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Should Brazil unify its public and private health systems?

. Apr 27, 2020
Should Brazil unify its public and private healthcare systems? Hospital in Pará. Photo: Secom/PA

On April 22, the Brazilian Health Council recommended that federal, state, and municipal governments step up to coordinate the allocation of privately-held resources — including hospital beds — during the Covid-19 pandemic. The council voiced concern that, if the public healthcare system collapses, the unequal access to private intensive care beds “will be an obstacle to the reduction of the lethality rate during the pandemic,” and people that could be saved will end up dying.

Linked to the Health Ministry, the council includes representatives from the government, civil society organizations, and healthcare workers. It is one of the most influential agencies regarding the regulation of Brazil’s public healthcare system.

</p> <p>According to official data cited in the council&#8217;s recommendation, there are currently 14,876 intensive care beds on the public health system, while another 15,898 beds are located in private hospitals. In other words, 52 percent of hospital beds are <a href="https://www.ans.gov.br/perfil-do-setor/dados-gerais">only available to the 22 percent</a> of Brazilians covered by private health insurance.</p> <p>In per capita terms, a <a href="http://www.ensp.fiocruz.br/portal-ensp/informe/site/arquivos/ckeditor/files/DISPONIBILIDADE%20DE%20UTI%20NO%20BRASIL_27_03_2020(1).pdf">study</a> published in March by researchers at the Oswaldo Cruz Foundation showed that there were 13.6 public intensive care hospital beds for every 100,000 Brazilians last year. On the private system, there were 62.6 intensive care hospital beds for every 100,000 citizens with health insurance.</p> <p>The council&#8217;s recommendation highlights that private hospitals in France, Italy, Ireland, and Austria are being administered by the public sector for the duration of the pandemic. It also points out that Brazil already has a unified — public and private — list for organ transplants.</p> <p>The council released its statement amid growing concern over the unequal nature of Brazil&#8217;s access to health treatment during the Covid-19 crisis. The campaign <em>Leitos Para Todos</em> (Hospital Beds for All) calls upon the government to monitor the availability of private hospital beds and to requisition them when necessary.</p> <h2>Without government involvement, task could fall to courts</h2> <p>According to Mário Scheffer, a professor at the University of São Paulo&#8217;s Preventive Care Department, if the government doesn&#8217;t take charge to unify access to public and private hospital beds, the decision will fall to the courts. &#8220;There will be several lawsuits filed in the state of Amazonas, or in small cities, for example.&#8221;</p> <p>&#8220;This would be the worst-case scenario, as it would be very disorganized. The access to hospital beds should be determined according to how critical the patient is, not to who got to the hospital first, who has a healthcare plan, or who filed a lawsuit,&#8221; said the researcher. On April 20, state judge Francisco Carlos de Queiroz ruled that one private hospital in Manaus should keep treating two severe Covid-19 patients in its intensive care unit. Neither have a private healthcare plan and were only admitted to private hospitals due to a lack of beds on the public network, already <a href="https://brazilian.report/society/2020/04/19/more-brazilian-states-facing-collapse-under-covid-19-pressure/">overburdened with Covid-19 patients</a>.</p> <p>In his preliminary decision, Mr. Queiroz ordered that the state of Amazonas should pay for the private medical expenses of both patients, reportedly amounting to BRL 50,000 (USD 9,170) every three days. The lawsuits were filed by the state&#8217;s Public Defender&#8217;s Office.</p> <p>According to Mr. Scheffer, this could be the beginning of the Covid-19 pandemic&#8217;s contribution to what scholars call the &#8220;judicialization of health&#8221; in Brazil. This <a href="https://brazilian.report/business/2019/03/22/healthcare-legal-matter-brazil/">decades-long process</a> involves key healthcare resources, such as public financing, doctors, and beds, being increasingly allocated not through centralized government decisions, but through disparate and often conflicting court orders.</p> <h2>Brazil&#8217;s unequal two-tier healthcare system</h2> <p>Written during the country&#8217;s return to democracy, Brazil&#8217;s 1988 Constitution establishes that access to health is a universal right that must be guaranteed by the state. Among the Constitution&#8217;s main practical outcomes was the structuring of Brazil&#8217;s <a href="https://brazilian.report/power/2018/07/11/brazil-public-healthcare-system/">public health system</a> (or SUS), making it the largest publicly-funded healthcare system in the world, relied on by roughly 70 percent of the Brazilian population.</p> <p>At the same time, higher-income Brazilians pay for private healthcare, with guarantees of shorter waiting times and more personalized treatment.&nbsp;</p> <p>The public and private systems are closely linked in Brazil. SUS frequently hires services from non-profit and for-profit private hospitals. Even privately-insured Brazilians often turn to SUS to gain access to highly complex procedures or medication that they would not be unable to obtain through their private healthcare plans.&nbsp;</p> <p>Though only 22 percent of the Brazilian population has access to health insurance, a 2018 study indicates that 57 percent of healthcare spending in 2015 was private. In other countries with universal healthcare, the percentage of private expenditure was much lower: 21 percent in France, 25 percent in Italy, 29 percent in Spain, and 20 percent in the United Kingdom.</p> <h2>The state has the power to take control of private beds</h2> <p>The radical left-wing Socialism and Liberty Party asked the Supreme Court to grant the SUS control over private hospital beds during the Covid-19 pandemic. The request was dismissed by Justice Ricardo Lewandowski, who argued that the decision is up to federal, state, and municipal governments&nbsp;— not the Supreme Court. On April 15, the party filed another similar lawsuit.</p> <p>However, there are already several legal instruments that allow the government to temporarily requisition private hospital beds. In February 2020, Congress passed a bill regarding exceptional measures that may be undertaken during the Covid-19 pandemic, allowing the government to commandeer &#8220;assets and services from individuals and companies,&#8221; with the right to compensation in the future.

 
André Cabette Fábio

André Cabette Fábio is an award-winning journalist who has previously been published by Folha de S.Paulo, UOL, Nexo, Estadão, and Die Zeit Online. He has mainly written about human rights, inequality, macroeconomics, and violence.

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