Strengthening Brazil Health System

For years, several developing countries have taken the initiative to address their public health issues in a more comprehensive and systematic methods. One such country that started building a universal public health system earlier is Brazil. Brazil, the largest country in Latin America has a population of about 204.4 million, with an expansive territory of more than 8.5 million km2. The country has 26 states, 1 federal district, and 5570 municipalities. According to the World Health Organization, the population of Brazil grew by 38.2% between 1990 and 2015. In 2014, the total government spending on health was 6.7% while out-of-pocket payments were at least 25%.1 As of 2013, the upper-middle income country had at least 5,843 hospitals in its healthcare network. According to Rocha et al.,9 out of these hospitals, 2,774 were small hospitals (hospitals with or less than 50 beds) while the rest were high complexity centers (hospitals with the capacity to handle emergency care services or recorded more than 1,000 deliveries in a month). Ideally, majority of small hospitals in Brazil are located in the Northeast region of the country while high complexity centers are largely concentrated in the Southeast region.
The 1988 Brazil Constitution outlines that citizens have a right to healthcare and it is the duty of the state to fulfill this right. The right to healthcare is upheld through a Unified Health System that addresses every individual’s social needs regardless of the ability to afford healthcare or their health status. For the last three decades, the government should have focused on building and strengthening the public health systems. Unfortunately, according to Ocke-Reis,6 this has not being the case and government incentives seem to benefit private health plans more. As private spending increases and economic power affects financial sustainability, the result is a reduced public health spending. At the same time, because SUS began working as a duplicated and parallel system, regulation is more complex for the government. More specifically, Brazilian constitution allows the existence of public and private health sector. People seeking health from private providers pay using private health insurance or out-of-pocket.6 Consequently, because income in Brazil is concentrated, high-income populations are able to purchase private health insurance while their low-income counterparts are left at the mercy of the public health sector.
A quick glance at Brazil’s health care system suggests that the Unified Health System ((Sistema Único de Saúde (SUS)) has had several notable and significant achievements. Some of the outstanding achievements include the provision of primary basic health care, prenatal care, vaccination, and free National Aids program.2 Unfortunately, considering the enormity of the Brazilian healthcare system; it is not surprising that it suffers persistent problems. According to Massuda,3 after more than two decades since its establishment, the Unified Health System is under major threats resulting from economic recessions, political crises, ill-conceived policies, and political decisions affecting the right to health. For instance, the health reforms started in 1980s failed to address fully the structural weaknesses in the system such as disparities in health resource allocation, limited financing, and challenges facing healthcare at the state government level. Of increased concern, disparities in health care access are likely to worsen based on the current political and economic problems. More specifically, persistent and social disparities in health care resource allocation have marginalized the poor communities and those with low education, and especially communities living in the northern region. These people have to battle with various challenges including poor quality services in hospitals and shortage of doctors due to the inequitable distribution of health care professionals. Nonetheless, after a comprehensive review of the various challenges affecting the Brazilian health care system, the most notable issues are underfunding of healthcare and extensive disparities in access to healthcare services and health outcomes in some regions.
Status of Brazil’s Universal Health Coverage
Underfunding of Healthcare in Brazil
In a country where poverty is rife and few people can afford private health insurance, majority of the people have to rely on the underfunded public healthcare system. The idea that the whole population of Brazil benefits from the Unified Health System is great. Unfortunately, due to the massive under-funding in a majority of Brazilian states and municipalities, this has not been realized. An imperfect system, the challenge of funding a healthcare system designed to provide equal access to all citizens is mainly due to its unique financing mechanism. Funding comes from tax revenue from the federal government, state, and municipalities. However, according to Machado et al.,4 federal government spending on public health decreased from more than 70 percent to 44.7 percent in 2010. The decrease in federal spending places the biggest burden of public health funding on states and municipalities. In particular, due to the reliance on municipal budgets, most of the municipalities in the northern region have reduced capacity to provide funding considering the level of poverty in these areas. As if that is not enough, in 2016, the government introduced one of the harshest austerity measures in history. According to Doniec et al.,5 a constitutional amendment called for the freezing of the federal budget on healthcare spending. The amendment passed by Congress limited the federal primary expenditure on health for the next 20 years and capped spending to 15% in 2017 with projected decline in health expenditure for the following years up to 2036.
