the brazilian national health system: an unfulfilled promise?

international journal of health planning and management

Int J Health Plann Mgmt 2010; 25: 318–329.

Published online 11 January 2010 in Wiley Online Library

(wileyonlinelibrary.com) DOI: 10.1002/hpm.1014

The Brazilian National Health System:an unfulfilled promise?

Carlos Octavio Ocke-Reis1* and Theodore R. Marmor2y

1IPEA—Instituto de Pesquisa Economica Aplicada (Brazilian Applied Economic ResearchInstitute), Brazil2Yale University, USA

SUMMARY

In 1988, Brazil became one of the first countries in Latin America to frame access to healthcare as a constitutional right. However, it would be misleading to call Brazil’s Unified HealthSystem (Sistema Unico de Saude, or SUS) a public health system that provides universalaccess and comprehensive care. This paper reveals a strong contradiction between the re-distribution model set out in the Brazilian Constitution and the inadequate level of publicspending on health care. The law states that health care is a basic social right, allocated by needrather than means. Meanwhile, in 2003, Brazil spent US$ 597 per capita on health, or 7.6 percent of its gross domestic product (GDP), while the average country from the Organization forEconomic Cooperation and Development (OECD) spent US$ 3145, or 10.8 per cent, andArgentina spent US$ 1067, or 8.9 per cent of its GDP. Copyright# 2010 John Wiley & Sons,Ltd.

key words: comparative health systems; government expenditure; analysis of health care

markets; health

INTRODUCTION

Brazil was one of the first countries in Latin America to make access to health

care a constitutional right, but in reality the universal access is not completely

implemented: a reasonably comprehensive system designed to give all the care to

most or all citizens. In other words, a public health system that provides universal

access and comprehensive health services is a promise yet to be fulfilled by Brazil’s

Unified Health System (Sistema Unico de Saude, or SUS). Based on the principle

that health care should be free at the point of use, the SUS was created in the new

Brazilian Constitution in 1988, adopting a re-distributionmodel along the lines of the

European welfare state.

*Correspondence to: C. O. Ocke-Reis, IPEA—Brazilian Applied Economic Research Institute, Av.Presidente Antonio Carlos 51, 108 andar, Centro da Cidade, Rio de Janeiro, RJ, Brazil—CEP 20020-010,Brazil. E-mail: [email protected] Emeritus of Politics, Public Policy, and Law at Yale University.

Copyright # 2010 John Wiley & Sons, Ltd.

BRAZILIAN NATIONAL HEALTH SYSTEM 319

It was designed to address poverty and social inequality and to overcome the

legacy of both the former statutory social health insurance (SHI) scheme, which only

those who contributed had access to, and the military regime (1964–85), which

supported the privatization of the health sector. In line with Cordeiro (1991), legal

provisions would exist for every citizen to prevent the risk of illness, cover medical

and hospital needs, and treat any suffering caused by injury, in the fashion of non-

income related services.

This reform of health care, which the Constitution designates as a ‘‘duty of the

state’’ and a ‘‘right of the citizen’’, is embedded in a strategy to provide universal

access based on ‘‘a combination of selective programs capable of providing

vulnerable groups with care while including them in the universal health system’’

(Fleury, 2000), designating adequate public resources to help reduce inequality

(Porto, 2002) without introducing indiscriminate cost controls or privatizing the

system (Campos, 1997). In practical terms, there would be a common ground

between equality and equity: ‘‘equality and equity would form the basis for

universalization and the focus of social policies for the most vulnerable, respectively,

from the standpoint of epidemiology,’’ according to the distinction given by

Medeiros (1999).

However, over the SUS’s 20-year existence, the state has failed to fulfill the health-

related rights established in the Brazilian Constitution.

This paper seeks neither to examine all the causes behind this unfulfilled promise

nor to discuss whether the causes lie in the history of the parallel Brazilian health

system. Rather, we will focus on the contradictory role assigned to health care in the

Constitution: on one hand, it allows for a free market, while on the other it states that

health care is a citizen’s right, an inconsistency which tends to overburden public

funding (Ocke-Reis, 2005a). Above all, we intend to contribute to discussions about

the financing of the SUS, which we will investigate from an international

perspective.

