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World Bank Document
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DIREC TIONS IN DE VELOPMENT
Human Development
Twenty Years of Health System
Reform in Brazil
An Assessment of the Sistema
Único de Saúde
Michele Gragnolati, Magnus Lindelow, and Bernard Couttolenc
Twenty Years of Health System Reform in Brazil
DIREC TIONS IN DE VELOPMENT
Human Development
Twenty Years of Health System
Reform in Brazil
An Assessment of the Sistema Único de Saúde
Michele Gragnolati, Magnus Lindelow, and Bernard Couttolenc
© 2013 International Bank for Reconstruction and Development / The World Bank
1818 H Street NW, Washington DC 20433
Telephone: 202-473-1000; Internet: www.worldbank.org
Some rights reserved
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Attribution—Please cite the work as follows: Michele Gragnolati, Magnus Lindelow, and Bernard
Couttolenc 2013. Twenty Years of Health System Reform in Brazil: An Assessment of the Sistema Único
de Saúde. Directions in Development. Washington, DC: World Bank. doi:10.1596/978-0-8213-9843-2.
License: Creative Commons Attribution CC BY 3.0
Translations—If you create a translation of this work, please add the following disclaimer along with the
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All queries on rights and licenses should be addressed to the Office of the Publisher, The World Bank, 1818
H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: [email protected]
ISBN (paper): 978-0-8213-9843-2
ISBN (electronic): 978-0-8213-9932-3
DOI: 10.1596/978-0-8213-9843-2
Cover photo: © Mariana Kaipper Ceratti. Used with the permission of Mariana Kaipper Ceratti. Further
permission required for reuse.
Cover design: Naylor Design
This publication has been produced thanks to the contribution of The Government of Spain, through the
Spanish Fund for Latin America and the Caribbean.
Library of Congress Cataloging-in-Publication Data has been requested.
Twenty Years of Health System Reform in Brazil • http://dx.doi.org/10.1596/978-0-8213-9843-2
Contents
About the Authors
xi
Abbreviationsxiii
Overview
1
Have the SUS Reforms Transformed the Brazilian
Health System?
2
Have the SUS Reforms Led to Better Outcomes?
5
Conclusions10
References13
Chapter 1
Introduction
15
SUS: Origins and 20 Years of Implementation
16
A Framework for Assessing SUS Performance
18
Contribution of This Report
21
Notes22
References22
Chapter 2
Have the SUS Reforms Transformed the Brazilian
Health System?
25
Expansion and Reorganization of Service Delivery
25
Toward Increased and More Equitable Health Financing
36
Enhancing Health System Governance
46
Notes53
References55
Chapter 3
Have the SUS Reforms Led to Better Outcomes?
57
Use of Health Services and Progress toward Universality
57
Are Health Care Needs Being Met?
66
Health System Efficiency
73
Has the Health System Improved Health Outcomes?
80
Has the SUS Contributed to Improved Health Outcomes? 83
Out-of-Pocket Payments and Financial Protection
88
Public Perceptions of and Satisfaction with
the Health System
93
Notes96
References100
Twenty Years of Health System Reform in Brazil • http://dx.doi.org/10.1596/978-0-8213-9843-2
v vi
Contents
Chapter 4
Conclusions
105
Sustaining Improvements in Access to Health Care
107
Improving Efficiency and Quality of Health Care Services 108
Clarifying Roles and Relationships across Levels of
Government109
Determining the Right Level of Health Spending and
Improving Efficiency
110
Conducting More and Better Health System Monitoring
and Research
111
Notes112
References112
Boxes
1.1
Assessment of Health System Performance in Brazil:
Approaches and Recent Developments
19
Primary Care and Prevention in Brazil:
The Family Health Strategy
27
Primary Care and Prevention in Brazil: Beyond the Family
Health Strategy
29
Assessing Local Capacity to Manage Decentralized
Responsibilities50
The Social Organization Model in São Paulo State
53
Brazil’s Program on HIV/AIDS
68
Cesarean Sections in Brazil
74
2.1
2.2
2.3
2.4
3.1
3.2
Figures
1.1
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
2.9
2.10
2.11
A Simple Framework for Assessing the Performance of
the Health System
20
Network of Health Facilities in Brazil, 1981–2009
26
Density of the Network of Health Facilities in Brazil, 1981–2009 27
Coverage of the ESF in Brazil, 1994–2010 28
Coverage of the ESF in Municipalities in Brazil,
by Income Quintile, 1985–2007
30
Coverage of the ESF in Brazil, by Income Quintile, 2008
30
Coverage of the ESF in Brazil, by State, 2008
31
Decentralization of Public Outpatient Facilities and
Hospital Beds in Brazil, 1981–2009
32
Local (State and Municipal) Management of Hospital Beds
in Brazil, 1992–2009
33
Municipal Management of Hospital Beds in Brazil, 1992–2009
33
Public-Private Composition of Hospitals and Hospital
Beds in Brazil, 1980–2010
34
Public-Private Composition of Outpatient Facilities in Brazil,
1980–201035
Twenty Years of Health System Reform in Brazil • http://dx.doi.org/10.1596/978-0-8213-9843-2
vii
Contents
2.12
2.13
2.14
2.15
2.16
2.17
2.18
2.19
2.20
2.21
2.22
2.23
2.24
2.25
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
3.9
Density of Hospital Beds and Outpatient Facilities across
States in Brazil, 1988 and 2009
35
Link between Income and Density of Facilities across States
in Brazil, 1988 and 2009
36
SUS and Social Security Spending on Health in Brazil,
by Level of Government, 1980–2009
39
SUS and Social Security Spending per Capita on
Health in Brazil, by Level of Government, 1980–2010
39
SUS and Social Security Spending on Health as a Percentage
of GDP in Brazil, by Level of Government, 1980–2009
40
Annual Growth in Government Health Spending per Capita
in Select Countries, 1995–2010
40
Government Health Spending as a Percentage of GDP
41
in Select Countries, 2010
Allocation of the Ministry of Health Budget in Brazil,
42
by Type of Care, 1995–2010
Allocation of Health Spending in Brazil, by Level
42
of Government and Type of Care, 1984 and 2010
Share of SUS Financing in Brazil, by Level of Government,
1980–200943
SUS Health Spending per Capita across States in Brazil,
44
1995 and 2009
SUS Spending per Capita on Health and Average
Monthly Income per Capita across States in Brazil,
45
1995 and 2009
Share of Private Health Spending in Total Health Spending
45
in Brazil, 1995–2009
Government Financing of Health Expenditures
in Select Countries, by GDP per Capita, 2010
46
Use of Private and Public Providers of Health Care
59
in Brazil, 2012
Main Source of Care in Brazil, by Type of Service, 2008
59
Medical Consultations, Basic Care Procedures, and Hospital
60
Admissions per Capita in Brazil, 1980–2009
Hospital Admissions in Brazil, by Type of Provider, 1985–2009
61
Health Services Used by Households in Brazil, 1986 and 2008
62
Source of Care in Brazil, by Type of Facility, 1981–2008
62
SUS Consultations per Capita and Hospitalizations per
100 Persons in Brazil, by State, 1995 and 2008 (or 2009)
63
SUS Consultations per Capita and Hospitalizations per
100 Persons in Brazil, by State Income per Capita,
64
1995 and 2008 (or 2009)
Percentage of the Population Who Sought and Used Care
65
in Brazil, by Income Decile, 1986 and 2008
Twenty Years of Health System Reform in Brazil • http://dx.doi.org/10.1596/978-0-8213-9843-2
viii
Contents
3.10
Immunization Coverage in Brazil and Other
Developing Countries, 1980–2009
67
3.11
Reasons Given for Not Seeking Care in Brazil, by Income Decile,
1986 and 2008
69
3.12
Share of Persons Reporting That They Sought Care but Did Not
Receive It in Brazil, by Income Decile, 1986 and 2008
70
3.13
Patterns of Care and Possible Points of Delay in Accessing
Health Care in Brazil
70
B3.2.1 Rates of Cesarean Section for Brazil as a Whole and for
INAMPS/SUS, 1970–2009
74
Quality of Care in the ESF and the Traditional Primary
3.14
75
Health Care System in Petropolis, Brazil, 2003
3.15
Potentially Avoidable Hospital Admissions for Chronic
75
Diseases and ESF Coverage in Brazil, 1997–2007
3.16
Distribution of Health Spending in OECD Countries, 2007
76
3.17
Density of Technology Use in Brazil and OECD Countries,
1985–200978
3.18
Bed Occupancy Rate in SUS Hospitals in Brazil, 1992–2010
79
3.19
Long-Term Trends in Life Expectancy and Infant Mortality
81
in Brazil, 1960–2009
3.20
Child Mortality and Mortality by Acute Diarrhea among
81
Children Younger Than Five Years Old in Brazil, 1990–2008
3.21
Maternal Mortality in Brazil and Latin America and
82
the Caribbean, 1990–2009
3.22
Life Expectancy and Infant Mortality in Brazil, by State,
84
1994 (or 1995) and 2007 (or 2009)
3.23
Link between Health Outcomes and Average Income per
Capita in Brazil, 1994 (or 1995) and 2007 (or 2009)
85
3.24
Infant Mortality in Brazil, by Region, 1997–2007
86
3.25
Infant Mortality in Brazil, by Income Group, 1990–2006
86
Share of the Household Budget Spent on Health in Brazil,
3.26
1987–200389
3.27
Composition of Household Spending on Health in Brazil,
1987–200990
3.28
Household Spending on Drugs and Private Health Plans
91
in Brazil, by Income Distribution, 1987–2003
3.29
Incidence of Catastrophic Spending on Health in Select Latin
American Countries, Various Years, 2002–08
92
3.30
Access to Dental Care and Medications from the SUS
in Brazil, 1981–2008
94
3.31
Drugs Paid for Out-of-Pocket in Brazil, by SUS List,
94
Type of Prescriber, and Use, 2008
3.32
Satisfaction with the Health System in Select Countries,
96
by GDP per Capita, 2010
Twenty Years of Health System Reform in Brazil • http://dx.doi.org/10.1596/978-0-8213-9843-2
Contents
Tables
2.1
Coverage of the ESF and the PACS in Brazil,
by Size of Municipality, 1998–2010
31
B2.3.1 Performance Scores for Essential Public Health Functions
of Five State Secretariats in Brazil, 2006
50
3.1
Change in Health Outcomes in Brazil and Comparable Countries,
1985–200982
Twenty Years of Health System Reform in Brazil • http://dx.doi.org/10.1596/978-0-8213-9843-2
ix
About the Authors
Michele Gragnolati is the Human Development Sector Leader for
Argentina, Paraguay, and Uruguay at the World Bank, based in Buenos Aires.
Previously, he served as Human Development Sector Leader for Brazil, based
in Brasilia; human development country sector coordinator for the Western
Balkans, based in Sarajevo; and human development economist, based in
Washington, DC. He holds a bachelor’s degree in economics from Bocconi
University in Milan, a master of science degree in demography from the
London School of Economics, and a doctorate in statistical demography from
Princeton University.
Magnus Lindelow is the Human Development Sector Leader (Health, Education,
and Social Protection) at the World Bank in Brazil. He holds a doctorate in economics from Oxford University. At the World Bank, he has worked on health
system reform, service delivery, public expenditure management, and poverty
and social protection issues. Over the last few years, he has been involved in
projects and research in Cambodia, China, the Lao People’s Democratic
Republic, Malaysia, Mongolia, the Republic of the Union of Myanmar, Thailand,
Timor-Leste, and, most recently, Brazil. He has published books and research
articles on impact evaluation of health sector programs, distributional issues in
the health sector, public finance, service delivery, poverty, and other topics. Prior
to joining the World Bank, he worked as an economist in the Ministry of Planning
and Finance in Mozambique and later as a consultant on public finance and
health sector issues.
Bernard Couttolenc is Chief Executive Officer of the Performa Institute, a new
policy research center in São Paulo, Brazil. He has a master’s degree in business
management and a doctorate in health economics from Johns Hopkins
University. He has worked for many years in executive positions in public and
private hospitals in Brazil as well as in planning and financing of the public
health system. He has nearly 20 years of experience consulting with international organizations such as the Asian Development Bank, Inter-American
Development Bank, World Bank, and World Health Organization, among ­others.
He has participated in projects in 15 developing countries in Africa, Asia, and
Latin America on health sector reform; health financing and payment
Twenty Years of Health System Reform in Brazil • http://dx.doi.org/10.1596/978-0-8213-9843-2
xi xii
About the Authors
mechanisms; hospital management, efficiency and reform; health care financing;
health systems planning and e­valuation; and public-private partnerships. For
more than 10 years, he held a teaching position at the University of São Paulo,
where he conducted research in health economics, financing, and economic
evaluation.
Twenty Years of Health System Reform in Brazil • http://dx.doi.org/10.1596/978-0-8213-9843-2
Abbreviations
AIH
autorização de internação hospitalar, the inpatient care information
and billing system of the SUS
AMS
Assistência Médico-Sanitária, a survey by the IBGE
ANS
Agência Nacional de Saúde Suplementar, National Regulatory
Agency for Private Health Insurance and Plans
BRICS
five upper-middle-income emerging countries: Brazil, Russia, India,
China, and (recently) South Africa
CNI
Confederação Nacional da Indústria, National Confederation of
Industry
CONASS Conselho Nacional de Secretários de Saúde, National Council of
State Secretaries of Health
CPMF
Contribuição Provisória sobre Movimentações Financeiras,
a ­contribution of financial transactions passed to finance the
­public health system
CT
computerized tomography
DATASUS data-processing arm of the Ministry of Health
ESF
Family Health Strategy
GAPA
Grupo de Apoio à Prevenção à AIDS
GDP
gross domestic product
HIV/AIDS human immunodeficiency virus/acquired immunodeficiency
syndrome
IBGE
Instituto Brasileiro de Geografia e Estatística, Brazilian Institute of
Geography and Statistics
IDSUS
Índice de Desempenho do SUS, SUS Performance Indicator
INAMPS Instituto Nacional de Assistência Médica da Previdência Social,
National Institute for Social Medical Assistance, in charge of
­curative care under the Social Security system that preceded SUS
IPEA
Instituto de Pesquisa Econômica Aplicada, Institute of Applied
Economic Research
MAC
média e alta complexidade, a grouping of medium- and high-­
complexity services in SUS classification of health care levels
Twenty Years of Health System Reform in Brazil • http://dx.doi.org/10.1596/978-0-8213-9843-2
xiii xiv
Abbreviations
and a block grant covering most inpatient care and specialized
care
MRI
magnetic resonance imaging
OECD
Organisation for Economic Co-operation and Development
PACS
Programa de Agentes Comunitários de Saúde, Community Health
Agents Program that preceded the ESF
PMAQ
Programa Nacional de Melhoria do Acesso e da Qualidade da
Atenção Básica, National Program for Improvement of Access and
Quality in Primary Care
Pesquisa Nacional por Amostra de Domicílios, IBGE’s yearly
PNAD
household survey
Pesquisa dos Orçamentos Familiares, a household survey
POF
PROCON Bureau of Consumer Protection
SAMU
Sistema de Assistência Médica de Urgência, Mobile Emergency
Service
Sistema de Informação sobre Orçamentos Públicos em Saúde,
SIOPS
Public Health Budget Information System of the Ministry of
Health, which records and monitors budgetary expenditures on
health from all levels of government
Unified and Decentralized Health System
SUDS
SUS
Sistema Único de Saúde, Unified Health System
Tribunal de Contas da União
TCU
WHO
World Health Organization
Twenty Years of Health System Reform in Brazil • http://dx.doi.org/10.1596/978-0-8213-9843-2
Overview
It has been more than 20 years since the 1988 Constitution formally established
the Brazilian Unified Health System (Sistema Único de Saúde, SUS). The ­impetus
for the SUS came in part from rising costs and a crisis in the Social Security system that preceded the reforms, but also from a broad-based political ­movement
calling for democratization and improved social rights. Building on reforms that
started in the 1980s, the SUS was based on three overarching principles: (a) universal
access to health services, with health defined as a citizen’s right and an obligation
of the state; (b) equality of access to health care; and (c) integrality (comprehensiveness) and continuity of care. Other guiding ideas included decentralization,
increased participation, and evidence-based prioritization (Couttolenc 2011a).
