The Particularities of Brazil’s Unified Health System
As this nationwide public program reaches 30 years of existence, this is a brief mapping of its strengths, weaknesses, and challenges ahead
Brazil’s health expenditure composition is somewhat unique in the world. It is formed by: 1) 43% of government-run, compulsory, publicly funded arrangements, on which around 75% of the population exclusively depends; 2) 28% of voluntary health insurance schemes; 3) 27% of out-of-pocket spending by individuals; and 4) 2% of other modalities (e.g. medical services being provided by NGOs, charities, etc). This means that 55% of all the moneys flowing within the country’s entire health system is based on the existence of privately controlled, for-profit actors in this scenario.
We must bear in mind that this corresponds only to the remaining 25% of Brazilian inhabitants, who in fact manage to afford paying extra for this kind of coverage. Although these health insurance companies are all subject to constant governmental monitoring and regulation by the National Supplementary Health Agency (ANS), this sector has been notably growing in the past few years while a harmful trend of systematic dismantling of Brazil’s Sistema Único de Saúde (Unified Health System), a.k.a. SUS, can also be observed. A few of the most recent Ministers of Health (e.g. Ricardo Barros and Luiz Henrique Mandetta), who were also representatives in Congress, had their campaigns funded by private health insurance companies.
This increasing unbalance can also be measured by analyzing the slice of Brazil’s GDP dedicated to health, which is around 9.2% as of 2017. This can be further divided into 3.8% public, which is basically Brazil’s public compulsory scheme, and 5.4% private. By comparing these numbers with the average of the Organization for Economic Cooperation and Development (OECD) countries, the developed world’s standard tends towards the opposite direction: 6.5% public and 2.3% private.
Looking into the proportion of the country’s spending in terms of its annual budget, Brazil’s overall investment in health has been growing since the past decade, having increased from 8.4% in 2005, to 9.2% in 2011, to 10.3% in 2017. This could be read as good news, but it is still at the same level of the global average of 10.2% and below the average of the American continent, which is of 13.2%. While European countries range between 15% and 20% of their annual governmental disbursements in this regard, countries like Japan (23%) and Costa Rica (26%) appear to truly prioritize this agenda. The disparity remains enormous.
Brazil’s Unified Health System was created in September 1990 as a direct result of the promulgation of the country’s current constitution of 1988, which enshrined health as a right of every citizen and a duty of the State. According to its guiding principles, it should remain universal (covering not only native Brazilians, but also foreign residents, regardless of their nationality, just for the sake of being human beings), equitably accessible (based on non-discrimination) and integral (meaning that health isn’t merely the absence of diseases, but seen in a more holistic way by encompassing social and economic factors for example).
Built in a decentralized way, SUS is the concrete result of Brazil having evolved from a essentially Bismarckian health system, originally based on a social insurance model attached to the citizens’ employment (similar to the US, Germany, the Netherlands and France), to a publicly funded, free of charge, Beveridgian permanent program, essentially sustained through tax collection by the State. Among other reasons, its singularity stands out due to the fact that it is a longstanding policy experience for a population of around 210 million, while there is nothing currently comparable to SUS in any nation above 100 million inhabitants. Nations like Norway, Denmark, Sweden, the UK, Italy, Ireland, Australia, New Zealand, Canada, Spain, Portugal, and Finland all have similar State-run structures when it comes to health provision, but with way smaller magnitudes.
Covering not only regular preventive, diagnostics, and treatment healthcare services for an array of conditions and diseases (tuberculosis, HIV/AIDS, malaria, cancer, diabetes, high blood pressure, etc), SUS also encompasses Brazil’s entire health surveillance system, the national vaccination program (PNI), ambulance service (SAMU), blood centers, the country’s national regulatory agency (ANVISA), the world’s largest public organ donation program and the most complex network of human milk banks. The system is certainly bold, overarching, and quite ambitious, but it is unquestionable that it requires proper resources (both human and material) to be kept running smoothly, particularly in times of COVID-19.
Above all, SUS should be taken seriously in Brazil as it is already in the rest of the developing and developed world — the country’s Unified Health System has been portraited as a benchmark for many nations which still struggle to develop comprehensive publicly funded health systems in their respective domestic contexts. The World Health Organization (WHO) has always been there to provide technical support in this direction, but lately the multilateral intergovernmental entity seems to be more worried with ensuring coverage rather than actual access. According to the above-mentioned data, among other challenges, SUS is certainly underfunded, and Brazilians should not take it for granted at the risk of jeopardizing this remarkable public policy trajectory.