The rest of the paper is organized as follows: the next section describes some

contradictions in the politics of SUS reform; the third section explains the main

features of the parallel health system in Brazil; the fourth section sets out the current

state of play in the debate about the financing of the Brazilian health system; the fifth

section presents the results of our data and the conclusion can be found in the last

section.

THE POLITICS OF SUS REFORM: VALUES VERSUS REALITY

Inspired by the vision of a national health system, the creation of the SUS is a legacy

of social democratic and socialist beliefs that surfaced during Brazil’s re-

democratization at the end of the 1980s. This development was supported by

progressive political parties, social movements, and left-wing intellectuals.

One can best understand this movement by using the approach put forward by Sen

(1999), who sees the health sector as incorporating a rationale that runs counter to

market dynamics. Also, Rawls’ theory of justice as fairness (Rawls, 1997) seems to

Copyright # 2010 John Wiley & Sons, Ltd. Int J Health Plann Mgmt 2010; 25: 318–329.

DOI: 10.1002/hpm

320 C. O. OCKE-REIS AND T. R. MARMOR

raise the value of an ethical dimension of health economics. It ultimately questions

the utilitarianism of individual preference. The justice paradigm clearly breaks with

the individualistic approach to preference: ‘‘social justice is not an issue of individual

preference (and) its judgment is made independent of the scrutiny made by

individuals based on their own interests (. . .) deriving from a set of values and

principles that are extrinsic to the preferences which the individuals should have as a

right’’ (Wagstaff and Doorslaer, 2000).

Given Brazil’s extreme poverty and inequality (Barros et al., 2000), one might

expect there to be an association between this ethical approach to health economics

and the reference to social rights as declared in the Constitution. After all, the

democratization process in Brazil lauded health care for all. Access to health care

was considered to be of collective public interest, whether the sponsors were public,

private, non-profit or not (Grau, 1992).

Questions remain to be asked and looked into. Why have the communitarian

values that organize the politics of reform not produced truly universal coverage?

Why have the principles set forth in the Constitution based on the European welfare

model not been put into practice?

Firstly, there is the presence of a parallel health system. Despite the fact that

Brazil’s Constitution stipulates that health care is a basic social right and must be

allocated by need rather than means, individuals can be covered by private health

insurance (PHI) and still use public services from the SUS. This leads to double

coverage for those middle and high-income workers, executives, civil servants,

and the few self-employed professionals that can afford it. Secondly, the state has

not designed any democratic institutions to regulate physicians and private

hospital providers. The health care reform has built neither a social deal, such as

the one that founded the United Kingdom (UK) system, nor a neo-corporate

structure such as the German SHI, which organizes workers’ and employers’

interests under self-regulatory institutions and state hierarchy (Wendt et al., 2005;

Brown and Amelung, 1999). Thirdly, since 1968, for-profit health insurance

companies have grown on the back of public financial support (tax exemptions),

mirroring the US liberal model, which is based on subsidies and employment

benefits. In general, they lobby the national congress on key health care issues and

avoid more wide-ranging negotiations between stakeholders to strengthen the

public health system. This is of particular concern since the workers at the heart of

the economy are covered by PHI and their political representatives in Congress do

not give as much support to the SUS as would be necessary to earmark more

resources for its financing. This sort of behavior has revealed a bias in the

decision-making process and resulted in residual and segmented health care

coverage (Vianna, 1998).

As Marmor and Boyum (1994) note in their reflections on competition in medical

care, the more Americanized a system is, the more exacerbated its segmentation and

privatization will become. This challenges the universalizm aspiration and the

capacity to reduce levels of poverty and inequality by means of health policies in

Brazil. To sum up, despite the powerful ideology that underpinned the introduction of

SUS, making health care a right of the members of society and an issue of public

interest, the State has not been capable of ensuring that the SUS provides inclusive


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health services for blue- and white-collar workers and civil servants, who to a greater

or lesser extent, have voice, vote, media and money.

There is an inconsistency between the community legacy of the SUS, which

considers health care a constitutional social right of central public interest, and the

importance and size of the private health care market.

FEATURES OF BRAZIL’S PARALLEL HEALTH CARE SYSTEM

Private funding mechanisms tend to have a negative impact on public financing,

though this varies from one country to another (Flood et al., 2002). This factor might

be useful to explain some features of the Brazilian public/private health care mix.