The SUS reforms established health as a fundamental right and duty of the
state and started a process of fundamentally transforming Brazil’s health system
to achieve this goal. This report focuses on two questions: What has been
achieved since the SUS was established? And what challenges remain in achieving the goals that were established in 1988? The report assesses whether the SUS
reforms have transformed the health system as envisaged more than 20 years ago
and whether the reforms have led to improved outcomes with regard to access
to services, financial protection, and health status.
Any effort to assess performance confronts a host of challenges concerning the
definition of boundaries of the “health system,” the outcomes that the assessment
should focus on, the sources and quality of data, and the role of policies and
reforms in explaining how the performance of the health system has changed
over time. Building on an extensive literature on health system assessment, this
report is based on a simple framework that specifies a set of “building blocks”
that affect intermediate outcomes such as access, quality, and efficiency, which,
in turn, contribute to final outcomes, including health status, financial protection,
and satisfaction. Based on this framework, the report starts by looking at how key
building blocks of Brazil’s health system have changed over time and then
reviews performance with regard to intermediate and final outcomes. The report
is, however, selective, and some important building blocks, such as human
resources and pharmaceuticals, are not discussed systematically.
Twenty Years of Health System Reform in Brazil • http://dx.doi.org/10.1596/978-0-8213-9843-2
1 2
Overview
Have the SUS Reforms Transformed the Brazilian Health System?
The SUS reforms envisaged profound changes in the organization and financing
of health services as well as the governance and accountability arrangements of
the system. Specifically, they targeted several perceived weaknesses of the preSUS system, including the limited availability of services in some parts of the
country, the weak primary care system, and excessive centralization. The future
role of the private sector was debated intensively in the lead-up to the new
Constitution; in the end, the Constitution and founding legislation of the SUS
defined the role of the private sector as “complementary.”
Expansion and Reorganization of Service Delivery
Since the establishment of the SUS, there have been many changes in the
organization of service delivery. Most notably, the capacity of the system has
­
expanded significantly, with the number of health care facilities growing from
nearly 22,000 in 1981 to almost 75,000 in 2009. The growth in facilities was
accounted for entirely by expansion of the outpatient network, while the n
­ umber
of hospitals remained fairly stable (from 6,342 to 6,875) and the number of
hospital beds actually declined. The expansion of outpatient facilities reflects a
growing emphasis on primary care, with the Family Health Strategy (ESF) which
was developed based on pilots of integrated primary care in Ceará and other
states in the 1980s, being a key driver of this change. Between 1988 and 2010,
the ­number of family health teams increased from 4,000 to more than 31,600,
with coverage reaching just over 50 percent of the Brazilian population.
The government’s efforts to expand the system were also targeted to addressing
regional disparities in access to health services. This is most apparent in the case of
hospital beds, where the restructuring of the system significantly reduced the
variation in the density of (public) hospital beds across states, and there is now
virtually no link between public hospital bed density and average income at the
state level. The trend in relation to the distribution of outpatient facilities is less
clear. However, the expansion of public outpatient facilities has tended to benefit
northeastern states the most. As a result, the density of public facilities is
­significantly higher in states with low per capita income.
The expansion and restructuring of the delivery network was accompanied by a
dramatic decentralization of responsibility for service delivery. The growth in
­outpatient facilities occurred almost entirely at the municipal level, and the share
of hospital beds under municipal control increased from 11 percent to nearly
50 percent between 1985 and 2009. Nonetheless, state and federal levels still
manage a significant share of public hospital beds.
The last 20 years also saw a changing mix of public-private hospitals.
Although the SUS did not have specific targets for expanding the network of
public facilities, policy clearly favored expansion of the public sector over
contracting with private providers, reducing both the number of for-profit
hospitals under contract and the payment rates to private providers. Reflecting
these changes, the share of hospital beds in the public sector increased
Twenty Years of Health System Reform in Brazil • http://dx.doi.org/10.1596/978-0-8213-9843-2
Overview
from 22 to 35 percent, but the private sector still accounts for more than
50 ­percent of hospital beds.
Toward Increased and More Equitable Health Financing
One of the major accomplishments of the SUS has been to unify and integrate
several independent systems of financing and service provision into a single publicly
funded system covering the whole population.
The SUS reforms also triggered several initiatives aimed at increasing and
stabilizing public financing for health, and government spending on health has
­
increased significantly since the early 1980s, growing 224 percent in real terms
between the first half of the 1980s and 2010 (an 111 percent increase in per
capita terms). In part, this growth in government spending on health simply
reflects economic growth; while government spending on health as a share of
gross domestic product (GDP) fluctuated during the 1980s and 1990s, it has
increased significantly since 2003. Government health spending in Brazil is currently
just under 4 percent of GDP, which is significantly lower than the level of spending in
most Organisation for Economic Co-operation and Development (OECD) and some
middle-income countries, although Brazil is by no means a clear outlier.
Focusing on the period 1995–2010, for which comparable data from other
countries are available, the average annual rate of growth in (real) per capita
­government health expenditure was lower in Brazil than in many other middleincome countries (3 percent a year in Brazil, compared with between 8 and
12 percent in China, the Republic of Korea, South Africa, and Turkey). The
growth in real spending picked up in the early 2000s (around 6 percent a year),
but it is still lower than in many of Brazil’s peers.
Changing Composition of Government Spending on Health
The expansion of the ESF was accompanied by a change in budget allocations,
with federal transfers for “basic care” increasing from 11 to 20 percent of total transfers
between 1995 and 2002. The reallocation of resources in favor of primary care has
helped to reduce the hospital-centric nature of the health system, although hospital services continue to account for nearly half of government spending.
Changing Financing Mix across Levels of Government
Reflecting the drastic decentralization of service delivery responsibilities, the
financing mix of different levels of government also changed notably over the last
two decades. In the late 1980s, immediately after formation of the SUS, federal
financing accounted for 85 percent of total government spending on health.
Since then, the federal share of financing has declined steadily, reaching 45 percent
in the late 2000s, while municipal and state spending has risen steadily, reaching
28 and 27 percent, respectively, in 2009.
Shrinking Regional Disparities in Government Spending
While the SUS reforms did not increase government spending on health as much
as anticipated, disparities in government spending across states and municipalities
have fallen significantly. This was achieved not only by making targeted
Twenty Years of Health System Reform in Brazil • http://dx.doi.org/10.1596/978-0-8213-9843-2
3
4
Overview
investments in expanding the health system in underserved parts of the country,
but also by changing the criteria for allocating federal and state funds for health
(Couttolenc 2011b).
The Role of Private Health Financing
When the SUS was established, the importance of the private (“supplemental”)
health system was expected to decline steadily. This did not happen. Indeed,
despite intentions to the contrary, private spending remained stable over the last
15 years or so (from around 57 percent of total health spending in 1995 to
54 ­percent in 2009). The share of direct out-of-pocket spending declined over time,
but still accounts for around 30 percent of total health spending, while the share of
spending on private plans rose and now stands at just over 20 percent. The
­number of individuals with private health plan coverage grew steadily, but the
share of total health spending financed by government is significantly lower in Brazil
than in OECD countries and many middle-income peers.
Enhancing Health System Governance
For the purposes of this report, governance is seen as being concerned with the
management of relationships between various stakeholders in health, including
individuals, households, communities, firms, governments of different levels,
­nongovernmental organizations, private firms, and other entities with the responsibility to finance, monitor, deliver, and use health services. Many of the changes
to the health system that the SUS reforms envisaged had important implications
for governance and accountability.
One important challenge linked to health system governance is the ­establishment
and consequences of the right to health. The right to health was enshrined in the
1988 Constitution and confirmed in the basic legislation of SUS. To ­operationalize
this right, the government expanded the health facility network and maintained
the legal provision that anyone can be treated for free under the SUS based on an
open-ended benefits package. Inevitably, the SUS has not been able to provide
all services for everyone, and many patients have resorted to the courts to
seek access to expensive drugs or treatments, resulting in judicial mandates that
pose an increasing burden on SUS finances. In recent years, the Ministry of
Health has attempted to develop a dialogue with the judiciary and to improve
the systems and procedures for incorporating new technologies.
A second important governance challenge concerns the institutions for
coordination and financing across levels of government. The drastic shift in
­
­responsibilities for financing and service delivery to lower levels of government
has required new mechanisms for coordination and negotiation across a­ utonomous
levels of government. Initially, this effort focused on the establishment of ­bilateral
and trilateral committees. These mechanisms not only improved coordination,
but also proved to be bureaucratic and cumbersome. In parallel, new mechanisms for intergovernmental transfers and payments to providers needed to be
established, with waves of reforms trying to find a balance between federal direction and local autonomy and between specificity of transfers and the risk of
Twenty Years of Health System Reform in Brazil • http://dx.doi.org/10.1596/978-0-8213-9843-2
Overview
excessive f­ ragmentation. The decentralization process also raised questions about
whether some of the 5,600 municipalities that now have primary responsibility
for ­delivering health services are too small to achieve economies of scale and
scope in managing the health system. Reflecting this concern, there are ongoing
efforts to define a new level of organization of the system—regional health
­networks—that sits between the state and municipal levels.
A third area related to health system governance concerns social participation
and voice. Democratization in the health system was a major objective of the
SUS reform, and this goal was reflected in the establishment of health councils
at each level of government. These councils provide formal mechanisms for
­society participation, but vary greatly in effectiveness.
Finally, the SUS reforms and subsequent policies have led to changing purchaser–
provider relationships. In the early 1980s, most payments to private hospitals were
done on the basis of fee-for-service, while public providers were financed on the
basis of traditional line-item budgets. Over time, fee-for-service payment was
replaced by a prospective payment mechanism based on medical procedures
(known as the authorization for hospital admission). In parallel to the early rounds
of payment reform, several initiatives have sought to develop new organizational
models for delivering services. Most prominently, São Paulo pioneered contracting
private not-for-profit organizations (organizações sociais), and other states and municipalities have followed suit. While the São Paulo model is deemed successful, there
is less evidence on performance in other parts of the country. Moreover, limited
capacity in contract design and monitoring has often proved to be a significant
constraint. Overall, innovations in organizational ­models, provider payment, and
contracting are limited, but gaining momentum (La Forgia and Couttolenc 2008).
Have the SUS Reforms Led to Better Outcomes?
While the SUS reforms focused on transforming how the health system was
financed and organized, the ultimate goal was to universalize access to health
services. The report assesses the extent to which this goal has been achieved and
looks at progress in relation to other intermediate health system goals, in particular quality and efficiency, as well as in relation to the ultimate goals of the health
system: improving health outcomes, reducing the financial burden of health
expenditures, and enhancing trust and satisfaction with the health system.
Trends in the Use of Health Services
Universality was a key founding principle of the SUS. Universal access or ­coverage
is typically understood to mean that all people have access to a full spectrum of
services without suffering financial hardship. Formally, the SUS reforms achieved
this goal by decree, but to what extent has this formal entitlement translated into
increased access and enhanced financial protection in practice?
SUS “Coverage” and the Persistent Fragmentation of the Health System
In 1981, 49 percent of the population reported that Social Security or the
National Institute for Social Medical Assistance (Instituto Nacional de Assistência
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Médica da Previdência Social, INAMPS) was their “regular source of care,” while
another 19 percent reported that they relied on the public system or free
­philanthropic services. By 2008, only 58 percent of individuals reported being
regular users of the SUS. Hence, if measured based on self-reported “regular
sources of care,” the goal of bringing a larger share of the population into the
public health system has not been achieved. However, other evidence suggests
that nearly all Brazilians use SUS services at some point, including a recent study
indicating that nearly 90 percent of the population uses the SUS exclusively or
in combination with the private sector.
Expansion in the Volume of Services Provided by SUS
Another approach to assessing coverage is to look at the volume of services
­provided by SUS facilities as a measure of realized access. The number of medical
consultations per capita increased 70 percent between 1990 and 2009, with the
volume of basic care procedures increasing even more rapidly. In contrast, the
quantity of hospitalizations provided by the SUS or INAMPS remained stagnant
at around 11.5 million. Administrative data on the volume and composition of
services are corroborated by survey data, which show that the share of i­ ndividuals
who reported seeking some form of health care in the last two weeks increased
nearly 30 percent between 1986 and 2008 (from 11.3 to 14.4 ­percent). The type
of services used by households also changed over time, with preventive visits and
dental consultations accounting for a growing share of all visits.
Convergence in Utilization Rates across States and Socioeconomic Groups
By 2009, all states had achieved rates of at least 2.35 consultations per capita per
year, with greater increases in utilization in low-income states. Most states
­experienced reductions in SUS hospital admission rates. Although geographic
disparities in utilization declined some, a significant income gradient remains in
average utilization rates across states. Moreover, notable disparities persist across
income groups, with higher levels of utilization among high-income groups. For
instance, household survey data indicate that utilization rates are around
50 ­percent higher for the top two deciles than for the bottom two.
Are Health Care Needs Being Met?
Trends and patterns in utilization of health services provide a good indication of
realized access. However, simple utilization rates do not shed much light on
whether individuals are able to access the preventive, diagnostic, and curative
services they need in a timely manner, even though this is a critical element in
assessing progress toward improving access and achieving universal coverage.
One way to address this question is to look at coverage of health interventions
with a clearly defined target group, such as immunizations, antenatal care, and
hospital deliveries. On this metric, Brazil is a stellar performer, with nearly u
­ niversal
coverage and limited geographic disparities.
Another approach to assessing the extent to which needs are being addressed
is to look at self-reported unmet need. Household surveys found a reduction in
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unmet need, as well as in the share of households reporting lack of money as a reason
for not using services, in particular for those at the lower end of the income
­distribution. Meanwhile, facility-related reasons (lack of or unfriendly staff, inadequate scheduling, waiting time) have increased, becoming the chief motive for
not seeking care.
Many care-seeking experiences involve multiple providers and services
(­
general practice, specialist care, diagnostic services), with effective access
depending not only on the availability of services, but also on the organization
and coordination of care, referral arrangements, and other factors. Access is
harder to assess in relation to these types of services, but waiting times provide
an important metric of unmet need. In this regard, a recent study of cancer care
by the Federal Audit Tribunal found that, as a result of weaknesses in primary
care and access to diagnostic procedures and specialist care, 60 percent of cancer
patients were diagnosed at a very late stage (stage three or four), reducing the
prospects of effective treatment and survival. The problem of late diagnosis is
compounded by delays in accessing treatment, with median waiting times in
2010 ranging from 76.3 to 113.4 days depending on the type of treatment. The
data on diagnosis and treatment delays compare very poorly with available data
from OECD countries.
Along similar lines, a study on the demand for specialist, diagnostic, and
­surgical procedures in Rio Grande do Sul found that, for the state as a whole,
with a population of 10.6 million people, there was an unmet need of nearly
500,000 consultations or procedures, mostly in the area of specialist consultation
and diagnostic procedures.
The Quality Dimension: A Missing Piece of the Puzzle?
Discussions of coverage tend to focus on access to and cost of services for
different groups. However, this concept of “coverage” does not adequately
­
­capture quality and the extent to which improvements in coverage of health
services translate into better health outcomes. In other words, not only do
­individuals need to access services, but also those services need to be of appropriate quality and well delivered if potential health gains are to be realized.
Limited data exist on the quality of health care in Brazil, but several studies
point to significant concerns with regard to staff training, appropriateness of care,
use of quality assurance systems or procedures, and compliance with licensing
requirements. There are, however, also signs of improvement, with assessments
of quality in the ESF comparing well with the traditional primary care approach
and with declines in avoidable admissions.
