Brazil's healthcare system reaches out to the poor
healthcare brazil

Brazil’s public healthcare system reaches out to the poor

In 2018, the Brazilian public healthcare system, known as SUS (literally, Unified Healthcare System), turns 30. It was born with the 1988 Constitution – and was considered one of the pillars of the new political and social system the country tried to establish after two decades of military dictatorship.

From then on, in principle, healthcare was regarded as a basic right that should be provided by the state to all citizens. Care had to be universal and access to services should be equal.

It took almost a decade for the system to be fully implemented, but in 1996, Brazil finally consolidated a healthcare system that spanned the whole country and was free. The country was the first outside the Organization for Economic Cooperation and Development (OECD) to include universal health coverage in its legislation.

Who uses public healthcare in Brazil?

Today, the SUS reaches more than 70 percent of the population. Before it was put in place, a large share of Brazilians didn’t have any access to health services. Nearly all municipalities have at least one team from the Family Health Program, which focuses on primary care. This type of healthcare is the strategy chosen to integrate all sectors of Brazil’s population and provide them with health services.

The SUS-led National Immunization Program administers 98 percent of all the vaccines in the country. Citizens have free access to every single vaccine recommended by the World Health Organization. More than 90 percent of transplant surgeries made are financed by SUS, and Brazil has the largest public program for organ transplants in the world.

The SUS was responsible, as reported by the World Bank in 2013, for a change in the way the health system is governed in Brazil. It decentralizes the administration of these services and shares responsibilities across federal, state, and municipal levels. Also, this system was able to increase and stabilize public spending and financing for health. Government spending has increased 224 percent between the 1980s and the 2010s; in the same period, a 111 percent increase in per capita spending was detected.

Even though the system is considered an example in how to structure and manage public healthcare throughout the world, healthcare is still the third biggest worry among Brazilians, behind only unemployment and corruption. When asked about what should be given priority in public policy, healthcare has been number one since 2014. There seems to be a gap between what the system appears to be and how it works in practice.

Does the SUS actually work or is an illusion?

For Ana Maria Malik, coordinator of the Center for Studies and Planning in Health at think tank Fundação Getúlio Vargas, the SUS works and there’s no doubt about it. In her opinion, there is a misleading perception that public health is completely ineffective. “The main problem with SUS or healthcare in Brazil is under-financing,” she says.

There are areas in which the system could do better and in order to solve those problems, she believes, public spending should be increased and managed in more rational ways. As examples of successful initiatives which sprouted from the SUS, Ms. Malik mentions Brazil’s vaccination program and the increased accessibility of medicine to the population, both “international benchmarks.”

Brazil public healthcare system

However, if you’re a Brazilian citizen, that seems a bit hard to believe, especially for those in the middle class. It is not uncommon to hear stories of people waiting in endless lines for an appointment with a SUS doctor. Newscasts will often show images of run down hospitals where there are not enough beds for everyone and some patients have to sleep on the floor.

According to André Lucirton Costa, a professor at the University of São Paulo in São Carlos and a specialist in public health, the apparent disconnect between what the service should be and what actually happens is easily explainable. The SUS, he says, “does not yet fulfill the role for which it was created,” he admits. “And why is that? Because it is a very new system. It has existed for only 30 years.” The first steps were to include the majority of the population in order to offer primary healthcare for all. Brazil “is betting on prevention,” he says.

Numbers show that public healthcare is important. Nearly all Brazilian citizens use SUS at some point in their lives. A study shows that almost 90 percent of the population uses it in some way: either exclusively or in combination with private services.

Brazilians’ reliance on private healthcare shows that the SUS is not quite seen as an actual public alternative. Experts predicted that spending on private healthcare would decrease as the public system managed to establish itself. But that has not proven to be true. Private spending remained stable from 1995 to 2009, a World Bank report shows. It remains slightly above 50 percent of the total spent on healthcare in Brazil.

There was a steady growth in the number of individuals with private health plan coverage. At the same time, government financing of health spending is lower in Brazil than in OECD countries and countries with middle-income.

Of course problems exist, Mr. Costa admits. As it is a new system, there is still a need for better coordination between the entities and governments that manage it. SUS’s main challenges, he believes, are “in terms of organization.” And there’s also the need for more investment. According to Mr. Costa, the per capita spending in the private healthcare sector is still larger than the spending in SUS. And that needs to change.

What could be done to improve the SUS and fulfill Brazilian’s wishes that public healthcare worked better? For Mr. Costa, a reformulation of the whole public sector is necessary. Management needs to be improved in order for the vision to become a reality. “The basic concept is great. The system needs efficiency,” he says.

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BY Diogo Rodriguez

Rodriguez is a social scientist and journalist based in São Paulo.