The Brazilian health care system combines public and private schemes that appear

to be parallel structures. But, the private system (PHI) does not operate in

cooperation with the public side of the system (Ocke-Reis, 2005b). Brazil has a

duplicate model, using the OECD classification (2004), whereby the PHI provides

coverage for the services already offered in the publicly-financed scheme. This

means the PHI insured contribute to the public system (see Wasem et al., 2004).

The SUS is one of the largest public health systems in the industrialized world. It is

responsible for putting Brazil second only to the United States worldwide in the

number of organ transplants performed. It provides healthcare for approximately 140

million people, ranging from primary care to treatments involving medium to high-

level technological complexity, as well as emergency services. Brazil’s Family

Health Program is the government’s flagship initiative to improve primary health

care. Brazil also has an excellent vaccination program and an internationally

acclaimed HIV program.

Whatever the issues still to be addressed in the funding and management of the

system, the SUS faces even more serious public health and delivery problems. These

include the high prevalence of chronic diseases among lower income groups; dengue

and yellow fever outbreaks; restricted access to and disorganized waiting lists for

specialized services; low income and poor patients left unattended in hospital

emergency rooms; high and regressive out-of-pocket drug expenditure; low level of

investments; shortage of physicians in public facilities in poorer regions and even in

Brazil’s largest cities, since they can earn more in private settings. This is

compounded by social problems that directly affect the health of Brazilians, such as

poverty, inequality, violence, traffic accidents, low levels of education and culture,

and poor sanitary conditions (see Cerqueira et al., 2007; Mesa-Lago, 2007; Uga and

Santos, 2007; Marinho, 2004).

Despite these access-related issues, the catastrophic cost burden of transplants,

cancer treatments, heart surgery, long-term care, and hemodialysis falls mostly to the

public system. This is one of the reasons why even those who have private health care

coverage tend to turn to the public service when requiring costly, sophisticated

services (Heimann et al., 2005).

Brazil’s PHI (medical and dental care) covers approximately 48 million people.

Most of these are employees in the formal sector, including civil servants, the self-

employed, and high earners. This represents almost one quarter of the Brazilian


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population. It generates annual revenues of US$ 27.2 billion (ANS, 2008), roughly

40% more than the federal spending on health care in 2007.

The federal government still grants tax exemptions designed to encourage

households and employers to take out PHI. This represents an adaptation to

inadequacy in the public system. The public program has not attracted the salaried

workforce by providing a range of comprehensive health services, in particular,

specialized consultants, diagnostic exams, advanced therapies (outpatient services)

and elective surgery (inpatient beds). Public tax subsidies of private health insurance

deprive the SUS of financial resources that could otherwise be used to improve its

access and quality. Meanwhile, bad risk and chronically ill privately insured patients

are pushed out of PHI and onto the SUS, without any significant impact on the profits

of health insurance companies (Ocke-Reis et al., 2006).

We noted above some economic incentives that have underpinned Brazil’s PHI.

Private funding mechanisms tend to undermine the public funding of health care, so

Brazil is not alone in this regard (Tuohy et al., 2004). In the next section, we will

present the debate on financing for the public health system, whose shortage of funds

is a concrete barrier to bring the SUS closer to its constitutional mandate.

THE PUBLIC HEALTH SYSTEM FINANCING DEBATE

The 1988 Constitution presumed there would be enough funding to support universal

coverage by means of taxes and social contributions—rather than on a payroll

basis—under the social security budget. However, re-current and unconstitutional

underfunding (Marques and Mendes, 1999), has meant the SUS has been unable to

attract the workforce.

The main causes for the limitation are deficits in the supply of care givers and the

poor quality of the services provided by the public health system. But might not the

gradual reduction in the funding of the public sector be the key to this ‘‘limited

universalization’’ of the SUS?

Although the SUS’s management leaves plenty of room for improvement, this can

in no way be used as an argument for indiscriminate cost controls. Efficiency is

understood as the relationship between the value of the resources effectively

consumed and the effective output of a given unit. This is even more important in the

health care area, where efficiency is measured by the efficacy of treatments, not by

any market mechanism (Marinho and Facanha, 2001).