Health System Efficiency
The concept of efficiency is concerned with the relationship between inputs and
outcomes or outputs. At the broadest level, an efficient health system is one that
produces the greatest improvement for a given level of spending. However,
assessments of efficiency often focus on specific links in the chain from spending
to outcomes, including the extent to which resources are allocated appropriately
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across programs or interventions (allocative efficiency) and the extent to which
the greatest volume and quality of health services are produced given available
inputs (technical efficiency).
Few studies have looked at allocative efficiency in the Brazilian health system,
but government spending clearly has been reallocated toward primary care,
which is expected to contribute to greater efficiency in the health system.
With regard to the use of medical technology and allocative efficiency at the
­
facility level, a substantial proportion of high-complexity equipment is adopted
without appropriate consideration of its implications for the cost, quality, and
effectiveness of care. Moreover, a substantial proportion of high-cost equipment
is installed in municipalities that do not have the size or the role to host it.
Notwithstanding partial initiatives in recent years, the Ministry of Health has few
established systems for regulating and organizing the adoption and supply of
medical technology.
Finally, the report discusses the question of hospital efficiency, noting evidence
that most Brazilian hospitals operate at a very low level of efficiency. Using data
envelopment analysis for a sample of 428 hospitals, the average score for technical efficiency in 2002 was 0.34 on a scale of 0–1. The main factors contributing
to inefficiency were small scale of operations, high use of human resources, and
low use of installed capacity and technical resources. Indeed, most Brazilian
­hospitals are too small to operate efficiently, with 65 percent having fewer than
50 beds. Moreover, the mean bed occupancy rate is very low: 37 percent for
acute care hospitals and 45 percent for all hospitals.
Improving Health Outcomes: What Has Been the Contribution
of the Health System?
Ensuring broad-based access to effective health services was a key concern of the
SUS reforms. However, the ultimate goals were to improve the level and
­distribution of health outcomes, ensure that financing of health care is affordable
and equitable, and achieve high levels of responsiveness and satisfaction.
Brazil achieved significant improvements in life expectancy, child and infant
mortality, and, to a lesser extent, maternal mortality over the last 20 years.
­
Geographic inequalities in health outcomes were significantly reduced, with
northeastern states benefiting the most, and disparities across socioeconomic
groups also declined. However, significant inequalities in health status remain.
While the improvements and reduced inequalities in health outcomes are
good news, these gains are attributable at least in part to developments outside
the health system: access to safe water and sanitation, quality food and education,
and the economic situation of households. There is, however, convincing ­evidence
that the SUS has played an important role in improving health outcomes. One
approach to assessing the contribution of the health system to better health
­outcomes is to look at trends in avoidable (or amenable) mortality—that is,
deaths that could have been avoided in the presence of timely and effective
health care. Several studies of avoidable mortality in Brazil suggest that SUS has
played an important role in improving outcomes, showing that mortality from
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Overview
avoidable causes declined significantly, while mortality from other causes remained
stable or even increased. This result was likely driven at least in part by
­improvements in coverage and quality of the health system.
In assessing the impact of the health system on health outcomes, evaluations
of the ESF provide another piece of the puzzle. Recent studies have found that
implementation of the ESF was associated with significant reductions in infant mortality, diarrhea incidence among children, h
­ ospitalization for strokes, and acute respiratory infections in the period between 1990 and 2002. However, one study reports
notable heterogeneity in impact, with large and significant reductions in infant
mortality in the North and Northeast and no significant impacts in other parts of
the country.
Out-of-Pocket Payments and Financial Protection
The principle of universality is related not only to utilization of services, but also
to the extent that individuals are able to access services without financial distress.
Improvements in financial protection are typically assessed using data on
­household spending on health over a defined period. Available data, which offer
data points ranging from 1987 to 2008, suggest that there was little change over time
in the share of total household spending dedicated to health, with estimates ranging
from 5 to 7 percent. There was, however, a notable reduction in the share of
household spending on health at the lower end of the income distribution in
2002/03 relative to earlier years.
While the overall share of household spending dedicated to health remained
stable over the last 20 years, service charges (consultations, hospitalizations,
­dental care) became relatively less important (declining from 50 percent of outof-pocket spending in 1987/88 to 20 percent in 2008/09); over the same period,
spending on private plans and drugs rose.
The average share of health spending in total consumption provides an
­important perspective on the burden of health expenditures for households (the
incidence of “catastrophic spending”), especially if a large share of it is in the
form of out-of-pocket spending. There is a wide range of estimates for the incidence
of catastrophic spending in Brazil. However, the most systematic studies have found
low incidence, with Brazil comparing favorably with other countries in the region. As
in many other countries in the region, in Brazil catastrophic spending is significantly higher among poorer households and households with elderly household
members (Diniz et al. 2007; Knaul et al. 2011; Xu et al. 2003).
Public Perceptions and Satisfaction with the Health System
The primary goals of the health system are to improve health outcomes and
provide effective financial protection. However, most people (and policy makers)
also consider satisfaction and responsiveness important intrinsic objectives.
Recent opinion polls concerning the health system in Brazil provide a very
mixed picture, reflecting differences in the sample (geographic focus,
socioeconomic profile of respondents) and how questions were asked.
­
However, several surveys show high levels of dissatisfaction with public health
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services, with some surveys suggesting that problems have gotten worse in recent
years. The most commonly reported problems are delays in access or treatment
and a lack of doctors. However, other surveys provide more positive assessments,
with the ESF receiving the most positive assessment.
Of course, given the nearly limitless demand for health care, all countries
struggle to meet expectations. Yet dissatisfaction with the health system appears
to be particularly high in Brazil. In a recently conducted round of the Gallup
World Poll, which asks randomly selected households across a wide range of
countries about their satisfaction with public services and other issues, only
40 percent of Brazilians were satisfied with the health system—significantly
lower than in many other middle-income countries (such as Malaysia, Thailand,
Turkey, or Uruguay) (CNI 2012; Folha de São Paulo 2012; IPEA 2011).
Conclusions
Over the last 20 years, Brazil has seen impressive improvements in health
­outcomes, with dramatic reductions in child and infant mortality and increases
in life expectancy. Equally important, geographic and socioeconomic disparities
in outcomes have become far less pronounced. There are good reasons to
believe that changes in the SUS have played an important role. The rapid
expansion of primary care has contributed to changing patterns of utilization,
with a growing share of contacts taking place in health centers and other primary care facilities. There has also been an overall growth in utilization of
health services and a reduction in the share of households reporting problems
in accessing health care for financial reasons. In short, the SUS reforms have
achieved at least partially the goals of universal and equitable access to
health care.
This report highlights five primary challenges facing Brazil’s health care
­system in the future.
Sustaining Improvements in Access to Health Care
Progress in this area will depend on sustaining expansion of the ESF. However,
it will also be important to recognize the diversity of primary care models that
are currently in use and to reach some consensus on their ­relative merits (and
costs). Primary care will also need to be linked effectively with other parts of the
health system. Many initiatives are under way to address these challenges: investment and upgrading of capacity, review of payment rates, implementation of
clinical guidelines, investment in systems for referrals and electronic medical
records, and so forth. In most cases, progress in these areas will require effective
coordination across municipalities through regional health care networks. As
part of this process, it will also be important to address the lack of integration
and clearly define the roles of the public and private sectors. The ­current lack of
coordination between the two sectors results in duplications of efforts and
resources, conflicts over who should pay for what, and difficulty addressing systemwide problems.
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Improving Efficiency and Quality of Health Care Services
In the face of persistent concerns about efficiency and quality, many states and
municipalities are experimenting with new models for providing services,
­including contracting with nonprofit organizations in Rio de Janeiro, São Paulo,
and increasingly in other states. Many parts of Brazil are experimenting with
public-private partnerships, in both the construction and management of public
facilities. While these contracting arrangements hold promise, they put ­significant
new demands on the state and municipal health secretariats in relation to
­determining not only what to contract, but also how to design, monitor, and
enforce contracts.
New contracting models provide an opportunity to change the way providers
are financed and how levels of government coordinate with one another.
However, outside of these experiences, weak payment mechanisms contribute to
inefficiency and poor quality. Correcting existing distortions and embarking on
the large-scale adoption of provider payment methods that provide clear
­incentives for improving performance would help to make more effective use of
available resources and further improve SUS performance within an achievable
funding envelope. In the case of public providers, payment reform would have to
go hand-in-hand with measures to strengthen the financial and managerial
autonomy of hospitals if payment-related incentives are to have an impact on
performance.
In the future, it will be important to ensure that efforts to improve quality and
efficiency in service delivery are systematically evaluated and that the lessons
from these evaluations are shared widely among stakeholders in Brazil.
Clarifying Roles and Relationships across Levels of Government
Decentralization can bring many benefits with regard to increased accountability,
tailoring of the system to local needs, coordination with other public services, and
so forth. Yet many municipalities lack the scale and technical capacity to manage
a health system involving all levels of care and complex supporting services.
A well-functioning system will depend on effective coordination and collaboration across municipalities, in particular when it comes to specialist and high-­
complexity services, referral systems, and medical logistics. It will also depend on
robust institutions and approaches for contracting and financing across levels of
government. In both of these areas, Brazil has made significant strides in recent
years, with new legislation to support a framework for contracting between
federal government and health regions and institutional mechanisms for
­
­coordinating between municipalities, states, and federal government.
However, implementation of this legislation will inevitably raise many
­political and practical challenges relating to the process of regional planning, the
management and coordination of “shared” services, the financing of investments
in systems and capacity to support regional networks, the sharing of financing
responsibilities across levels of government, and so forth. States will proceed with
this process at different speeds, and it will be important to study and learn from
the early adopters.
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Raising the Level and Efficiency of Government Spending
There is continuous pressure from the health establishment to increase public
funding to health. The report presents data showing that spending increased
significantly over the last 20 years in absolute terms (and to a lesser extent as
a share of GDP). However, the growth in spending was slower than in many
other middle- and high-income countries, particularly in those where coverage
expanded rapidly (for example, Korea, South Africa, Thailand, and Turkey).
The increase in spending did not keep up with the rapid expansion of the system and the volume of services provided, particularly if cost increases associated with the introduction of new drugs and procedures are considered. More
government spending on health would undoubtedly help to finance more
health system resources (facilities, equipment, staff), medical supplies, and
services.
Yet the report shows that the lack of resources and supplies is in many cases
not the binding constraint to improving access and quality. The health system
clearly could produce more health services and better health outcomes with the
same level of resources if it were more efficient. For instance, significant gains
could be achieved by better aligning hospital capacity with need, enhancing the
technical efficiency of hospitals, reducing waste and misuse of funds, and so forth.
Gains could also be realized through improved prioritization in the allocation of
government spending based on more robust processes for introducing and
­managing the use of existing and new technologies. There are no simple solutions
for dealing with these issues, but there is a wealth of international experience on
which Brazil could draw. At the same time, even with improvements in ­efficiency,
spending pressures are unlikely to abate in coming decades. As Brazil continues
to grow and develop, the combination of unmet needs in both primary and
­specialist care, the introduction of new technology, growing demands for health
care associated with noncommunicable diseases, and the increase in utilization
associated with an aging population is likely to put significant pressure on public
spending on health. As in other advanced health systems around the world, it will
be essential to enhance efficiency and improve prioritization, but it will also be
important to prepare for significant and sustained increases in government
spending on health and put in place mechanisms for managing the cost pressures
already evident in the system.
Conducting More and Better Health System Monitoring and Research
Brazil has a strong tradition of evidence-based policy making in the health sector
and a vibrant health research community. The report highlights the need to build
on these strengths by improving the information and evidence to support
continued health system reform. For instance, although vast amounts of
­
administrative data on health outcomes, service delivery, and financing are
­
­publicly available, data suffer from problems related to poor quality, inconsistent
definitions, and the structure of data over time and space. This makes
­benchmarking of health system performance over time, across space, and internationally difficult in some areas.
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Data are also lacking on many important dimensions of performance,
i­ncluding waiting times for elective procedures, quality of care for chronic
­diseases, and survival rates for specific conditions such as cancer or heart attacks.
Data on these types of indicators have played a very important role in understanding and addressing health system challenges in OECD countries and will
gain importance in Brazil as the country grapples with issues relating to access,
quality, and coordination of care.
Beyond the monitoring of health system performance, the report highlights
some areas in which in-depth research is warranted, including on the merits of
different service delivery models, the impacts of different approaches to
improving quality and efficiency, and approaches to reducing out-of-pocket
­
spending on medicines. These are merely some examples of questions that
­rigorous research and evaluation, based on strong partnerships between policy
makers and the research community, can help to answer and, in that way,
­contribute to making the Brazilian health system more efficient, effective, and
equitable.
References
CNI (Confederação Nacional da Indústria). 2012. Retratos da sociedade brasileira: Saúde
pública. Pesquisa CNI-IBOPE. Brasilia: CNI.
Couttolenc, B. F. 2011a. “Health System Performance and Accountability Assessment in
Brazil.” Consultant report, World Bank, Washington, DC.
———. 2011b. “Taking Stock of Performance Reforms at the Sub-National Level in Brazil:
Recent Performance Gains Achieved in the Health Sector, Hypotheses on Possible
Drivers of Good and Bad Performance.” Consultant report, World Bank, Washington,
DC.
Diniz, B., L. Servo, S. Piola, and M. Eirado. 2007. “Gasto das famílias com saúde no Brasil:
Evolução e debate sobre gasto catastrófico.” In Gasto e consumo das famílias brasileiras
contemporáneas, edited by F. Faiger, L. Servo, T. Menezes, and S. Piola, 143–60. Brasilia:
Instituto de Pesquisa Econômica Aplicada.
Folha de São Paulo. 2012. “Insatisfação com a saúde sobe 11 pontos em um ano (2012).”
Folha de São Paulo, January 25.
IPEA (Instituto de Pesquisa Econômica Aplicada). 2011. Sistema de indicadores de percepção social: Saúde. Brasilia: IPEA.
Knaul, F., R. Wong, H. Arreola-Ornelas, and O. Mendez. 2011. “Household Catastrophic
Health Expenditures: A Comparative Analysis of Twelve Latin American and
Caribbean Countries.” Salud Pública Mexicana 53 (Suppl. 2): S85–95.
La Forgia, G. M., and B. F. Couttolenc. 2008. Hospital Performance in Brazil: In Search of
Excellence. Washington, DC: World Bank.
Xu, K., D. B. Evans, K. Kawabata, R. Zeramdini, J. Klavus, and C. J. Murray. 2003.
“Household Catastrophic Health Expenditure: A Multicountry Analysis.” Lancet 362
(9378): 111–17.
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C h a pter 1
Introduction
It has been more than 20 years since Brazil’s 1988 Constitution formally
­established the Unified Health System (Sistema Único de Saúde, SUS). Building
on reforms that started in the 1980s, the SUS represented a significant break
with the past, establishing health care as a fundamental right and duty of the
state and initiating a process of fundamentally transforming Brazil’s health
­system to achieve this goal.
As in all health systems, reform begets further reform, such that the process
never quite ends. Nonetheless, after 20 years of implementation, it is apt to ask
what the SUS has achieved to date and what challenges remain in achieving the
goals established in 1988. Such an inquiry is particularly apt now because the
demands placed on and the expectations of the health system are growing
rapidly. Over the past 20 years, Brazil has experienced profound economic,
­
political, and demographic changes. After considerable turmoil in the 1960s,
1970s, and 1980s, political and economic stability was achieved in the mid1990s, and economic growth took off in the early 2000s.1 Economic growth,
steadily rising employment, increases in the minimum wage, and social transfer
programs all contributed to higher household income and lower poverty and
inequality.2 Recent decades have also seen a profound demographic transition,
with a near doubling of the elderly population (60 years of age and older)
between 1960 and 2010, from 5.3 to 10.2 percent of the population (World
Bank 2011). This economic, social, and demographic transition has had profound
implications for the health system, with expanding and changing health needs
and rising expectations of what the health system can and should deliver.
This report aims to answer two main questions.3 First, have the SUS reforms
transformed the health system as envisaged 20 years ago? Second, have the
reforms led to improvements with regard to access to services, financial
­protection, and health outcomes?
