Brazilian health system
Paulo M. Buss, MD, MPH
Director, FIOCRUZ Center for Global Health
Full Member, National Academy of Medicine
Cape Town, PHA3, July 2012
1988 Constitution
Since 1988, Brazil has been developing a dynamic,
complex health system based on the principles of
health as a citizen’s right and state’s duty.
It strives to provide comprehensive, universal,
preventive and curative care through decentralized
management and provision of health services and
promotion of community participation at all levels
Infant Mortality and Income
Ricos
Pobres
2001-2
1991
0
20
40
60
80
100
Difference between richer and poorer quintiles
Brazilian health system: complex network of
complementary and competitive service providers and
purchasers, forming a public–private mix
Three subsectors:
1. Public subsector (SUS): services financed and provided
by the state at the federal, state, and municipal levels
2. Private (for-profit and non-profit) subsector: services
financed in various ways with public or private funds
3. Private health insurance subsector: different forms of
health plans, varying insurance premiums and tax
subsidies
Public and private components distinct but
interconnected
Basic structure of the SUS
• Three tiered system
– Federal, 27 States, 5,562 Municipalities
• Sharing in financing
– Federal
58.0 %
– States
24.7 %
– Municipalities 17.3 %
• Integrative Commissions at Federal and State
level
• Community involvement through health
conferences and councils
Financing
• Taxes, social contributions, families and
employers
• 8,8% GDP in health (2009):
– 43,6% public expenditure
UK (82%), Italy (77,2%), Spain (71,8%),
USA (45,5%), Mexico (46,9%)
Primary Health Care (PHC)
[Family Health Strategy] was
the cornerstone to build an
universal, accessible,
integral, comprehensive and
equitable Brazilian National
Health System
National Primary Health Care Policy
Since March, 2006
PHC: group of health interventions, both at
individual and collective levels, that include
health promotion and protection, disease
prevention, diagnosis, treatment, rehabilitation
and health support
Actions developed through a multidisciplinary work team, in a
geographically defined territory and its correspondent
population
PHC: preferential and first contact point in the health system
Principles: Universality, accessibility, coordination, vinculation,
integration, responsibility, comprehensiveness, humanization,
equity and social participation.
Family Health Team
At least: a physician, a nurse, a nurse assistant
and 4 to 6 community health agents
Most of the places include dental and social
work professionals
All of them work full time (40 hours per week)
***
Salary is equal to having two or three different
jobs for a physician
Employment contracts under responsibility of
municipalities
Source:José Noronha, Icict/Fiocruz
Family Health Team
Community Health Agents
To live in the same area where they
work
240 thousands workers
Must know their community’s
problems
To be able to facilitate and improve connections between
primary care professionals and the community (cultural
competency)
They are one of the core members of the Brazilian primary
health care strategy
As a general health care professional focus on illnesses but
also health promotion and prevention plus intersectoral
connections
Family Health Strategy
Evolution of the coverage of Family Health Teams
BRASIL, 1998/2010
1998
2002
2000
2006
0%
1 a 25%
2011
25 a 50%
50 a 75%
75 a 100%
Family health teams: Evolution 1994-2011
Coverage of population (1994-2011)
FHP figures (2012)
32,080 teams
5,284 municipalities
Coverture: 52% Brazilian population; 98 million
people
Oral health teams: 21,038; 4,850 municipalities
Communitarian agents: 240 thousands
Expenditures: around USD 35 per person
covered per year; no drugs included
SUCESS, INSUCESS,
CHALLENGES
The expansion of the Family Health Strategy has improved the access to
integral and permanent care, creating a platform for the prevention and
management of the non-communicable diseases . For each 10% coverture
raises, 4.5% of infant mortality falling.
+ Vulneráveis
Média
– Vulneráveis
Schilling CM et al. Health Policy and Planning 2011 (no prelo)
The National Immunisation Programme set up in
1973 stands out as one of Brazil’s most successful
public health programmes, as reflected in its high
vaccination coverage and sustainability, the latter
guaranteed in part by the National Self-Sufficiency
Programme in Immunobiologicals
There have been no cases of poliomyelitis in
Brazil since 1989, nor measles since 2000
Immunization
• Between 1980 and 2007 the number of deaths due
to tetanus falls 81% and for coqueluche 95%
• In2007, no deaths due to diphtheria, poliomyelitis or
measles
• The incidence and lethality due to meningitis caused
by HiB in children under 5 reduced dramatically after
the introduction of HiB vaccine into de Brazilian
vaccination program in 1999
Family Health and
Family Subsidies
Intersectoral action
Bolsa Família
Brazilian Cash Transfer Programme
7 years of evolution
Reducing extreme poverty
Reducing inequalities in wealth
distribution
Very important complement to
the universal health system
Better access to food and other
fundamental goods
Health condicionalities
Dynamic intern market
http://www.mds.gov.br/bolsafamilia/mural/es
pecial-bolsa-familia-7-anos-1
Social participation
SUS built during the re-democratization process and was
its central political and ideological component
(Health is democracy and democracy is health)
Nest of SUS: VIII National Conference of Health (around
5,000 participants from all levels; social movements –
academic sector – politicians – managers – private sector)
National, ‘provincial’ and municipal (local) Councils of
Health
Fragmentation of the social movement: ‘Social’ councils
vs. ‘health’ or other sectorial councils? No connections
(competition) among councils
Final remarks
• The main strategy for improving healthcare should be
through the strengthening of health system and services
provided in an integrated manner
• Healthcare systems should be strongly anchored on a sound
primary care strategy
• Healthcare networks, with well-defined lines of care and
appropriate disease management protocols are essential to
good healthcare delivery
• Disease specific programmes can only succeed when
supported by healthy healthcare systems
• Targeted programmes should be directed to specific
populations rather than to specific diseases
• For good health outcomes it is crucial articulate health to
other social policies