Brazil's health care system vastly expands coverage, but universality, equity remain elusive

Two decades after Brazil's constitution recognized health as a citizen's right and a duty of the state, the country has vastly expanded health care coverage, improved the population's health, and reduced many health inequalities, but universal and equitable coverage remains elusive, experts from four major Brazilian universities and New York University have concluded.

According to their analysis—one of six articles published in the medical journal The Lancet as a special series on health in —while federal expenditures have nearly quadrupled over the past 10 years, the health sectors' share in the federal budget has not grown, resulting in constraints on health care financing, infrastructure, and human resources.

The paper's co-authors were: Jairnilson Paim of the Federal University of Bahia; Claudia Travassos of Center for Communication, Scientific Information and Technology at the Oswaldo Cuz Foundation; Celia Almeida of the National School of Public Health, Oswaldo Cruz Foundation; Ligia Bahia of the Federal University of Rio de Janeiro; and James Macinko, an associate professor at New York University's Steinhardt School of Culture, Education, and Human Development.

After more than 20 years of a military dictatorship, Brazil created its present constitution in 1988, which included health as a right of citizenship. Health care reform in Brazil, then, occurred under unique circumstances--simultaneously with the process of democratization and spear-headed by health professionals along with civil society movements and organizations.

To meet this constitutional guarantee, the country established the Unified Health System, or Sistema Único de Saúde (SUS), which was based on the principles of universality, equity, integrality, and social participation. The SUS, which serves more than 192 million citizens, is supplemented by private insurers, which cover about 25 percent of Brazilians.

Overall, the Brazilian health system is made up of a complex network of complementary and competitive service providers and purchasers, forming a public–private mix that is financed mainly by private funds.

During the past two decades, the researchers noted, the SUS has undergone significant changes. Among these were granting municipalities greater responsibility for health service management, along with the flexibility and means which to bring about social participation in health policy making and accountability.

In the Lancet study, the researchers found vastly increased access to health care for a substantial proportion of the Brazilian . In 2009 alone, the SUS financed about 12 million hospitalizations, delivered nearly 100 million ambulatory care procedures per month, and reached universal coverage of vaccination and prenatal care. It also expanded the supply of related human resources and technology, including enhanced production to meet most of the country's pharmaceutical needs.

But the researchers also observed that "the SUS is a health system under continual development that is still struggling to enable universal and equitable coverage."

"As the private sector's market share increases, interaction between the public and private sectors are creating contradictions and unfair competition, leading to conflicting ideologies and goals—notably, universal access vs. market segmentation," they wrote. "All of this has a negative effect on the equity of access and outcomes."

Further complicating the nation's goal of universal coverage are constraints on federal funding. While federal expenditures have increased nearly four times over the past 10 years, they added, the health sectors' share in the federal budget has not grown, producing constraints on financing, infrastructure, and human resources.

"The development of the Brazilian reflects the uneven process of social, economic, and political development within the country," the researchers wrote. "Ultimately, to overcome the challenges that Brazil's system faces, a revised financial structure and a thorough reassessment of public-private relations will be needed. Therefore, the greatest challenge facing the SUS is political. Such issues as financing, composition of the public–private mix, and the persistent inequities cannot be solved in the technical sphere only."

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