In addressing these questions, the report revisits ground covered in previous
assessments, but also brings to bear additional or more recent data and places
Brazil’s health system in an international context. The report shows that the
health system reforms can be credited with significant achievements.
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In particular, the last 20 years have seen an impressive expansion in access to and
use of primary care, a profound restructuring of the health system—in particular,
a steady decentralization of responsibilities to municipalities—and a rise in
­government spending on health. There is convincing evidence that some of these
reforms have contributed to improvements in health outcomes. Yet, perhaps
inevitably, many challenges remain. Access to diagnostic services and specialist
care is problematic for large segments of the population; services are ­fragmented
and coordination of care is weak; and service delivery is often poor quality and
inefficient in many contexts. As a result of these issues, health outcomes are not
as good as they could be, private spending continues to account for a large share
of health spending, and levels of satisfaction with the health system are low.
There are no silver bullets for addressing these challenges, but the report points
to some promising directions for health system reforms that will allow Brazil to
continue building on the achievements made to date.
Although it is possible to reach some broad conclusions, there are many gaps
and caveats in the story. Given the inherent challenges in assessing health system
performance, this is neither surprising nor unusual. Nonetheless, a secondary aim
of the report is to consider how some of these gaps can be filled through
improved monitoring of health system performance and future research.
The remainder of this introduction presents a short review of the history of
the SUS, describes the core principles that underpinned the reform, and offers a
brief description of the evaluation framework used in the report. Chapter 2
­presents findings on the extent to which the SUS reforms have transformed the
health system, focusing on delivery, financing, and governance. Chapter 3 asks
whether the reforms have resulted in improved outcomes with regard to access
to services, financial protection, quality, health outcomes, and efficiency. The
concluding chapter presents the main findings of the study, discusses some policy
directions for addressing the current shortcomings, and identifies areas for
­further research.
SUS: Origins and 20 Years of Implementation
The Brazilian Unified Health System was formally established by the 1988
Constitution, with details outlined in Laws 8.080 and 8.142 of 1990.4 Prior to
establishing the SUS, Social Security institutions—in particular, the National
Institute for Social Medical Assistance (Instituto Nacional de Assistência
Médica da Previdência Social, INAMPS)—formed the cornerstone of the
health system, with the Ministry of Health (Ministério da Saúde) focusing
­primarily on public health and disease-specific programs. Initially, the Social
Security system provided medical coverage only for formal sector workers,
primarily through contracts with private sector providers; states and
­philanthropic organizations provided services for the rest of the population.
However, by the late 1970s, rural workers, the self-employed, and domestic
­workers had been included. INAMPS also provided emergency coverage for the
entire population.
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The impetus for the SUS came in part from rising costs and a crisis in the
Social Security system, but also from a broad-based political movement calling
for democratization and improved social rights. In the health sector, the
“sanitary movement” (movimento sanitário) championed far-reaching health
­
system reforms (Cornwall and Shankland 2008). Protagonists of the movement
pointed to chronic underfunding, duplication and inefficiency due to fragmentation and a lack of systemwide coordination, and unequal access to care as key
problems of the system. Most important, they argued for a shift away from the
“curative privatizing model” that prevailed in the 1970s and early 1980s. This
model was premised on the expansion of Social Security coverage to workers
outside the original target population, prioritization of curative personal medical care over collective public health programs, the establishment of a “medicalindustrial complex,” and the migration of service provision to private providers
(Silva 1983).5
Significant health system reforms were introduced in the 1980s, initially
through implementation of “integrated health activities,” which sought to
improve the coordination among levels of government and reduce duplication in
the health system. Later, in the mid-1980s, a second phase of reform turned
attention to rearranging institutional roles within the system and decentralizing
responsibilities to states and municipalities through establishment of the Unified
and Decentralized Health System (SUDS). These reforms, and the Eighth
National Health Conference in 1986, laid the foundations for the SUS.
As stated in the Constitution and its basic laws, the SUS has three overarching
principles:
• Universal access to health services, with health defined as a citizen’s right and
an obligation of the state
• Equality of access to health care
• Integrality and continuity of care.
These overarching principles were underpinned by others, including
­decentralization of most responsibilities to municipalities and joint financing
responsibilities; increased community participation; reorganization of the system
to enhance integration, improve coordination, and reduce duplication; patient
autonomy and right to information; and enhanced effectiveness through the use
of epidemiology to define priorities and allocate resources.
Transforming these principles into reality has been an ongoing process ever
since the SUS was founded. The first wave of implementation, from 1988 to
1990, focused on establishing the basic legislation and regulations, including the
transfer of INAMPS from Social Security to the Ministry of Health,6
­decentralization to the state level, and establishment of mechanisms for social
participation. The second wave, from 1991 to 1995, emphasized detailing the
norms and rules of the system’s organization, financing, and operation, including
the “municipalization” of service delivery and the implementation of financial
mechanisms for allocating federal funds. A third wave, starting in the mid-1990s,
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18
Introduction
addressed issues in the organization and provision of health care by emphasizing
primary care. The fourth and most recent wave of implementation, starting in the
mid-2000s, is addressing efficiency and quality issues by reforming governance of
the system as well as contracting and payment mechanisms and by establishing
regional health care networks.
A Framework for Assessing SUS Performance
The SUS reforms were very ambitious in scope.7 What have been the results
after 20 years? To what extent has the performance of the health system
improved? And how does Brazil compare with other countries? Efforts to answer
these questions confront a host of challenges that are inherent to any health
system assessment. What are the boundaries of the “health system”? What
­outcomes are important in assessing health system performance? How should
outcomes be measured? What importance should be given to different
­dimensions of performance in assessing the overall system? To what extent can
differences across time and space (for example, countries or states) be attributed
to reforms or features of the health system?
Various frameworks are available for assessing health system performance
(Hurst and Jee-Hughes 2001; OECD 2002; Roberts et al. 2003; Smith, Mossialos,
and Papanicolas 2008; WHO 2000, 2007). These frameworks differ in important
ways, but also share significant commonalities, not only among themselves, but
also with frameworks that have been developed and used previously in Brazil to
assess health system performance (box 1.1).
In respect for the “boundaries” of the health system, some frameworks take an
expansive view, focusing on all activities whose primary intent is to improve or
maintain health (for example, WHO 2000, 2007). Based on this approach,
­public health functions such as disease control, injury prevention, protection
against environmental hazards, and food and drug safety should all be considered
in assessing the performance of the health system. Other frameworks focus
explicitly on the health care system and exclude most public health activities and
other wider issues (for example, OECD 2002; Hurst and Jee-Hughes 2001). This
report largely follows the latter approach: it touches on some issues relating to
public health, but is concerned primarily with the financing and delivery of
health care.
When it comes to health system goals, there are notable differences in
­terminology across assessment frameworks, but broad agreement on the ultimate
aims of health systems: to improve the level and distribution of health outcomes,
responsiveness, and financial protection. In addition to these intrinsic goals, some
frameworks also highlight important intermediate outcomes, including access and
coverage, efficiency, quality, and sometimes others.8 Finally, many health system
performance assessment frameworks identify key health system functions or
­elements (sometimes referred to as “building blocks” or “control knobs”), which
are subject to policy and important determinants of health system performance.
The list varies across frameworks, but financing, service delivery, governance, and
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Introduction
Box 1.1 Assessment of Health System Performance in Brazil: Approaches and
Recent Developments
The approach adopted in this study is consistent with models and frameworks already
developed or adapted in Brazil, including the Ministry of Health’s Health Sector Performance
Assessment Policy of 2006, the framework of the State Secretariat of Health of São Paulo, the
Primary Health Care Assessment Tool of the Ministry of Health, the Quality Improvement
Program for Private Health Plans of the National Regulatory Agency for Private Health
Insurance and Plans (Agência Nacional de Saúde Suplementar, ANS), and the Programa de
Avaliação do Desempenho do Sistema de Saúde (Program for Evaluation of Health System
Performance) methodology of the Oswaldo Cruz Foundation (see Couttolenc 2011a) for a
review of these models and frameworks).
Recently, the Ministry of Health launched an initiative to monitor the performance of state
and municipal health systems. A composite indicator of performance at the municipal level—
the SUS Performance Indicator (Índice de Desempenho do SUS, IDSUS)—was developed,
based on 24 indicators in five broad areas:
• Access and coverage in basic care (coverage by family health teams, coverage by oral health
teams, and percentage of live births from mothers with seven or more antenatal care
consultations)
• Access to medium-complexity outpatient and hospital care (coverage of screening for
cervical cancer, mammography tests, selected outpatient procedures, and mediumcomplexity clinical and surgical admissions)
• Access to high-complexity and referral outpatient and inpatient care (coverage of selected
high-complexity procedures, high-complexity clinical and surgical admissions, mediumand high-complexity services to nonresidents in the municipality)
• Effectiveness of basic care (percentage of admissions for conditions sensitive to basic care,
incidence rate for congenital syphilis, percentage of new cases of tuberculosis and Hansen’s
disease cured, coverage of dengue tetravalent vaccine, coverage of group-supervised tooth
brushing, and proportion of tooth extractions over all dental procedures)
• Effectiveness of medium- and high-complexity care and emergency care (percentage of
normal deliveries, intensive care unit mortality among children ages 15 and younger, and
mortality from acute myocardial infarction admissions).
The launch of the indicator and the first ranking of states and municipalities have sparked a
lively debate. There are legitimate concerns about the choice of indicators, consistency and
lags in the data (in some areas, the data refer to 2008 or 2009), the approach to grouping small
municipalities, and the weights ascribed to each indicator in constructing the overall index.
Nonetheless, IDSUS represents a big step forward in performance measurement in its clear
focus on measuring outcomes rather than processes and commitment to transparency (data
are available on the Ministry of Health website). As methodological and data issues are
resolved and trend data become available, IDSUS has the potential to become an important
tool for monitoring and benchmarking performance across subnational entities.
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20
Introduction
Figure 1.1 A Simple Framework for Assessing the Performance of the Health System
Health system building blocks
•
•
•
•
•
•
Service delivery and organization
Financing and resource allocation
Governance and stewardship
Human resources
Information
Medical products and technologies
Intermediate outcomes
• Access and coverage
• Quality and safety
• Efficiency
Level and distribution
Final outcomes
• Health outcomes
• Financial protection
• Responsiveness and
satisfaction
Level and distribution
Sources: Based on various health system performance frameworks, including Hurst and Jee-Hughes 2001; OECD 2002; WHO 2000, 2007; Roberts
et al. 2003; Smith, Mossialos, and Papanicolas 2008.
human resources feature in many of them. Building on the approaches
­highlighted above, our assessment of the SUS and the structure of this report are
based on the simple framework outlined in figure 1.1.
Given the focus on assessing a reform process (as opposed to performance of
the health system at one point in time), the report starts by looking at how key
elements or building blocks of the health system have changed over time. In doing
so, the objectives and principles defined by the founding legislation of the SUS
provide the starting point. In particular, given the emphasis of the SUS reforms on
expanding access, enhancing primary care and health system integration, increasing public spending on health, and achieving decentralization, much of chapter 2
reviews changes in the structure and organization of service delivery, as well as the
financing of health services. The report also looks at selected ­elements of health
system governance and accountability. Other health system functions or building
blocks—notably human resources, information, and the production and management of medical products and technologies—receive less attention because they
featured less prominently in the original SUS vision for reform and because the
last two areas (production and management of medical products and technologies) have less impact on the final outcomes of interest in the assessment.
Chapter 3 then reviews performance with regard to intermediate and final
outcomes, focusing first on access and coverage, quality, and efficiency and then
on the extent to which the health system has improved health outcomes, reduced
the financial burden on households, and achieved higher levels of satisfaction.
Performance of the system is assessed with reference to a broad range of
­indicators relating to inputs, outputs, and outcomes. For most indicators, 1985
(or the closest year) is used as a reference point for comparison over time. As
with any assessment of health system performance, this report had to contend
with various data limitations, with the most significant challenges being the lack
of consistent data over time (due to definitional, measurement, or data quality
issues) and the dearth of data for the period before reform. In areas where
­household or subnational data are available, these are used to shed light on
­disparities in outcomes.
For the most part, performance is assessed in relation to levels or outcomes
before reform and to any goals or targets established at the outset of reform.
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Introduction
Insofar as possible, the report tries to determine the extent to which ­improvements
in outcomes (for example, access, health status, or financial protection) can be
attributed to changes in the building blocks or functions (for example, service
delivery or financing) of the health system. In some areas, this can be achieved
by looking at the relative performance of states or municipalities with different
coverage or timing of reforms or by focusing on outcomes that can be linked
more directly to changes in the health system. However, neither approach can
provide a complete picture. The assessment also puts trends and levels of key
indicators in an international context, thereby providing a comparative p
­ erspective
on performance and remaining challenges.
Contribution of This Report
In recent years, several efforts have been made to assess the SUS reforms and the
performance of the Brazilian health system more broadly (for example, Passos
2010; CONASS 2006; Medici 2011; Paim et al. 2011; Economist Intelligence
Unit 2010; Victora et al. 2011; Wagner 2008). Most of these assessments point
to a mix of important advances and serious shortcomings.
There is significant agreement on the strengths of the SUS, with improved
access and outcomes and successful programs and initiatives in primary health
care and public health being the most cited. There is somewhat less agreement
on the weaknesses of the system. Some authors emphasize the remaining gaps
­relative to coverage and access, quality of care, and persistent fragmentation.
Others highlight inefficiency, the inability of reforms to confront old vices of the
public sector (for example, patrimonialism, capture by health professions and
private interests, and weak management), and lack of innovation in the sector.
There is, however, broad agreement on the need to improve the performance of
the system to meet the expectations and needs of a rapidly aging population,
with expansion of primary care, establishment of regional health networks, new
models of service delivery (increased autonomy or contracting approaches) for
hospitals and primary health care, and quality assurance programs as recurring
strategies.
Building on these earlier assessments, this report seeks to provide an objective
assessment of the performance of the system and the challenges ahead. The
report expands on earlier efforts in several areas, with updated data and more
in-depth discussion of government spending on health, intergovernmental
finance, and out-of-pocket expenditures. Furthermore, by comparing the
achievements of the SUS against three benchmarks—the original objectives of
the SUS, the pre-SUS characteristics of the health system, and the achievements
of health systems in comparable countries—the report provides a comprehensive
discussion of the evolution of the government health system, its successes to date,
and remaining challenges.
The report also attempts to reconcile the evidence on expansion in access and
use with high levels of public dissatisfaction, pointing to important areas of
unmet need and widespread problems with regard to accessing specialist care
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22
Introduction
and many diagnostic services. Finally, the report reviews and summarizes
­evidence on how health system reforms over the last couple of decades have
contributed to improved outcomes. This requires looking beyond high-level
trends in mortality and morbidity to take into account recent research on
­hospital admissions for conditions sensitive to primary care, avoidable mortality,
and impact of the expansion of the Family Health Strategy.
Based on this analysis, the report offers recommendations that not only are
based on the diagnosis presented and the experiences of other countries in
addressing similar reforms but also reflect the operational and political
­complexities of policy making. It also identifies key gaps in evidence and how
additional data and research may be able to shed light on important policy
­challenges in the health sector.
Notes
1.The average gross domestic product (GDP) growth rate between 2004 and 2010 was
approximately 4.4 percent (Ferreira de Souza 2012).
2.The incidence of extreme poverty (US$1.25 purchasing power parity a day) fell from
16.4 to 4.7 percent of the population between 1995 and 2009; inequality, as m
­ easured
by the Gini coefficient, fell from 0.599 to 0.539 over the same period (Ferreira de
Souza 2012).
3.The report is based on three background papers: a review of health system
­performance and accountability in Brazil (Couttolenc 2011a), an assessment of the
Family Health Strategy (Macinko 2011), and a report on equity in the Brazilian health
system (Rocha 2011). It also draws from a recent analysis of state-level performance
under the SUS (Couttolenc 2011b) and a recent World Bank book on the implications
of aging in Brazil (Gragnolati et al. 2011).
