A Healthy Debate: Does the Brazilian Healthcare Model Offer a Guide to the U.S.?
DEVELOPMENTS
Recently, the Brazilian Minister of Health, José Gomes Temporão, defended his country’s unified healthcare system, Sistema Único de Saúde (S.U.S.), and recommended that U.S. President Barack Obama adopt a similar system for universal health care, stating that S.U.S. has been well-recognized for its successes in combating the health care problems facing Brazil.
As pressure grows within the U.S. to enact reforms that make healthcare more accessible, other countries’ healthcare systems that have made strides towards universal health should be looked at as models. Brazil, which has its own universal healthcare system that has become increasingly effective in recent years, offers both strengths that might be emulated by the U.S. and weaknesses that should be avoided.
BACKGROUND
Prior to the implementation of S.U.S., Brazil’s public health system was known as Instituto Nacional de Assistência Médica da Prevedência Social (I.N.A.M.P.S.) and was restricted to only those who contributed to national social security. I.N.A.M.P.S. was created by the Brazilian military in 1974. The system had its own hospitals, yet most of the procedures were outsourced to the private health sector, which would then be refunded for medical procedures by the program. However, a significant segment of Brazil’s population worked outside of the formal sector and thus did not contribute to social security. These individuals often lacked funds for medical expenditures, and were dependent on the assistance of private hospitals or philanthropic institutions to receive healthcare.
The creation of the Brazilian healthcare system has been widely considered one of the most important social reforms attempted by the Brazilian government in the last two decades. Brazil’s publicly funded system of care, centered on the S.U.S. program, was created after the passage of Article 196 of the Brazilian Constitution of 1988, which was based on the constitutional provision that “health care of a right of all and an obligation of the state”. The goals of the Ministry of Health for achieving the objectives of the 1988 Constitution were to expand health coverage and reduce inequalities in health care coverage between the rich and poor. Thus, S.U.S. was not created as a health system specifically for the poor, but rather as a system to provide efficient quality health care to all Brazilian citizens.
The strategies that the Ministry of Health has chosen to achieve the goals underlying S.U.S. include decentralizing healthcare, so that medical service are performed and overseen by municipalities and states, while minimizing the role of the federal government. Although the provision healthcare has been decentralized, the creation of S.U.S. has also heralded the establishment of a single unitary administrative system for healthcare, which avoided duplicative oversight efforts by multiple levels of competing government bureaucracy that previously plagued Brazilian healthcare. In addition, S.U.S. offers mechanisms that encourage public participation on the federal, state, and municipal level through the creation of public councils that offer input into the system functions. Currently, S.U.S. has been used by approximately 80% of the Brazilian population and its health network is comprised of more than 65,000 outpatient clinics and 6,000 hospitals as well laboratories and health centers.
Although S.U.S. was always intended to offer a range of medical treatments, the program was structured with the expectation that it would primarily be used to treat people with acute conditions, which tend to be abrupt health problem of a limited duration that typically are not difficult to diagnose. However, the World Health Organization (W.H.O.) has noted a significant increase in chronic disease in recent years in developing nations such as Brazil, which are generally defined gradually developing illnesses that frequently may have multiple causes and relatively long durations, such as diabetes, cancer, and tuberculosis. Thus, the initial structure of S.U.S. has become increasingly at odds with the major health problems affecting the Brazilian public. One of the challenges S.U.S. faces is to change the way healthcare is administered from a system in which individuals receive immediate treatments for acute symptoms to one that appropriately addresses long-term prevention and management of chronic illnesses.
Some of the main pressures on S.U.S. relates to the way in which private insurance rates are assessed. As in many other countries, Brazilian private insurance rates are assessed at different levels that increase with a person’s age, leading to insurance costs that may be six times higher for elderly participants than for younger participants. As a result, the majority of the middle class population over the age of 59, many of whom live on fixed pensions, are giving up their private health insurance and becoming participants in S.U.S. Such migration from the private sector to S.U.S. is also the product of the degree to which access to quality healthcare through the system has improved over the past two decades.
The increase in public participation has coincided with growing concerns about how the system will continue to be funded, particularly since an important financial transaction tax that had been used to finance S.U.S. was repealed at the end of 2007. Continuing to find means to fund S.U.S. will be a major priority for the Brazilian government as use of Brazil’s public healthcare system becomes ever more widespread.
Despite the challenges S.U.S. continues to face, the program has achieved undeniable success in certain areas. Brazil’s AIDS program has emerged as a global model in HIV/AIDS prevention and treatment for developing nations around the world. In addition, S.U.S. has proved highly successful with regards to providing for complex procedures such organ transplants, gastric bypass, and even sex-reassignment surgeries for free. By improving public sanitation through one of its programs that emphasize prevention, treatment, and education, S.U.S. was able to reduce infant mortality in Brazil by 50% and radically reduce certain preventable illnesses. As a result, Chagas disease has been completely eliminated from the country, and the prevalence of numerous other dangerous diseases has been significantly reduced. These advances, combined with highly successful mass vaccination campaigns, including what has been labeled as the largest vaccination campaign in the world for rubella, has yielded tangible health benefits even for those individuals who do not directly participate in the government health programs.
ANALYSIS
It is in many ways difficult to compare the U.S. healthcare with that of Brazil since the U.S. spends so much more money per capita on healthcare than Brazil. As the Brazilian Minister of Health himself noted, the U.S. currently spends about $670 billion a year on healthcare for its approximately 300 million citizens compared to a mere 50 billion reais (approximately $22 billion) a year spent in Brazil, for a nation with a population of roughly 200 million. However, some lessons can be drawn from the Brazilian healthcare model as the U.S. develops its own plan to expand healthcare.
First, Brazil pursued a method of expanding healthcare that did not single out its poor population, seeking instead to develop a universal healthcare system that is equally accessible to all Brazilians. Decentralization of healthcare has likewise allowed for a more personal and immediate focus on the specific needs of communities; the system overall, however, remains under a single unitary system of oversight to provide safeguards against the potential local corruption in the administration of funds.
Should the U.S. seek a similarly decentralized means for expanding healthcare coverage, it would likewise need to ensure that any universal system it develops provides sufficient accountability and oversight to avoid abuse on the municipal level. The U.S. should try to find multiple avenues of funding expansion of healthcare coverage, and should look at Brazil’s track record of finding alternate sources of funding for its own system following the repeal of its unpopular financial transaction tax.
Most importantly, Brazil’s example shows that even countries with limited means can achieve highly ambitious goals to expand public health care over time. It also shows that when it comes to improving a nation’s public health, a comprehensive healthcare plan does not need to be perfect, but it does need to be initiated.
Michel F Guiraldelli is a research fellow at National Institutes of Health and has worked with the Family Health Program under the auspices of the Brazilian Ministry of Health. He has a PhD in Sciences from the University of Sao Paulo and has written articles for scientific journals in the US and Brazil.
Adam Benz is the Americas Region Editor for Foreign Policy Digest.