Brazil is a country committed to establishing an effective unified healthcare system. Unfortunately, the country has failed to achieve the objective. Inadequate funding of healthcare is associated with several negative outcomes such as lack of infrastructure and human capital. For instance, according to da Silva Gama et al.,10 despite government’s initiatives to improve the quality of care in Brazil hospitals, lack of sufficient infrastructure hinders the exercise. In part, lack of sufficient infrastructures has also been associated with increased hospital-acquired infections. For example, the prevalence of catheter-associated urinary infections, lack of influenza vaccines, and hand hygiene protocols were associated with lack of sufficient infrastructures and supplies. Another study by Gomez et al.,11 that sought to examine the challenges facing individuals seeking organ transplantation services indicate that among other issues, financing significantly affected access to transplantation services. Ideally, organs are scarce and most of the time, hospitals have more patients waiting for organ transplants than the available organs. The process of identifying suitable candidates and extracting the organ from the donor is resource intensive and without proper funding, it cannot be executed effectively and efficiently. An ongoing challenge in the transplantation of organs is inadequate human resource, especially neurologists and neurosurgeons. While the problem is prevalent in Brazil public hospitals, Northern Brazil has been extensively affected, as a high number of neurologists reside in the more affluent southeast side of Brazil. Gomez et al.,11 also highlight that hospitals lack adequate laboratories, which make it hard for experiments. Along with that, most public hospitals do not have Blood Circulation Support networks, implying that when patients need blood they do not have a backup to provide emergency blood. In this case, relatives or friends of the patients are required to donate blood to patients, which is not always easily available. Additionally, some hospitals lack intensive care units or are poorly equipped to handle patients admitted. Again, majority of hospitals in the northern region of Brazil lack essential health care infrastructure such as x-ray machines and beds.
Extensive Disparities in Access to Healthcare Services
Brazil is marked with deep extremes in income and social inequalities. Reforms to create a unified national health system were designed to ensure equity in the provision of health care. Unfortunately, after the initial expansion of the Brazilian health care system, it was perceived by weak technical capacity of the federal government, inadequate financing, and extreme disparities. According to Massuda et al.,3 disparities in resource allocation have left populations living in the northern regions with several unmet healthcare needs. For instance, although the number of physicians in Brazil has increased, the North and Northeast regions still experience shortages. Besides, distribution of doctors in public and private hospitals is largely inequitable with public hospitals experiencing high shortage of physicians.7 The scarcity of doctors as Girdi et al.8 highlight, started worsening during the first decade of the twenty first century throughout the world. In Brazil, the scarcity of physicians is especially prevalent in rural areas where a significant population of Brazilians lives. For instance, in 2013, it was estimated that at least 20% of all municipalities in Brazil experienced a scarcity of physicians. This scarcity was highly prevalent in North and Northeast regions. Consequently, the scarcity of doctors is highly attributed to increasing demand of doctors due to high number of public and private hospitals. Low number of medical professionals graduating, combined with the increasing demand has significantly contributed to the scarcity of doctors, especially in public hospitals where remunerations are not as enticing as private hospitals.
Along with that, Brazil’s pharmaceutical system has been identified as the most complex in the world. the government established the National Medicines Policy in 1998 to provide guidance on the standardization, prescription, and supply of essential medicines.12 Since then, Brazil has experienced an increase in the access to essential drugs. However, while Brazil has improved access to medicines by encouraging the use of generic drugs, disparities persist. In particular, access to these drugs is often influenced by socioeconomic and sociodemographic factors. Besides, the increased access to medication seem to affect sustainability of healthcare technology provision due to the high cost of medicine.