4.For a detailed account of the process leading up to establishment of the SUS,
see Lima et al. (2005).
5.Private providers under contract with INAMPS constituted the larger part of the
INAMPS system, jumping from 26.5 percent of INAMPS total expenditure in 1984
to 55 percent in 1987 (Couttolenc 2011a).
6.INAMPS was formally abolished only in 1993.
7.This section is based on a detailed review of approaches to assessing health system
performance that was conducted as a background paper for the study. Counterparts
in the Ministry of Health reviewed the framework used in this assessment and found
it to be consistent with past and current efforts of the Ministry of Health aimed at
evaluating the performance of the Brazilian health system.
8.These are “intermediate” goals in the sense that they are valued not in their own right,
but for their contribution to outcomes.
References
CONASS (Conselho Nacional de Secretários de Saúde). 2006. SUS: Avanços e desafios.
Brasilia: CONASS.
Cornwall, A., and A. Shankland. 2008. “Engaging Citizens: Lessons from Building Brazil’s
National Health System.” Social Science Medicine 66 (10): 2173–84.
Twenty Years of Health System Reform in Brazil • http://dx.doi.org/10.1596/978-0-8213-9843-2
Introduction
Couttolenc, B. F. 2011a. “Health System Performance and Accountability Assessment in
Brazil.” Consultant report, World Bank, Washington, DC.
———. 2011b. “Taking Stock of Performance Reforms at the Sub-National Level in Brazil:
Recent Performance Gains Achieved in the Health Sector, Hypotheses on Possible
Drivers of Good and Bad Performance.” Consultant report, World Bank, Washington, DC.
Economist Intelligence Unit. 2010. Broadening Healthcare Access in Brazil through
Innovation. London.
Ferreira de Souza, P. 2012. “Poverty, Inequality, and Social Policies in Brazil, 1995 to 2009.”
IPC-IG Working Paper 97, International Policy Centre for Inclusive Growth, Brasilia.
Gragnolati, M., O. Jorgensen, R. Rocha, and A. Fruttero. 2011. Getting Old in an Older
Brazil: Implications of Population Aging on Economic Growth, Poverty Reduction, Public
Finance, and Service Delivery. Directions in Development Series. Washington, DC:
World Bank.
Hurst, J., and M. Jee-Hughes. 2001. “Performance Measurement and Performance
Management in OECD Health Systems.” Labour Market and Social Policy Occasional
Paper 47, OECD Publishing, Paris.
Lima, N., S. Gerschman, F. Edler, and J. Suárez, eds. 2005. Saúde e democracia: História e
perspectivas do SUS. Rio de Janeiro: Editora Fiocruz.
Macinko, J. 2011. A Preliminary Assessment of the Family Health Strategy (FHS) in Brazil.
Consultant report, World Bank, Washington, DC.
Medici, A. C. 2011. “Propostas para melhorar a cobertura, a eficiência e a qualidade no
setor saúde.” In Brasil: A nova agenda social, edited by E. L. Bacha and S. Schwartzman,
23–93. Rio de Janeiro: LTC.
OECD (Organisation for Economic Co-operation and Development). 2002. Measuring
Up: Improving Health System Performance in OECD Countries. Paris: OECD.
Paim, J., C. Travassos, C. Almeida, and J. Macinko. 2011. “O sistema de saúde brasileiro:
História, avanços e desafios.” Série Saúde no Brasil 1, thelancet.com (May 9): 11–31.
Passos, R. P., ed. 2010. Determinação social da saúde e reforma sanitária. Rio de Janeiro:
CEBES.
Roberts, M., W. Hsiao, P. Berman, and M. Reich. 2003. Getting Health Reform Right:
A Guide to Improving Performance and Equity. New York: Oxford University Press.
Rocha, R. 2011. “Equidade no sistema de saúde brasileiro.” Consultant report, World Bank,
Washington, DC.
Silva, P. 1983. “O perfil médico-assistencial privatista e suas contradições: A análise
política da intervenção estatal em atenção à saúde na década de 70.” Cadernos
FUNDAP 3 (6): 27–50.
Smith, P., E. Mossialos, and I. Papanicolas. 2008. “Performance Measurement for Health
System Improvement: Experiences, Challenges, and Prospects.” Background document, World Health Organization on behalf of the European Observatory on Health
Systems and Policies, Copenhagen.
Victora, C., E. Aquino, M. do Carmo Leal, C. Monteiro, F. Barros, and C. Szwarcwald.
2011. “Saúde de mães e crianças no Brasil: Progressos e desafios.” Série Saúde no Brasil
1, thelancet.com (May 9): 32–46.
Wagner, G. 2008. “SUS: 20 anos depois.” Interview by Cátia Guimarães. Escola Politécnica
de Saúde Joaquim Venâncio, Fundação Oswaldo Cruz, Rio de Janeiro, September.
http://www.epsjv.fiocruz.br/upload/d/gastao_wagner.pdf.
Twenty Years of Health System Reform in Brazil • http://dx.doi.org/10.1596/978-0-8213-9843-2
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24
Introduction
WHO (World Health Organization). 2000. World Health Report 2000: Health Systems;
Improving Performance. Geneva: WHO.
———. 2007. Everybody’s Business: Strengthening Health Systems to Improve Health
Outcomes; WHO’s Framework for Action. Geneva: WHO.
World Bank. 2011. World Development Indicators. Washington, DC: World Bank.
Twenty Years of Health System Reform in Brazil • http://dx.doi.org/10.1596/978-0-8213-9843-2
C h a pter 2
Have the SUS Reforms Transformed
the Brazilian Health System?
The reforms of Brazil’s Unified Health System (Sistema Único de Saúde, SUS)
envisaged a fundamental transformation, with universality, equity, integration,
decentralization, and participation as key principles. Needless to say, turning
these principles into reality required profound changes to how the health system
is financed and organized.
This chapter reviews the evidence on whether and to what extent this
­transformation has happened, focusing on the expansion and reorganization of
service delivery, financing of health services, and governance and accountability
arrangements of the system. It finds that significant progress has been made. The
capacity to deliver services has expanded, regional disparities in the availability
of services have been reduced, primary health care has been strengthened, most
of the responsibilities for delivering services have been decentralized to municipalities, government health expenditures have increased, and various institutional
mechanisms and innovations have been introduced to enhance coordination,
participation, and efficiency. But the chapter also finds that the SUS reforms are
an unfinished agenda, with intergovernmental finance and coordination and the
evaluation and consolidation of models for contracting, integrating, and ­delivering
health services standing out as important challenges for the future.
Expansion and Reorganization of Service Delivery
Universalization of access to health services and improvements in equity depend
critically on the availability of services. In this regard, the SUS reforms targeted
several perceived weaknesses of the pre-SUS system, including scarce services in
some parts of the country, a weak primary care system, and excessive
­centralization. While the Eighth National Health Conference (1986) debated
gradual nationalization (estatização) as a guiding principle of health system
reform, the Constitution and subsequent legislation (Laws 8.080 and 8.142)
merely defined the national system under construction as public and publicly
financed and the private sector’s role as “complementary.”1
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Have the SUS Reforms Transformed the Brazilian Health System?
Expansion of the Delivery Network and Increased Focus on Primary Care
Since the early 1980s, the Brazilian network of health facilities has expanded
significantly, with the number of health care facilities growing from nearly
22,000 in 1981 to almost 75,000 in 2009. This growth in facilities began during
the 1970s and 1980s, when the military government promoted expansion of the
system through contracts with private providers. However, the SUS reforms
signaled an important shift in policy direction and resource allocation, with
­
­outpatient facilities accounting for most of the growth in facilities. Indeed, the
growth in facilities was accounted for entirely by expansion of the outpatient
network, while the number of hospitals remained stable (from 6,342 to 6,875)
and the number of hospital beds declined (figure 2.1).
Focusing on the density of facilities and beds, both the number of hospitals
and the number of hospital beds per 10,000 population declined over the last
20 years, while the density of outpatient facilities increased almost threefold,
from 1.3 facilities per 10,000 population in 1981 to 3.6 in 2009 (figure 2.2).
The growth in outpatient facilities indicates the growing emphasis on primary
care over the last couple of decades. A key driver of this change has been the rapid
deployment of the Family Health Strategy (ESF) and its sibling, the Community
Health Agents Program (PACS).2 The ESF was piloted in the 1980s in Ceará and
some other states and was adopted in 1994 as a national strategy for reorganizing
health care delivery in the public system (see box 2.1 for a s­ ummary of features
of the ESF).3 The ESF, which forms an integral part of the SUS, was intended to
improve the country’s existing primary health care services (delivered through
basic care units or unidades de atendimento basico). Problems with the earlier
model included inadequate availability of basic care units, poor geographic distribution, lack of trained health providers (especially physicians), little or no community engagement, widespread dissatisfaction with the quality of services, and
Number of hospitals and outpatient
facilities (thousands)
80,000
600
70,000
500
60,000
400
50,000
300
40,000
30,000
200
20,000
100
10,000
0
1980
1990
Hospital beds
2000
Ambulatory facilities
0
2010
Number of hospital beds (thousands)
Figure 2.1 Network of Health Facilities in Brazil, 1981–2009
Hospitals
Sources: Data from Pesquisa de AMS (IBGE, 2010; IBGE 2010.
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Have the SUS Reforms Transformed the Brazilian Health System?
4.0
50
3.5
45
40
3.0
35
2.5
30
2.0
25
1.5
20
15
1.0
10
0.5
5
0
1980
1985
Hospital beds
1990
1995
2000
Outpatient facilities
2005
Number of hospital beds per
10,000 population
Number of hospitals and outpatient
facilities per 10,000 population
Figure 2.2 Density of the Network of Health Facilities in Brazil, 1981–2009
0
2010
Hospitals
Sources: Data from Pesquisa de AMS (IBGE, 2010); IBGE 2010.
Box 2.1 Primary Care and Prevention in Brazil: The Family Health Strategy
The Family Health Strategy was inspired by the Community Health Agents Program, a
­community health initiative piloted in rural areas of Ceará during the 1980s. The Family
Health Strategy (ESF) was initially developed in parallel with the PACS (Programa de
Agentes Comunitários de Saúde), gradually replacing it. It was designed to ­provide first
contact, comprehensive, and whole person care coordinated with other health services,
emphasizing care that takes place within the context of family and community. In the ESF,
multiprofessional health teams (composed of a physician, a nurse, a nurse ­assistant, and
four to six community health workers) are organized by geographic regions, with each
team providing primary care to approximately 1,000 families (or about 3,500 people). In
2004, oral health teams were added to the program, filling a long-standing gap in the
public system.
The ESF teams are based in basic care units and backed by professionals that are not part of
the team. Their activity is heavily focused on prevention and promotion outreach activities,
with monthly visits to enrolled families. The ESF was meant to correct the limitations of the
facility-centered, passive, and curative approach to care. It includes not only typical primary
health care activities, mostly targeting children and women, but also activities focusing on the
control of communicable and chronic diseases, including tuberculosis, Hansen’s disease,
hypertension, and diabetes.
The program is monitored through an intergovernmental “Agreement on Basic Care”
(Pacto de Atenção Básica) and more recently through a broader “Agreement for Life” (Pacto
pela Vida), which covers 12 indicators related to the ESF strategy. However, the quality and
­reliability of the indicators reported are questionable and vary by state.
Sources: Macinko 2011; Schmidt et al. 2011; Ministry of Health website.
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Have the SUS Reforms Transformed the Brazilian Health System?
long waiting times. In contrast, the ESF sought to provide first contact, comprehensive, and whole person care coordinated with other health services.4
The ESF has grown rapidly: between 1998 and 2010, ESF teams increased
from 4,000 to more than 31,600, and enrollment expanded from 10.6 million to
more than 100 million people, or just over half of the Brazilian population (­figure
2.3). The expansion proceeded unevenly throughout the country, but the ESF is
now present in more than 90 percent of Brazil’s 5,565 municipalities. The expansion of the ESF has been complemented by several other important public health
programs and initiatives focused on prevention and health education (box 2.2).
The expansion of the ESF started in poor and underserved areas of northeastern states. This can be seen clearly in figure 2.4, which shows program coverage
by level of economic development of the municipality. After controlling for
several confounding variables, Rocha and Soares (2009) found that adoption has
tended to be greater in areas with poorer initial health and fewer resources (for
example, water and sanitation) and limited or no prior access to health services.
This pattern is also reflected in household survey data. Figure 2.5, using
­individual-level data from the 2008 Pesquisa Nacional por Amostra de Domicilios
(PNAD), shows that people listed as enrolled in the ESF are most likely to be
found in the lowest-income quintiles and that the proportion of families enrolled
in the ESF declines as family income increases (IBGE 2008). Nevertheless,
even in the second-richest quintile (quintile 4), more families were covered by
the ESF in 2008 than were enrolled in private health insurance plans.
However, after the initial deployment and rapid expansion of the program
until around 2002, growth has been slow and uneven (Macinko 2011; table 2.1).
Expansion of the program slowed down not only in the early adopters, but also
Figure 2.3 Coverage of the ESF in Brazil, 1994–2010
35
90
30
80
70
25
60
20
50
40
15
30
10
20
5
10
0
Number of ESF teams (thousands)
Population covered (millions)
100
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
0
Population coverage (millions)
Number of ESF teams
Source: Ministry of Health, DAB 2011.
Note: ESF = Family Health Strategy. Coverage is estimated based on the approach of the Ministry of Health, which entails
multiplying the number of teams by 3,450.
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Have the SUS Reforms Transformed the Brazilian Health System?
Box 2.2 Primary Care and Prevention in Brazil: Beyond the Family Health Strategy
Several new public health programs have been adopted in recent years, testifying to the
renewed emphasis on primary care, prevention, and health promotion. The Smiling Brazil
Program has expanded access to dental care, and the Popular Drugstores Program has
facilitated access to free or subsidized essential drugs, addressing two of the greatest
­
­weaknesses in SUS (Sistema Único de Saúde) coverage. Other initiatives have focused on the
prevention and control of chronic diseases. The National Tobacco Control Program has
changed smoking habits to some extent, and smoking is now prohibited in public places;
based on a strong component of health information and education, the program has contributed to the decline in ­noncommunicable diseases and significantly reduced both the number
of tobacco users (from 35 percent of the adult population in 1989 to 16 percent in 2006) and
the intensity of use (Iglesias et al. 2007).
Other programs focus on the prevention and control of chronic diseases. A program for the
control of hypertension and diabetes focuses on routine measurement of blood pressure, pharmaceutical control through the distribution of drugs, and the promotion of exercise. The
national programs for the control of breast and cervical cancer focus on prevention, early
­detection, and treatment of the disease. Psycho-Social Care Centers have been implemented in
many municipalities to expand coverage of outpatient mental health services and facilitate the
return home of people with mental disorders, and the Program on Alcohol and Drug Abuse
aims to reduce the rate of hospitalization for these disorders. These programs are ­evidence of an
increased focus on managing chronic diseases and controlling their risk factors.
More recently, these initiatives were consolidated into one National Plan for the Control of
Chronic Non-Transmissible Diseases, which includes (a) surveillance, information generation,
research, and monitoring and evaluation; (b) health promotion through a multisectoral
approach to addressing risk factors, the promotion and facilitation of exercise and healthy
­eating, the promotion of active aging, and campaigns to reduce the consumption of tobacco
and alcohol; and (c) integral care including screening, early detection, clinical guidelines, free
drugs, and emergency and home care.
Sources: Macinko 2011; Schmidt et al. 2011; Ministry of Health website.
in all groups of municipalities. As a result, larger municipalities (state capitals and
metropolitan areas), which were late adopters of the strategy, continue to lag,
with coverage rates in the range of 35–45 percent of the population.5 One possible reason for the stagnation in coverage is the reliance on short-term contracts
in many municipalities.6 These unstable arrangements have been increasingly
criticized and challenged on regulatory grounds, which may have prevented
municipalities from expanding the program further. However, restrictions on the
hiring of civil servants (associated with the Fiscal Responsibility Law, which
­limits the proportion of the budget that can be spent on personnel) offered little
alternative to the outsourcing strategy. Moreover, as Rocha and Soares (2009)
found, the probability and timing of a given municipality adopting the ESF was
influenced by political factors, with municipalities governed by left-wing parties
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29
30
Have the SUS Reforms Transformed the Brazilian Health System?