TheWorld Bank, which has produced a set of technical papers evaluating different

social areas, believes that ‘‘increasing the efficiency and effectiveness in the use of

health resources to contain rising costs is perhaps the greatest challenge facing the

Brazilian health system,’’ (World Bank, 2007). It is surely the case that

improvements in the SUS’s efficiency would be desirable. It is important both to

increase social expenditure and to guarantee an efficient allocation of resources in

general (Mussi and Afonso, 2008). No-one would argue against introducing a

cheaper, more comprehensive, and effective government program or hospital service.

But, what does the World Bank’s argument really mean?


DOI: 10.1002/hpm


The Bank seems to draw a correlation between efficiency and cost containment

measures. The challenge here is to identify whether this putative inefficiency is

actually caused by the low-public spending rate (see Marinho, 2004).

Might health care cost containment measures cause inefficiency or not? The

argument in favor of increased efficiency should not be taken as an excuse for cutting

financial or organizational resources, just as waiting lists cannot appropriately serve

as an instrument to restrict access. Basically, we have to take into account the

opportunity cost relating to the allocation of resources for health care instead of other

sectors of society. The best practice must be understood as a rational action to assure

‘value for money’ in all medical and hospital services designed to guarantee and

improve the population’s level of health. (This includes better allocation of

resources, contract incentives, improved productivity, cutting down on waste,

curbing corruption, etc.).

The SUS needs more funds, better management, and improved quality. If the

Brazilian government were to focus its spending on the public system, that might

imply that then private spending would have to be reduced. It then would require

spending more on maintaining and expanding the SUS. However, the government

cannot turn a blind eye to the growing cost of medical care, whether public or private,

under its tight fiscal policy (see Remler et al., 2005).

The proposal for a stable, comprehensive source of funding is currently most

favored by those who advocate a reform of SUS financing in the Brazilian Congress

(IPEA, 2008). Below, we examine some international data that suggest there is a

contradiction between the re-distribution model of health care described in the

Brazilian Constitution and the level of public spending in Brazil. We do that without

going into a more in-depth analysis of what is being done to improve management

practices inside the SUS.

EVIDENCE FOR EXPANDING THE FINANCING OF THE SUS

International comparisons of health care spending have attracted considerable

interest among economists and political scientists (see Marmor et al., 2006; Ocke-

Reis, 2006; Baumol, 1993). If we look at comparative studies that investigate

different health systems, we can see that some make statistical descriptions of their

features and performance, while others seek to analyze a group with a view to

illuminating their legacy, their similarities and, diversities, and even go so far as to

prescribe a set of policies (cost control, preventative measures, PHI regulation etc.)

(Conill, 2006; Marmor, 2001).

One approach is to describe the characteristics of the health systems and seek to

understand why they have developed as they have, in order to extract some policy-

related lessons. This will depend on a variety of issues, such as the social welfare

structure in place, the background of the institutions, the level of education of the

professionals, health financing, the means by which service providers are paid, and

the managerial techniques being used. It seems reasonable to argue that an accurate

description must first be provided before we can understand how they work and why

they might be embody useful lessons (Marmor et al., 2005).


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Table 1. Socioeconomic indicators: population and gini index 1999–2005

Country Population(per 1000)(f)

GDP per capita(PPP)(e) US$

GINI

Brazil 186 405 8140 58(d)

Argentina 38 747 13 331 52.8(d,g)

Chile 16 295 12 505 57(b)

Colombia 45 600 7319 58.6(d)

Mexico 107 029 10 158 49.5(c,h)

Venezuela 26 749 6104 44.1(b)

Latin America 5 MEAN 46 884 9883 51.7(i)

Germany 82 689 28 075 283(b)

Canada 32 268 31 389 326(b)

Netherlands 16 299 31 143 309(a)

UK 59 668 31 308 36(a)

USA 298 213 39 901 40.8(b)

OECD 5 MEAN 47 731 30 479 37.2(i)

Source: World Health Statistics 2006; The World Health Report 2006; World Bank 2006(World Development Indicators).Note: (a) 1999; (b) 2000; (c) 2002; (d) 2003; (e) 2004; (f) 2005; (g) urban sector; (h) spendingper capita; (i) weighted average.Prepared by: IPEA.