Ideally, universal health coverage remains top of the priority list on the International Political Agenda. However, several countries are still struggling with the complexities and practicalities involved in providing universal health coverage to its citizens. Several elements are responsible for the success of universal health coverage. For instance, according to Hone and Gómez-Dantés,13 in order to advance universal health coverage, it is crucial to have thoughtful, robust, and usable evidence. These would help in systematic and reliable assessments, assessing the quality of interventions – their long-term and short-term effects, and evidence gap in the current system of health care. Considering the current challenges facing Brazil, two countries with best practices that Brazil can emulate include Mexico and Canada.
Mexico has been on the limelight in its effort to expand universal health coverage. Their reforms and progress towards Universal Health Coverage have been highlighted as an example for other countries. Major lessons that countries can learn from Mexico’s universal health coverage include promoting health as a social right, investing in infrastructure and human resources, and expanding health coverage to individuals who cannot afford health insurance. One highlight of Mexico’s universal health coverage is the Seguro Popular, which has made improvements in coverage, health conditions, and financial impoverishments for individuals who do not have health insurance coverage, in particular, the poor. The Seguro Popular provides healthcare coverage to individuals who do not have access to other social insurance schemes by providing a universal benefits package and funds to cater for high-cost treatments.
On healthcare funding,

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World Health Organization. Brazil: country case studies on primary health care. Published 2018. Accessed November 14, 2019.
Muzaka V. Lessons from Brazil: on the difficulties of building a universal health care system. J Glob Health. 2017;7(1):19-23. doi:10.7189/jogh.07.010303
Massuda A, De CMC, Atun R, Hone T, & Leles, FAG. The Brazilian health system at crossroads: Progress, crisis and resilience. Bmj Global Health. 2018;3(4):1-8. doi:10.1136/bmjgh-2018-000829
Machado CV, Lima LD, Andrade CLT. Federal funding of health policy in Brazil: trends and challenges. Cadernos de Saúde Pública. 2014; 30(1):187-200.
Doniec K, Rafael D, Lawrence K. “Brazil’s health catastrophe in the making”. The Lancet. 2018; 392 (10149): 731-732.
Ocke-Reis CO. Financial sustainability of the Brazilian Health System and health-related tax expenditures. Scielo. 2018;23(6).
Alves SMC, Oliveira FP, Santos LMP, Delduque MC, Matos MFM. International cooperation and shortage of doctors: An analysis of the interaction between Brazil, Angola and Cuba. Ciencia E Saude Coletiva. 2017;22 (7): 2223-2235.
Girardi SN, Van Stralen ACS, Cella JN, Der Maas LW, Carvalho CL, Faria EO. Impact of the Mais Médicos (More Doctors) Program in reducing physician shortage in Brazilian Primary Healthcare. Ciencia E Saude Coletiva. 2016; 21 (9): 2675-2684.
Rocha TAH, da Silva NC, PV Amaral, ACQ Barbosa, JVM Rocha, V Alvares, de Almeida DG, et al. Addressing geographic access barriers to emergency care services: a national ecologic study of hospitals in Brazil”. International Journal for Equity in Health. 2017;16 (1): 1-10
da Silva Gama ZA, Pedro JSH, Marise RF, Maria CP, Cecília OPOS, Laiane GP, Sibele FA. Good infection prevention practices in three Brazilian hospitals: Implications for patient safety policies. Journal of Infection and Public Health. 2019;12 (5): 619-624.
Gómez EJ, Jungmann S, Lima AS. Resource allocations and disparities in the Brazilian health care system: insights from organ transplantation services”. BMC Health Services Research. 2018;18 (1):1-7. DOI 10.1186/s12913-018-2851
Monteiro CN, RJ Gianini, MB Barros, CL Cesar, and M Goldbaum. 2016. “Access to medication in the Public Health System and equity: populational health surveys in São Paulo, Brazil”. Revista Brasileira De Epidemiologia = Brazilian Journal of Epidemiology. 19 (1): 26-37.
Hone T, Gómez-Dantés O. Broadening universal health coverage for children in Mexico. The Lancet. Global Health. 2019;7(10): 1308-1309. DOI:

Uga, Maria Alicia Dominguez, and Isabela Soares Santos. An Analysis of Equity In Brazilian Health System Financing. Health Affairs. 2007;26 (4): 1017.

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