Figure 2.4 Coverage of the ESF in Municipalities in Brazil, by Income Quintile, 1985–2007
Population covered (%)
100
90
80
70
60
50
40
30
20
10
0
1999 2000 2001 2002 2003 2004 2005 2006 2007
Q1: Poorest 20%
of municipalities
Q2
Q3
Q4
Q5: Richest 20%
of municipalities
Source: Macinko 2011, from Ministry of Health, DATASUS data.
Note: ESF = Family Health Strategy.
Figure 2.5 Coverage of the ESF in Brazil, by Income Quintile, 2008
100
Population covered (%)
90
80
70
60
50
40
30
20
10
0
Q1
Q2
Health plan
Q3
ESF only
Q4
Q5
No health plan, no ESF
Source: IBGE 2008.
Note: ESF = Family Health Strategy. Includes poststratification weights and controls for complex survey design (Macinko 2011).
and by the Brazilian Social Democracy Party (which held power at the federal
level from 1994 through 2002) being more likely to adopt it.
As a result of this pattern of expansion, ESF coverage varies significantly, with
coverage tending to be higher in the states with low household income per capita
(figure 2.6).
In addition to the rapid expansion of outpatient care facilities and the ESF in
previously underserved areas, other initiatives have also sought to improve access
to specific services, in particular dental care and free medications. These
­initiatives have targeted states in the Northeast and North, along with other
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Have the SUS Reforms Transformed the Brazilian Health System?
Table 2.1 Coverage of the ESF and the PACS in Brazil, by Size of Municipality, 1998–2010
Coverage (% of population)
Change in coverage (%)
Size of municipality
1998
2002
2006
2010
1998–02
2002–06
2006–10
More than 1 million
350,000–999,999
100,000–349,999
50,000–99,999
20,000–49,999
Less than 20,000
2.0
4.4
9.2
17.3
20.6
23.3
21.0
30.5
38.4
54.5
62.7
73.8
32.9
42.5
49.6
66.6
75.3
85.4
36.8
45.4
56.7
71.7
87.2
98.5
19.0
26.1
29.2
37.1
42.0
50.5
11.9
12.0
11.3
12.1
12.7
11.6
3.9
2.8
7.1
5.2
11.9
13.1
Source: Ministry of Health, Primary Care Information System online database.
Note: ESF = Family Health Strategy, PACS = Programa de Agentes Comunitários de Saúde.
Figure 2.6 Coverage of the ESF in Brazil, by State, 2008
100
Population covered (%)
90
80
70
60
50
40
30
20
10
Mar
anh
ã
Alag o (343)
oas
Cea (373)
rá (4
1
Pern Piauí 1)
(424
amb
)
uco
(
Bah 425)
ia (4
Par 39)
Serg á (439)
Ama ipe (45
7)
zon
a
Para s (463)
í
b
a (4
Rio
63
A
Gran
de d mapá (4 )
o No
7
rte ( 2)
4
Acre 88)
(520
Rorâ
)
i
Toc ma (53
anti
1)
n
s (53
Ron
Min dônia 6)
as G
(540
e
Espí
)
rito rais (67
San
2)
to (6
Mat
81)
o Gr
G
osso oiás (6
8
d
6)
oS
Mat
o Gr ul (708
osso
)
(7
Rio
Gran Paran 38)
á (8
de d
09)
o
Rio
de J Sul (8
49)
a
n
San
ta C eiro (89
atar
8)
ina
Dist São Pa (898)
rito
u
Fed lo (911
eral
)
(1,4
30)
0
State (household income per capita, R$)
Source: Ministry of Health, DATASUS data.
Note: ESF = Family Health Strategy. States are sorted by household income per capita (in parentheses) IPEA data of the
Institute of Applied Economic Research (Instituto de Pesquisa Econômica Aplicada, IPEA).
states with poor indicators (Distrito Federal, Mato Grosso do Sul, Paraná, Rio de
Janeiro, and Rondônia).
Of course, in many parts of the country, the traditional model of providing
primary care through basic care units is still being implemented, making it
difficult to determine coverage of primary health care (as opposed specifi­
cally to the ESF). For instance, in Rio de Janeiro Municipality, 599 family health
teams were operating from family clinics and health centers in February 2012.
This translates into ESF coverage of approximately 33 percent. However, the
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32
Have the SUS Reforms Transformed the Brazilian Health System?
municipality estimates that an additional 17 percent of the population have
access to municipal health centers that offer a more limited package of services
and another 30–40 percent of the population have private health plans that
cover primary health care.
Decentralization and a Changing Public-Private Mix
The expansion and restructuring of the delivery network were accompanied by
a dramatic decentralization of responsibility for service delivery. Indeed, the
growth in outpatient facilities occurred almost entirely at the municipal level,
and by 2009 virtually no outpatient facilities were under state or federal
­management (figure 2.7). Decentralization of hospital care has not been as dramatic: the share of hospital beds under municipal control increased from
11 ­percent to nearly 50 percent between 1985 and 2009, but state and federal
governments still manage a significant share of public hospital beds.
There is notable variation across states in the degree of decentralization of
hospital beds, with the share of beds managed by states and municipalities
(as opposed to federal government) ranging from 60 to 100 percent (figure 2.8).
In most states, the share of hospital beds managed by states and municipalities
has been rising over the last 20 years. There is also significant variation across
states in the relative importance of states and municipalities in hospital management (figure 2.9). However, in most states, the share of beds under municipal
management has been rising.
The last 20 years have also seen a change in the mix of public and private
service provision in the hospital sector. Prior to establishment of the SUS, the
National Institute for Social Medical Assistance (Instituto Nacional de Assistência
Figure 2.7 Decentralization of Public Outpatient Facilities and Hospital Beds in Brazil,
1981–2009
b. Hospital beds
a. Outpatient facilities
90
90
Share of public hospital beds (%)
100
Share of public outpatient facilities (%)
100
80
70
60
50
40
30
20
10
0
1981 1985 1990 1992 1999 2005 2009
Municipal
State
80
70
60
50
40
30
20
10
0
1981 1985 1990 1992 1999 2005 2009
Federal
Sources: Data from Pesquisa de AMS; IBGE 2010.
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Mar
anh
Alag ão (34
3)
oa
Cea s (373)
rá (4
Pern Piau 11)
amb í (42
uco 4)
Bah (425)
ia
Pa (439)
Serg rá (439
)
i
Pa pe (4
Ama raíba ( 57)
zon 463)
Rio
as (
Gran
de d Amapá 463)
o No (472
)
rte
Ac (488)
Rorâ re (520
Toc ima ( )
5
a
Ro ntins 31
Min ndônia (536)
Espí as Gera (540)
rito
i
San s (672)
Mat
to (6
o Gr
G
o
osso
iás 81)
Mat do Su (686)
o Gr
l
oss (708)
Rio
Gran Para o (738)
n
San de do S á (809)
ta
u
Rio Catarin l (849)
de J
an a (898
Dist São P eiro (89 )
rito
Fed aulo (9 8)
1
eral
(1,4 1)
30)
Share of hospital beds (%)
Mar
anh
Alag ão (34
3)
oa
Cea s (373)
rá (4
Pern Piau 11)
amb í (42
uco 4)
Bah (425)
ia
Pa (439)
Serg rá (439
)
i
Pa pe (4
Ama raíba ( 57)
zon 463)
Rio
as (
Gran
de d Amapá 463)
o No (472
)
rte
Acre (488)
Ror
(52
Toc âima (5 0)
anti
ns 31)
Ro
Min ndônia (536)
a
Espí s Gera (540)
rito
i
San s (672)
Mat
to (6
o Gr
osso Goiás 81)
Mat do Su (686)
o Gr
l
osso (708)
Rio
Gran Paran (738)
San de do á (809)
ta
S
Rio Catarinul (849
de J
ane a (898)
Dist São P iro (89
rito
Fed aulo (9 8)
1
eral
(1,4 1)
30)
Share of hospital beds (%)
Have the SUS Reforms Transformed the Brazilian Health System?
Figure 2.8 Local (State and Municipal) Management of Hospital Beds in Brazil, 1992–2009
100
80
60
40
20
0
–20
State (household income per capita, R$)
Local share (2009)
Change in local share, 1992–2009 (% points)
Source: Based on Ministry of Health, DATASUS data.
Figure 2.9 Municipal Management of Hospital Beds in Brazil, 1992–2009
100
80
60
40
20
0
–20
Municipal share
State (household income per capita, R$)
State share
Change in municipal share 1992–2009 (% points)
Source: Based on Ministry of Health, DATASUS data.
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Have the SUS Reforms Transformed the Brazilian Health System?
Figure 2.10 Public-Private Composition of Hospitals and Hospital Beds in Brazil, 1980–2010
b. Hospital beds
80
4,000
70
Share of hospital beds (%)
Number of hospitals
a. Hospitals
4,500
3,500
3,000
2,500
2,000
1,500
1,000
500
0
1980
1990
2000
Private SUS
2010
Public
60
50
40
30
20
10
0
1980
1990
Private non-SUS
2000
2010
Sources: Data from Pesquisa de AMS; IBGE 2010.
Note: SUS = Sistema Único de Saúde.
Médica da Previdência Social, INAMPS) had contracted most hospital care from
the private sector. As noted, the SUS did not have specific targets for expanding
the network of public facilities, but policy clearly favored expansion of the public
sector over contracting with private providers. This is reflected in the data, which
show that the slight reduction in the number of hospitals is mainly accounted for
by the closure of private ­
hospitals under contract with the SUS (and with
INAMPS before the SUS), especially in the for-profit sector. The number of
publicly managed facilities actually increased, as did the number of private nonSUS hospitals (figure 2.10).
This change was achieved in part by simply reducing the number of ­for-profit
hospitals under contract and in part by decreasing—in real terms—the SUS
­payment rates to private providers, which made it impossible for many hospitals
to survive based on SUS contracts. As a result of these changes, the share of
­hospital beds in the public sector increased from 22 to 35 percent, but the
­private sector still accounts for more than 50 percent of hospital beds.
In the case of outpatient care, much of the growth has been in the public
­sector, but there has also been a rapid increase in the private sector, which by
2009 accounted for 30 percent of all outpatient facilities (figure 2.11).
Regional Disparities in the Availability of Services
The expansion of the SUS network has helped to reduce regional ­inequalities
in the distribution of health system resources. This is most apparent in the
case of hospital beds, where the restructuring of the system has significantly reduced the variation in the density of (public) hospital beds across
states (figure 2.12). The trend in relation to the distribution of outpatient
facilities is less clear. However, the expansion of public outpatient
­facilities has tended to benefit northeastern states the most. As a result,
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Have the SUS Reforms Transformed the Brazilian Health System?
Number of outpatient facilities (thousands)
Figure 2.11 Public-Private Composition of Outpatient Facilities in Brazil, 1980–2010
70,000
60,000
50,000
40,000
30,000
20,000
10,000
0
1980
1990
Total
2000
Public
2010
Private
Sources: Data from Pesquisa de AMS; IBGE 2010.
Number of SUS outpatient facilities
per 10,000 population
Number of SUS hospital beds
per 1,000 population
Figure 2.12 Density of Hospital Beds and Outpatient Facilities across States in Brazil,
1988 and 2009
a. Public hospital beds
1988
2009
0
1
2
3
4
b. Public outpatient facilities
1985
2009
0
1
2
3
4
Source: Based on Ministry of Health, DATASUS data.
Note: SUS = Sistema Único de Saúde.
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Have the SUS Reforms Transformed the Brazilian Health System?
Figure 2.13 Link between Income and Density of Facilities across States in Brazil, 1988 and 2009
b. Public outpatient facilities
5.0
4.0
4.5
Number of outpatient facilities
per 1,000 population
Number of SUS beds per
1,000 population
a. Public hospital beds
4.5
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0
0
500
1,000
1,500
Average monthly income per capita (R$)
1988
4.0
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0
0
500
1,000
1,500
Average monthly income per capita (R$)
2009
Sources: Based on Ministry of Health, DATASUS data. Data on average monthly income from the Institute of Applied Economic Research (Instituto
de Pesquisa Econômica Aplicada, IPEA).
Note: SUS = Sistema Único de Saúde.
the density of public facilities is now significantly higher in states with low
per ­capita income (figure 2.13). The opposite used to be true for public
hospital beds, but two decades of restructuring of the public system has
delinked the ­density of public hospital beds from average income at the
state level.
Toward Increased and More Equitable Health Financing
While the SUS reforms did not establish explicit goals or targets regarding the
sources and mix of financing, they were premised on a perception that g­ overnment
spending on health was inadequate and that the high reliance on private spending
was contributing to both system fragmentation and inequalities. Implementation
was expected to be accompanied by a significant increase in government spending
and a reduction in private spending. Moreover, the reorientation toward primary
care and the decentralization were expected to have large impacts on the patterns
­ appened in practice?
of both financing and spending. What has h
Government Financing
In the early 1980s, the health sector was funded through four main financing
schemes or sources: (a) Social Security through the INAMPS, which covered the
working population in the formal sector and its dependents; (b) independently
managed federal and state government facilities that provided basic services
mostly to the poor and other groups not covered by Social Security; (c) the
­private health insurance system; and (d) direct out-of-pocket payments for drugs
and services (mainly provided by the private sector). In other words, the health
system was composed of several vertical, independent, and uncoordinated ­systems;
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Have the SUS Reforms Transformed the Brazilian Health System?
each had its own source of funding and its own network of facilities and covered
a defined population (even when this was simply “population groups not covered
by other schemes”).
One of the major impacts of the SUS has been to unify and integrate these
independent financing and service provision systems into a single publicly funded
system covering the whole population.7 Given the SUS architecture and the
shared responsibilities across government levels, financial mechanisms have
always been at the core of SUS legislation, regulations, and policies and a major
force in organizing the system. As indicated earlier, the first years of SUS
­implementation focused mostly on designing mechanisms for transferring federal
funds to states and municipalities and defining prerequisites for these to receive
the transfers. This bureaucratic approach had its downsides (for example, the
complex set of administrative regulations and requirements and financial flows),
but helped to build the basic architecture and principles that make up the SUS
today: financing mechanisms, monitoring and evaluation systems, and negotiating
bodies (health councils and committees) that determine resource allocation and
set priorities.
Critical elements of the SUS are the health funds established at each level of
the system under a single command. Federal taxes and social contributions
finance the federal health fund, which in turn finances nearly all Ministry of
Health facilities and programs and contributes significantly to the financing of
university hospitals (within the Ministry of Education). The federal health fund
is a major contributor to state and municipal funds, which are also financed by
state and municipal revenues. These federal transfers are a key element of the
system, since they are the main incentive for subnational governments to buy
into national health policies and priorities and to implement them within a
­federalist political system.
In principle, municipal governments should, through their municipal health
funds, be the main provider and purchaser of health services. However, because
most municipalities are small and have limited technical or financial capacity,
many facilities and a large part of SUS finance remain at the hands of regional
and central authorities.
The SUS reforms also triggered several initiatives aimed at increasing and
stabilizing public financing for health. The first, during the late 1980s, sought to
earmark a fixed share (30 percent) of Social Security revenues for health. This
law was never passed; in fact, at the turn of the decade, health spending was
taken out of Social Security altogether and was funded by general revenues and
new “social contributions.” In the 1990s, a second initiative established a new
excise tax earmarked for health (Contribuição Provisória sobre Movimentações
Financeiras, CPMF). However, CPMF revenue was never fully allocated to
health, and other sources of finance were reduced, such that funds from the
CPMF had little impact. Finally, a constitutional amendment passed in 2000
(Constitutional Amendment no. 29) sought to establish a minimum level of
government health spending (as a share of overall government spending). It succeeded in increasing state and municipal expenditures by mandating that a
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37
38
Have the SUS Reforms Transformed the Brazilian Health System?
minimum share of the budget be allocated to health (12 and 15 percent,
­respectively), but a corresponding mandate was never approved for the federal
budget.