We have made an ad hoc selection of a few Latin American and Organization for

Economic Cooperation and Development (OECD) countries and compared their

outcomes with Brazil’s, using socioeconomic and health care indicators. Our

findings represent efforts to collect data from official databases, assuring a minimum

of consistency within a cross-national comparison.

Table 1 shows Brazil, a nation of continental proportions, with a population of 186

million, which is higher than the average of the selected Latin American and OECD

countries, except the US. The per capita income of Brazilians is US$ 8140, which is

adjusted by the country’s purchasing power parity (PPP), a rate that is often used to

account for differences among the cost of living in different countries. This figure is

lower than in countries such as Argentina (US$ 13 331), Chile (US$ 12 505) and

Mexico (10 158), and falls far short of the average in the OECD countries.

Table 2 shows that 7.6% of Brazil’s GDP is spent on health, which is just above the

average for the Latin American countries, though it is lower than health spending in

Argentina and the OECD countries. Further, the proportion of public spending on

health compared to total health spending in Brazil is lower than the average of 54.4%

for Latin America, and falls short of the average seen in the OECD countries. It is

worth noting, however, that in relative terms, the proportion of public health

spending in Brazil (45.3%) is comparable to that of the US (44.6%). In per capita

terms, private health spending included, Brazil spends US$ 597, just short of the

average of the Latin American countries (US$ 622), and around five times less than

the average of the selected OECD countries.

Table 3 shows that Brazil’s ratio of physicians (2.1 per thousand inhabitants) is

greater than the average in the other Latin American countries, and close to the

average in the OECD countries (2.6). Germany has the highest ratio of physicians


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Table 2. Indicators of health spending—2003

Country % GDP % Public Per capita(PPP) US$

Brazil 7.6 45.3 597Argentina 8.9 48.6 1067Chile 6.1 48.8 707Colombia 7.6 84.1 522Mexico 6.2 46.4 582Venezuela 4.5 44.3 231Latin America 5 MEAN 6.7 54.4 622Germany 11.1 78.2 3001Canada 9.9 69.9 2989Netherlands 9.8 62.4 2987UK 8.0 85.7 2389USA 15.2 44.6 5711OECD 5 MEAN 10.8 68.2 3415

Source: World Health Statistics 2006; The World Health Report 2006; World Bank 2006(World Development Indicators).Prepared by: IPEA.


(3.4 per thousand inhabitants). Furthermore, the number of nurses is slightly lower

than in the other Latin American countries and 20 times lower than the average in the

OECD countries, despite their lower hiring costs and great potential for having a

positive impact on health service effectiveness (see Fagin, 1990). There are also 2.6

inpatient beds available in Brazil, which is higher than the average in the Latin

American countries (1.9), though lower than the OECD countries (4.8), especially

Germany (8.6). Any indiscriminate cost controls affecting the number of public

Table 3. Indicators of health care supply: professionals and inpatient beds—2003, (per 1000inhabitants)

Country Physicians Nurses Beds

Brazil 2.1(a) 0.5(b) 2.6(c)

Argentina 3.2(d) 0.4(d) 4.1(a)

Chile 1.1 0.6 2.5Colombia 1.3(c) 0.5(c) 1.2(d)

Mexico 1.5 2.1 1Venezuela 1.9(b) 0.8(a) 0.9(e)

Latin America 5 MEAN 1.8 0.9 1.9Germany 3.4 9.7 8.6(d)

Canada 2.1 10 4Netherlands 3.1 13.7 4.6(c)

UK 2.3(c) 7.9(c) 3.3USA 2.2 9.1 4OECD 5 MEAN 2.6 10.1 4.8

Source: World Health Statistics 2006; The World Health Report 2006; OECD Health Data2005; OPAS 2005 (Situacion de Salud en las Americas: Indicadores basicos).Note: (a) 2000; (b) 2001; (c) 2002; (d) 2004; (e) public sector.Prepared by: IPEA.


