, the LGBTQ+ community been denied a special mention of being protected by the Ministry of Women, Family, and Human Rights, which states that ‘diversity policies have threatened the Brazilian family’.
The Ministry of Education also supported a policy that did not allow to teachers to encourage students to talk about gender identity, diversity, sex ed, and politics. New laws also allow for guns to be more easily available, that too in a country that already has a high number of violent death cases. Something Prof Massuda and his team say does not bode well for health.
A toast to national health
As such, the researchers recommend that the SUS maintain the principles of universality, completeness, and free care, if Brazil wants to achieve universal health care. Yet, clear definitions on what is covered by the SUS at various levels and better regulation are needed to prevent unnecessary litigation, which yields unfair results for access to treatment.
The SUS also needs adequate public funding to continue the good work it has accomplished in the delivery of health services. These, the researchers further contend, need to be delivered through a network that is properly integrated at the primary, secondary, and tertiary levels of care. To this end, the network also needs to take into account the private health care system, which needs to be well-regulated, and be supported by a strong PHC system.
The success of the SUS thirty years ago depended largely on the decentralisation of power. While essential at the time, this model needs to evolve to cater to the organisational burden placed on these municipalities. This means the development of a new ‘interfederative governance model’ that will improve coordination and restore equity in the system.
Also needed are expanding investments in the health sector, coupled with improving policies in others such as training, industrial, regulatory, and social. And better career paths for those in the SUS and an environment that promotes social debate among the stakeholders of public health—the entire Brazilian people—for it is only they who should get to decide what is in their best interests, as they move towards better health and prosperity. Saúde!
- View Profs Massuda and Malik‘s academic profiles
- Link up with Adriano Massuda and Ana Maria Malik via LinkedIn
- Download the Council’s white paper on Health & Healthcare at the Crossroads of Business and Society
- Discover the learning experience at FGV-EAESP, Brazil
- Enquire about the FGV-EAESP OneMBA
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