The available evidence indicates that public spending on health has increased
significantly since the early 1980s (figures 2.14 and 2.15), growing 224 percent
in real terms between the first half of the 1980s and 2010, or from R$339 to
R$714 per capita (111 percent growth).8 Despite this increase in spending over
time, expenditures have fluctuated significantly, with a few distinct phases:
(a) the first half of the 1980s, when spending oscillated with economic crisis and
recovery (which is why the mean value for 1980–85 is used here as the base for
comparison); (b) the second half of the 1980s, when expenditure nearly doubled
to reach a peak in 1989; (c) a severe drop in 1990–94; (d) stagnation at a higher
level from 1995 through 2003; and (e) a period of steady growth starting in
2003, during which expenditure nearly doubled, helped by strong economic
growth.
While spending has increased substantially in absolute and per capita
terms, the share of government health spending in gross domestic product (GDP) has grown more slowly (figure 2.16). From a level of around
2.5 ­percent in the early 1980s, it increased rapidly to 4 percent by 1989. In
the decades that followed, it oscillated at lower levels, regaining its 1989 level
only in 2009. In other words, the initial effort to expand public spending in
the late 1980s was not sustained, and spending did not begin to increase notably until 2003. Figure 2.16 also ­illustrates the strong link between government health spending and the economic cycle: increases during economic
expansion and sharp reductions during economic downturns. This link with
the economic cycle was a typical feature of public financing before the SUS
reforms and has remained in spite of being one of the key concerns of the
health reform.
Focusing on the period 1995–2010, for which comparable data from other
countries are available, the average annual growth of (real) government health
spending per capita was lower in Brazil than in many other middle-income
countries (figure 2.17). For instance, while China, the Republic of Korea,
South Africa, and Turkey experienced annual rates of growth between 8 and
12 ­percent, government health spending per capita in Brazil grew at around
3 percent. Government health spending per capita has grown more rapidly
since the early 2000s (around 6 percent a year), but is still lower than in many
of Brazil’s peers.
While growth in spending has been relatively slow, Brazil started from a
higher base than many of its peers. Consequently, government spending on
health as a share of GDP, currently just under 4 percent, is significantly lower
than the level of spending in most Organisation for Economic Co-operation
and Development (OECD) countries and some middle-income peers, but
Brazil is by no means a clear outlier (figure 2.18). Nonetheless, the slow growth
in ­government spending stands in stark contrast to the rapid e­ xpansion of service delivery capacity and volume of services provided through the SUS.
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39
Have the SUS Reforms Transformed the Brazilian Health System?
Figure 2.14 SUS and Social Security Spending on Health in Brazil, by Level of Government, 1980–2009
Expenditure on health (constant 2010 R$ billions)
140
120
100
80
60
40
20
19
8
19 0
19 81
1982
8
19 3
8
19 4
1985
1986
1987
8
19 8
8
19 9
9
19 0
19 91
9
19 2
9
19 3
1994
9
19 5
19 96
9
19 7
9
19 8
2099
0
20 0
20 01
0
20 2
20 03
0
20 4
0
20 5
0
20 6
07
20
2008
0
20 9
10
0
SUS/SS
Federal
State
Municipal
Sources: Based on Ministry of Health, Public Health Budget Information System (SIOPS) data; Ministry of Finance, STN 2010; Medici 1991.
Note: SUS (Sistema Único de Saúde) expenditure includes funding from federal, state, and municipal governments; Social Security (SS) through
1990 includes only federal funding (a mix of payroll contributions and other “social contributions” and taxes).
800
700
600
500
400
300
200
100
0
19
8
19 0
19 81
1982
8
19 3
84
19
1985
8
19 6
1987
8
19 8
8
19 9
9
19 0
19 91
9
19 2
19 93
1994
9
19 5
19 96
9
19 7
9
19 8
20 99
0
20 0
20 01
0
20 2
20 03
0
20 4
0
20 5
06
20
0
20 7
2008
0
20 9
10
Government spending per capita (constant 2010 R$)
Figure 2.15 SUS and Social Security Spending per Capita on Health in Brazil, by Level of Government,
1980–2010
Brazil
Federal
State
Municipal
Sources: Based on Ministry of Health, SIOPS data; Ministry of Finance, STN 2010; Medici 1991.
Note: SUS = Sistema Único de Saúde.
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40
Have the SUS Reforms Transformed the Brazilian Health System?
Figure 2.16 SUS and Social Security Spending on Health as a Percentage of GDP in Brazil, by Level of
Government, 1980–2009
Health expenditure as percentage of GDP
5
4
3
2
1
19
8
19 0
8
19 1
8
19 2
8
19 3
84
19
8
19 5
8
19 6
8
19 7
8
19 8
8
19 9
9
19 0
9
19 1
92
19
9
19 3
94
19
9
19 5
9
19 6
97
19
9
19 8
9
20 9
0
20 0
0
20 1
02
20
0
20 3
0
20 4
0
20 5
0
20 6
0
20 7
0
20 8
0
20 9
10
0
SUS/SS
Federal
State
Municipal
Sources: Based on Ministry of Health, SIOPS data; Ministry of Finance, STN 2010; Medici 1991; IBGE 2010 (for GDP data).
Note: GDP = gross domestic product, SS = Social Security, SUS = Sistema Único de Saúde.
Annual growth in government health expenditures,
1995–2010 (%)
Figure 2.17 Annual Growth in Government Health Spending per Capita in Select Countries,
1995–2010
12
Vietnam
China
Korea, Rep.
10
8
Turkey
Thailand Malaysia
Pakistan
Poland
Philippines
India
6
Guatemala
El Salvador
Honduras
4
0
Peru
Ecuador
Bolivia
15
Chile
Portugal
Colombia
Russian
Nicaragua Federation
2
South Africa
Mexico
Brazil
Uruguay
Argentina
60
240
960
Total health spending per capita in 1995 (US$), logarithmic scale
3,840
Source: Based on data from the World Health Organization (WHO) National Health Accounts (http:// www.who.int/nha).
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Have the SUS Reforms Transformed the Brazilian Health System?
Government health spending as percentage of GDP
Figure 2.18 Government Health Spending as a Percentage of GDP in Select Countries, 2010
10
9
8
Portugal
7
Argentina
6
Nicaragua
Honduras
5
4
3
2
1
Bolivia
Colombia
Turkey
El Salvador
Uruguay
Poland
Brazil Chile
Korea, Rep.
Mexico South Africa
EcuadorPeru
Russian
Paraguay China
Thailand Federation
Vietnam
Guatemala
Malaysia
Philippines
India
Pakistan
0
800
3,200
12,800
GDP per capita in 2010 (US$), logarithmic scale
51,200
Source: Based on data from the World Health Organization (WHO) National Health Accounts (http:// www.who.int/nha).
Note: GDP = gross domestic product.
Composition of Government Spending on Health
The expansion of the outpatient care network and the ESF was accompanied by
a change in funding priorities, with primary care receiving an increasing share of
federal funds (figure 2.19). Federal transfers for basic care increased p
­ roportionally
between 1995 and 2002 (from 11 percent to around 20 percent of total
­transfers), but then stabilized at around 17 percent.9 In constant (2010) per
capita values, Ministry of Health spending on primary health care increased from
R$27 in 1995 to R$50 in 2010.
The composition of spending also shifted at the state and municipal levels
(figure 2.20). Municipal governments clearly spend the larger part of their health
budget on primary care, while state governments spend a low and decreasing
proportion on primary care (as much of this activity was transferred to
­municipalities); the proportion of federal budget spending on primary care is
associated with transfers to municipalities, as the Ministry of Health has almost
no responsibility for primary health care. However, the decline in the proportion
of municipal spending on primary health care is due to the transfer of hospitals
and outpatient referral facilities to local governments in association with the
municipalization process.
It is difficult to estimate total SUS expenditure by these service categories
over such a long period of time due to gaps or inconsistencies in the data.
However, available data suggest that the proportion of government budget for
health (health budget function) allocated to basic care (basic care sub function)
increased steadily between the early 1970s and 2010, from 10 percent to around
20 percent. The increase is greater if public health and health surveillance are
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Have the SUS Reforms Transformed the Brazilian Health System?
Figure 2.19 Allocation of the Ministry of Health Budget in Brazil, by Type of Care, 1995–2010
50
40
30
20
10
0
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
Percentage of Ministry of Health
budget
60
Secondary and tertiary care (MAC)
Basic care
Drugs
Source: Ministry of Health, DATASUS.
Note: MAC (média e alta complexidade) is a grouping of medium- and high-complexity services.
Figure 2.20 Allocation of Health Spending in Brazil, by Level of Government and Type
of Care, 1984 and 2010
100
Share of health spending (%)
90
80
70
60
50
40
30
20
10
0
1984
2010
Federal
Other
1984
2010
1984
State
Secondary and
tertiary care
2010
Municipal
Drugs
Basic care
Source: Based on budget data from the Ministry of Health and the Ministry of Finance, STN 2010.
Note: The estimates may be biased because of inconsistencies and changes in expenditure classification and programs or
activities included in “administrative and other.”
added to primary care. But the importance of primary health care spending varies
by level of government.
The reallocation of resources in favor of primary care has helped to reduce the
hospital-centric nature of the existing system of the 1970s and 1980s.
Nonetheless, hospital services continue to account for nearly half of government
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spending, and spending on the hospital sector has grown steadily despite a
decrease in SUS admissions per capita. Some of this increase has been the result
of investment in high-complexity services. Meanwhile, medium-complexity care,
which provides the link between improved and expanded primary care and the
successful high-complexity programs, has been identified as a major weakness in
the SUS for several years (see, for example, Ministry of Health 2011). Indeed,
general inpatient care and specialized outpatient care have received little attention, and this segment of the system is often unable to meet the increase in
demand generated by the expansion of primary health care and the growing
burden of chronic disease (Ministry of Health 2011).10
Financing Mix across Levels of Government
Reflecting the drastic decentralization of service delivery responsibilities, the
financing mix by level of government changed notably over the last two decades
(figure 2.21). During most of the 1980s, federal spending accounted for the
larger part of public expenditure (74 percent on average) increasing to 85 percent in the years immediately preceding the formal creation of the SUS. Since
then, the federal share has decreased steadily, reaching 45 percent in the late
2000s. In contrast, both municipal and state spending has increased steadily since
1988, reaching 28 and 27 percent, respectively, in 2009. This increase preceded
the constitutional amendment in 2000, but has been more pronounced since.
This change in financing pattern was a clear result of the transfer of responsibilities to municipal governments. However, SUS analysts and supporters alike
have criticized the stagnant level of federal spending as being inconsistent with
the goals of the system. Moreover, many states and especially municipalities
appear to have reached a level of financial contribution that is difficult to
Figure 2.21 Share of SUS Financing in Brazil, by Level of Government, 1980–2009
100
Share of SUS financing (%)
90
80
70
60
50
40
30
20
10
19
8
19 0
19 81
8
19 2
19 83
19 84
1985
1986
1987
1988
8
19 9
9
19 0
1991
19 92
19 93
19 94
1995
1996
1997
1998
20 99
0
20 0
2001
2002
20 03
20 04
20 05
20 06
2007
2008
09
0
Municipal
State
Federal
Sources: Based on Ministry of Health, SIOPS data; Medici 1991; Ministry of Finance, STN 2010.
Note: SUS = Sistema Único de Saúde.
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Have the SUS Reforms Transformed the Brazilian Health System?
increase further and maybe even to maintain (see, for example, Pereira et al.
2006; de Sousa and Hamann 2009; Macinko 2011).
Regional Disparities in Government Spending
While the SUS reforms did not increase government spending on health as much
as anticipated, they did manage to reduce disparities in government spending
significantly across states and municipalities. This was achieved not only by making targeted investments in expanding the health system in underserved parts of
the country, but also by changing the criteria for allocating federal and state funds
for health. Indeed, federal transfers were increasingly targeted toward the poorer
states of the Northeast and North: 5 of the 10 states with relatively large
increases in federal spending are in the Northeast and 3 are in the North. In the
richer states of the Southeast, South, and Center-West, only three states experienced an increase in federal spending (Espírito Santo, Mato Grosso do Sul, and
Santa Catarina). As a result, not only did the variation in spending per capita
decline (figure 2.22), but the relationship between a state’s average income and
health spending also weakened over time (figure 2.23). Even so, significant
spending gaps remain, with spending per capita ranging from around R$500 in
Ceará, Maranhão, and Pará, to more than R$1,300 in Mato Grosso do Sul, Rio
Grande do Sul, and São Paulo.
Private Health Financing: Out-of-Pocket Payments and Private Insurance
Although the SUS reforms did not establish explicit goals for private s­ pending,
the “supplemental” health system was expected to decline in importance as
the national health system expanded and matured. This did not happen.
Indeed, despite intentions to the contrary, private spending remained stable
over the last 15 years or so (from around 57 percent in 1995 to 54 percent of
total health spending in 2009; figure 2.24). The share of direct out-of-pocket
spending declined over time, but still accounts for around 30 percent of total
health spending, while the share of spending on private plans increased and
now stands at just over 20 percent. The number of individuals covered by
private health plans grew steadily over the last 20 years—by 2009, more than
50 ­million Brazilians were covered by some form of plan.
Figure 2.22 SUS Health Spending per Capita across States in Brazil, 1995 and 2009
1995
2009
0
500
1,000
1,500
2,000
2,500
Government health spending per capita (R$)
3,000
3,500
Source: Couttolenc 2011.
Note: SUS = Sistema Único de Saúde.
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Figure 2.23 SUS Spending per Capita on Health and Average Monthly Income per Capita
across States in Brazil, 1995 and 2009
Government health spending
per capita (R$)
3,500
3,000
2,500
2,000
1,500
1,000
500
0
500
1,000
Average monthly income per capita (R$)
1995
1,500
2009
Sources: Couttolenc 2011; IPEAData (from IBGE) for state income levels.
Note: SUS = Sistema Único de Saúde.
Figure 2.24 Share of Private Health Spending in Total Health Spending in Brazil, 1995–2009
Share of total health spending (%)
70
60
50
40
30
20
10
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
96
19
19
19
95
0
Private health
Out-of-pocket spending
Spending on private plans
Source: Based on data from the WHO National Health Accounts (http:// www.who.int/nha).
As a result of the continued growth in private spending, the share of total
health spending financed by government in Brazil is significantly lower than what
is observed in OECD countries and in many middle-income peers (­figure 2.25).
For instance, in Colombia, Thailand, and Turkey, all of which e­ stablished universal
health coverage over the last couple of decades, government spending accounts
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Government as percentage of total health spending
Figure 2.25 Government Financing of Health Expenditures in Select Countries, by GDP per Capita, 2010
90
80
Thailand
70
60
Honduras
Bolivia
Nicaragua
Turkey
Poland
Argentina
Portugal
Uruguay
Colombia
Russian Federation
El Salvador
Peru
Korea, Rep.
Malaysia
China
Mexico
50
Paraguay
Guatemala
Vietnam
Ecuador
40
30
800
India
Brazil ChileSouth Africa
Pakistan Philippines
3,200
12,800
51,200
GDP per capita in 2010 (US$), logarithmic scale
Source: Based on data from the WHO National Health Accounts (http:// www.who.int/nha).