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Table 4. Health status indicators: infant mortality and life expectancy—2004

Country Infant mortality(Deaths per 1000 lives birth)

Life expectancyat birth (years)

Brazil(a) 23 72Argentina 16 75Chile 8 78Colombia 18 73Mexico 23 75Venezuela 16 74Germany 4 78Canada 5 80Netherlands 4 79UK 5 79USA 6 77

Source: World Health Statistics 2006; The World Health Report 2006; World Bank 2006(World Development Indicators).Note: (a) PAHO-RIPSA 2008 (Indicadores Basicos Saude Brasil: Conceitos e Aplicacoes).Prepared by: IPEA.


hospital beds might further burden the SUS, which is already overwhelmed by its

constitutional mission to provide universal health coverage.

Table 4 reveals that Brazil has the highest rate of infant mortality, despite the

outstanding performance of the Family Health Program, and the shortest life

expectancy of the selected countries, which are approximate measures of the

performance of health systems. Twenty-three out of every one thousand babies born

alive in Brazil die before they reach 1 year of age, which is far above the rate in the

OECD countries and even higher than in Latin America, except Mexico. Last but not

the least, Brazil’s Family Health Program has been associated with reducing infant

mortality rates, making it an important, albeit not exclusive, contributory factor to

improving this indicator in recent years (Macinko et al., 2006).

The reform and health policies introduced after 1988 would appear to have had a

positive impact on reducing poverty and health inequalities (Mesa-Lago, 2007).

However, in order to fulfill its Constitutional mandate, a stable source of financing

must be established for the SUS (Uga and Santos, 2007), to counteract Brazil’s low-

public spending, low-inpatient bed ratio and inadequate health outcomes.

CONCLUSIONS

How do policymakers deal with the tension between the high hopes of producing a

national health system and the financial constraints of the state?

There seems to be a contradiction between the re-distributivemodel set forth in the

Brazilian Constitution and the levels of public health spending in Brazil. They are

limited regarding the characteristics of the Brazilian population (size and gini index)

and we can highlight that comparing Brazil’s, Argentina’s, and Chile’s health status

(Table 4) and health spending (Table 2). Besides, observing the indicators of health

spending, one can also realize that Brazil spent much less per capita than Argentina


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and even Chile. The GDP per capita (Table 1) does not justify this discrepancy; on

the contrary, we shall argue that there is an association between poverty or inequality

and health need (given reason for rising the public expenditures).

The UK’s national health system, though less pluralistic, is similar to what is

described in the Brazilian Constitution, and public health spending absorbs 85.7% of

all resources allocated to health (while absorbs only 45.3% in Brazil). It is, however,

true to say that the UK is in the throes of a public debate about whether the system is

underfunded or whether it would be better to turn to privatization, given the long-

waiting lists for non-urgent surgical procedures (Maynard, 2005).

The government cannot turn a blind eye to the growing cost of medical care,

whether public or private, under its tight fiscal policy. But Brazil faces a serious

health care dilemma, which could deteriorate if SUS financing should be reduced or

access restricted low level of quality of health care delivered. The state is incapable

of responding to the coverage-related problems caused by budget constraints and this

both prevents the SUS from becoming stronger and leaves ample room for the growth

of an oligopolistic PHI market.

We suggest that the Health Ministry and the regional and local authorities improve

the SUS’s position by allocating more resources on a needs basis and by, taking a

stronger interventionist role to increase the relationship between public spending and

improving the quality of care.

The Brazilian PHI should cover only the highest income class who have the means

to pay for the private system. It would seem to make no sense for Brazil to import

pro-market health models (see Marmor, 2004), namely, the American model, called

‘‘managed care’’ (Stocker et al., 1999), since the private sector would expand and

public health spending would be cut as privatization and tax-exemption policies were

strengthened.

The reform of the SUS should aim to gradually provide inclusive health services

for both blue- and white-collar workers (including civil servants), giving the program

a stronger, more influential participation in the political arena.

There is a considerable uncertainty surrounding the tax reform proposal and the

future of the social security budget. But a stable source of financing for the health

sector would begin to assure the promise of a national health system for all Brazil’s

workers and citizens.

ACKNOWLEDGMENT

This study received financial support from the National Council for Scientific and

Technological Development (CNPq), an agency linked to the Brazilian Ministry of

Science and Technology (MCT), as part of Ocke-Reis’ post-doctorate at Yale School

of Management.

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the brazilian national health system: an unfulfilled promise?

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