Note: GDP = gross domestic product.
for somewhere between 70 and 75 percent of total health spending, compared
with around 45 percent in Brazil. Although part of this p
­ rivate spending is for
private health plans, which, at least in principle, provide some protection against
high out-of-pocket spending, the high share of private spending has important
implications for equity and fairness of both access to care and financing burden.11
Enhancing Health System Governance
Although the SUS reforms did not articulate explicit goals or principles for
­governance and accountability, these concepts were implicit in many of the
changes to the health system that the reforms envisaged. For the purposes of this
report, governance is seen as being concerned with the management of
relationships between various stakeholders in health, including individuals,
­
­households, communities, firms, levels of governments, nongovernmental organizations, private firms, and other entities that have the responsibility to finance,
monitor, deliver, and use health services. The systems and institutions that
­manage these relationships can have a profound impact on the performance of
the health system.
Although this report does not undertake a comprehensive assessment of
health system governance in Brazil, it highlights several questions for which the
SUS reforms have significant implications for governance. First, to what extent
has the universal right to health care established by the 1998 Constitution been
operationalized (and can be operationalized), and what are the main legal
consequences associated with it? Second, to what extent have adequate
­
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Have the SUS Reforms Transformed the Brazilian Health System?
i­nstitutions and systems for financing and intergovernmental coordination been
developed to meet the needs of the drastic decentralization of service responsibilities? Third, have the principles of participation and voice been translated
effectively into reality? Finally, has there been sufficient innovation in the way
that the government provides and pays for services to ensure that improvements
in efficiency, effectiveness, and integration are realized?12
Establishment and Consequences of the Right to Health
Establishing the universal right to health was a key element of the SUS and the
movement leading to it. It emerged from the democratic movements that led to
the country’s democratization in the early to mid-1980s, and in that sense it was
a political and social achievement rather than a technical decision. The right to
health progressed on two fronts during the 1970s and 1980s: politically, by being
a key aspiration of the democratization movement that began in the late 1970s,
leading to the first presidential election in 1985 and to the Constitution of 1988,
and technically, by gradually bringing different social groups (rural workers and
informal workers) under Social Security to provide a stronger basis for the
“Brazilian economic miracle” of the 1970s. In the mid-1980s, several National
Health Conferences (especially that of 1986) strengthened the movement, and
the requirement to show that one contributed to the Social Security system in
order to receive care within the INAMPS system was dropped. Finally, all of this
culminated in establishing the constitutional right to health. However, as a
mostly political process, the decision to grant universal and free coverage to
health care was not accompanied by a discussion of the resources needed to
­support it.
The right to health was confirmed in the basic legislation of the SUS,
­published in 1990 (the Health Organic Law/Law 8.080 and Law 8.142), which
merely repeated the statements in the Constitution that “the state should provide the necessary conditions for its full exercise,” through economic and social
policies to reduce health risks and efforts to ensure the “conditions” for universal
and equitable access. The extensive regulations published over the following
years provided no strategy or guidance on how to operationalize this right. In
2006, the Ministry of Health published a Chart of Health Rights, which
­proposed explicit and operational principles and guidelines for the rights to
health care.
Indirectly, although not formally, the right to health was operationalized
through two general principles: first, by legally ensuring that anyone can be
treated for free under the SUS and, second, by expanding the public network of
health facilities and services to make those services accessible. In fact, neither of
these two principles is a necessary condition to ensure the right to health care,
since health services do not need to be free or provided within a public system
to be accessible. In several countries where the right to health care is considered
to be guaranteed and universal, health services are not free (they are subsidized)
and are not necessarily provided by a public system (coverage may be mandated
rather than provided, as in the Netherlands). Moreover, by not offering an
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Have the SUS Reforms Transformed the Brazilian Health System?
explicit list of covered services (and therefore implicitly covering all services
needed by a sick person), the SUS is more generous, at least on paper, than the
systems in most developed and rich countries, which have regulated and defined
a list of covered services and the conditions or circumstances under which they
are covered. For instance, countries such as Canada and the United Kingdom
limit or prioritize the coverage of certain expensive procedures to cases in which
the patient is most likely to benefit from them (along a cost-effectiveness
principle).
A significant contradiction between the universal right to health and the
access to health services it implies lies in the fact that, in spite of the open-ended
service package, the SUS pays or reimburses providers for a limited list of
­services. Moreover, the open-ended benefits package is unlikely to be enforceable
in a sustained manner, a contradiction that has generated two important legal
conflicts.
First, many patients seek to obtain expensive drugs or treatments that are not
yet included on the SUS list by seeking a legal injunction. Such mandates
represent an increasing and significant burden on SUS finances, while not
­
necessarily providing clear benefits to patients. They also tend to create
­
­inequalities, as rich patients are more likely to be aware of new procedures and
treatments that are available internationally and to go to court to obtain them.
Second, private insurers challenge in court the requirement to reimburse the
SUS for the cost of services provided to SUS enrollees, based on the principle of
universal coverage. Moreover, the absence of a clear list of covered services and
goods allows providers to expand the supply and use of expensive new
­technologies. This has been shown to be an important source of inefficiencies and
unnecessary costs, as Brazil has been quick to adopt new technologies and
­allocates them in an inefficient way.
The SUS has recently undertaken significant efforts to face these challenges, in particular with respect to incorporating new technologies and establishing a dialogue with the courts. In the first case, the Ministry of Health has
established an internal unit to develop guidelines for assessing new technologies and including them in SUS lists. In the latter case, health authorities are
developing a ­dialogue with the courts to ensure that judges consider the technical and cost implications of new technologies when ruling on a claimant’s
request.
Institutions for Coordination and Financing across Levels of Government
As a result of the SUS reforms, the provision of most primary health services and
nearly half of hospital care has been transferred to municipal governments.
Decentralization has been achieved to a large extent, even though the degree of
decentralization of facilities and resources varies substantially across states. The
drastic shift in responsibility for financing and delivery to lower levels of
­government required the development of new mechanisms for coordination and
negotiation across autonomous levels of government, in particular because these
had been a key weakness of the pre-SUS system.
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Much effort was spent in the early years of the SUS to design and implement
basic legislation and internal management mechanisms, leading to the ­establishment
of bilateral and trilateral committees in 1993.13 With these ­
institutional
innovations, coordination improved, and many of the pre-SUS ­
­
problems of
­duplication and fragmentation were resolved. However, these mechanisms have
proved bureaucratic and cumbersome, with unclear assignment of decision-­
making power leading to slow and inefficient planning and budgeting processes
and high transaction costs.
On the financing side, payment mechanisms evolved over time, both for
­intergovernmental transfers and for payments to providers. Transfers were ­initially
made directly to providers based on service volume (outpatient and inpatient
care); starting in the early 1990s, they became conditional on a set of formal
administrative and financial requirements, globally known as SUS ­accreditation
of states and municipalities. In order to provide incentives for states and municipalities to implement or expand national policies and programs, specific transfers
were linked to specific programs.
The second half of the decade saw a major change in transfer mechanisms,
when comprehensive block grants were devised to finance the expansion of
­primary care. Two parallel mechanisms were implemented: (a) the Basic Care
Grant (Piso da Atenção Básica), based on a monthly amount per capita to finance
most decentralized public health programs and activities, and (b) the payment
mechanism to finance strategic primary health care programs, especially the ESF
and the PACS.14 However, in order to provide incentives to implement or expand
specific programs, the Ministry of Health multiplied the number of payment
mechanisms to an unmanageable number: in 2002, more than 100 transfer
mechanisms were in place. More recently, they were grouped into five broad
block grants: basic care, medium- and high-complexity care, health surveillance,
pharmaceutical care, and SUS management. However, many of the original
­payment mechanisms are still maintained as formulas making up the five blocks.
Over most of the 1990s and early 2000s, a conflict raged between unconditional federal transfers (fund-to-fund) and transfers linked to service volume or
program targets. On the one hand, because subnational governments are fully
autonomous under Brazil’s federal system, they see conditional transfers as an
undue interference from the Ministry of Health in regional and local allocation
of resources and health system management. On the other hand, the federal
government sees conditional transfers as a means of stimulating and guiding
implementation of the SUS and national health policies. In the early 1990s, as
the SUS was implemented and regulated, emphasis was placed on transfers
­conditional on states and municipalities meeting administrative and financial
criteria to be “accredited” for SUS implementation. In the mid-1990s, transfers
for primary care started, including a variable incentive linked to negotiated
­program and service targets and coverage by the PACS and the ESF. Later, the
proportion of unconditional fund-to-fund transfers gradually increased.
More generally, the decentralization process has raised questions about the
capacity of states and municipalities to perform designated functions (box 2.3)
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Have the SUS Reforms Transformed the Brazilian Health System?
Box 2.3 Assessing Local Capacity to Manage Decentralized Responsibilities
A pilot survey of state-level capacity to manage the Sistema Único de Saúde (SUS) was
undertaken in 2005–06 under the coordination of the National Council of State Secretaries
of Health (Conselho Nacional de Secretários de Saúde, CONASS), using the Pan American
Health Organization’s framework for assessing essential public health functions (CONASS
and OPAS 2007). The report, covering five states (Ceará, Goias, Mato Grosso, Rondônia, and
Sergipe), assessed each state’s infrastructure, institutional capacity, processes, and outcomes
in performing the essential functions. Using a participatory approach, it measured overall
performance on a scale of 0–1.
The mean scale for the five states was only 0.55, varying between 0.43 and 0.63 (table
B2.3.1). But the score for specific functions varied widely. The stronger essential functions
among the five states were coordination (F11) and policy, planning, and management (F5),
while the weakest were health promotion and quality (F9), promotion of universal access
(F7), and human resources (F8). Most of the functions associated with outcomes (F7, F9) had
poor ratings, while those associated with SUS administrative processes had better ones. This
is not surprising given the early emphasis on administrative processes and formal
requirements during SUS implementation. However, the instrument was applied to smaller
states with relatively weaker institutional capacity, although at least two of them (Ceará and
Sergipe) have recent initiatives related to the organization and delivery of health care;
overall, the survey findings are not necessarily representative of the situation and capacity
in the majority of states.
Some process indicators also describe the extent to which state governments achieve SUS
regulatory requirements: (a) SUS health agreements signed by a state and its municipalities;
Table B2.3.1 Performance Scores for Essential Public Health Functions of Five State
Secretariats in Brazil, 2006
Function
F1. Monitoring, analysis, and evaluation of health situation in the state
F2. Surveillance, investigation, and control of risks and harms to health
F3. Health promotion
F4. Social participation in health
F5. Policy development and institutional capacity for planning and public
management of health
F6. Capacity for regulation, oversight, control, and audit in health
F7. Promotion and guarantee of universal and equitable access to health services
F8. Human resources management, development, and formation
F9. Promotion and guarantee of quality in health services
F10. Research and technology incorporation in health
F11. Coordination of the regionalization and decentralization process in health
Final score
Mean
Range
0.54
0.64
0.52
0.54
0.46–0.59
0.50–0.76
0.43–0.67
0.37–0.70
0.71
0.56
0.47
0.38
0.31
0.55
0.79
0.55
0.57–0.86
0.22–0.70
0.33–0.58
0.08–0.55
0.09–0.51
0.39–0.80
0.72–0.91
0.43–0.63
Source: CONASS and OPAS 2007.
Note: The states covered are Ceará, Goias, Mato Grosso, Rondônia, and Sergipe.
box continues next page
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Box 2.3 Assessing Local Capacity to Manage Decentralized Responsibilities (continued)
(b) up-to-date planning documents (state health plan and integrated planning and
programming document); (c) establishment and coverage of regional health councils, a recent
strategy to strengthen regionalization; (d) approval of annual management reports by state
and municipal health councils; and (e) implementation of a contracting instrument with
private providers and the proportion of providers covered.
These indicators varied widely across states. The best achievers were Bahia, Mato Grosso do
Sul, Paraná, São Paulo, and Tocantins, while the worst were Maranhão, Piauí, Roraima, and—a
surprising finding—Rio Grande do Sul. While some of these responsibilities are conducted at
the municipal level, a strong and active state secretariat of health can help municipalities
under its jurisdiction to achieve better functions, especially in implementing SUS regulations.
and about whether some of the 5,600 municipalities that now have primary
responsibility for delivering health services are too small to achieve economies of
scale and scope in managing the health system. Reflecting this concern, there are
ongoing efforts to define a new level of organization of the system: regional
health networks that sit between the state and municipal levels. This idea dates
back to the 1980s, but became an official policy in early 2000, when the SUS
Health Care Operational Guideline (Regulations 01/2001 and 01/2002) identified implementation of a “hierarchical and regionalized health system” as a key
objective.
Several disease-specific networks were defined in the early 2000s (cardiology,
transplants, burns, emergency care), and some of them were successfully implemented, such as the Mobile Emergency Service (Sistema de Assistência Médica
de Urgência, SAMU). More recently, the Ministry of Health is seeking to develop
and implement networks based on treatment guidelines for specific types of care,
including hypertension, diabetes, cancer, and perinatal mortality, and ongoing
initiatives are seeking to establish regional networks organized around new intermunicipal organizations.15 However, very few functional networks have been put
in place so far, and integrated care networks remain one of the major challenges
for improving SUS effectiveness and overall performance.
Social Participation and Voice
Democratization in the health system has been a major objective of the health
reforms, and mechanisms for ensuring the democratization of decision making,
planning, and evaluation within the SUS have been a major feature of the new
system. In the early 1980s, the public health system not only was centralized,
with little participation and decision-making power at the state and municipal
levels, but also reflected the authoritarian rule of the military regime that ended
in 1985. The health councils that were established at each level—federal, state,
and municipal—provide formal mechanisms for society participation and voice
and include representatives from health authorities, health professionals, providers, and users. However, their effectiveness varies greatly; in many cases, they end
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Have the SUS Reforms Transformed the Brazilian Health System?
up being rubber-stamping entities or being captured by political interests (see, for
instance, Paim et al. 2011).
Purchaser-Provider Relationships
On the provider side, the last 20 years has seen a slow but steady shift away from
contracting services from private hospitals and toward providing services through
public hospitals. This shift has been accompanied by some limited changes in
how the SUS finances or purchases services. In the early 1980s, most payments
to private hospitals were done on the basis of fee-for-service, which produced
substantial inefficiencies and distortions. Public providers, in contrast, were
financed on the basis of traditional line-item budgets. The system was improved
in the early 1980s, with computerization and the adoption of automatic checks
and controls to identify errors and fraud (La Forgia and Couttolenc 2008). For
inpatient care, fee-for-service was replaced by a prospective payment mechanism
based on medical procedures known as the authorization for hospital admission
(autorização de internação hospitalar, AIH). As shown in La Forgia and Couttolenc
(2008), this represented a major improvement over the previous fee-for-service
system, but became gradually and increasingly distorted by the absence of systematic revisions and reliable information on costs.
In parallel to the early rounds of payment reform, several initiatives have been
undertaken to develop new organizational models for delivering services. Early
efforts focused on transforming hospitals into public foundations and public
enterprises. Some of these initiatives were successfully implemented, but have
proved difficult to replicate. More recently, São Paulo State started contracting
private not-for-profit organizations—known as social organizations (organizações
sociais)—to deliver health services, and other states and municipalities have followed suit. Under this model, facility managers have significant autonomy, but
also explicit contractual obligations (box 2.4). However, concern over facility
governance, remuneration, and performance has been gaining strength more
broadly. This concern has translated into new contracting arrangements between
the SUS and university and nonprofit hospitals and into new legislation regarding
public foundations.
Although limited in scale, new provider models have resulted in innovative
payment and contracting arrangements. For instance, São Paulo State uses
­performance-based contracts to purchase hospital services from social organizations, and Rio de Janeiro Municipality uses a similar model to contract both
hospital services and primary care services (family clinics). While the São Paulo
model has been deemed successful, there is less evidence on performance in
other parts of the country. However, capacity in contract design and monitoring
is often a significant constraint.
Overall, innovations in organizational models, provider payment, and contracting are limited, but gaining momentum. Many of these innovations hold
promise, but it will be important to evaluate the reforms carefully, looking both
at the extent to which they are achieving intended results and at the conditions
required for effective implementation. Only with this information can informed
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Have the SUS Reforms Transformed the Brazilian Health System?
Box 2.4 The Social Organization Model in São Paulo State
Based on the state reform framework proposed in 1995 and legally established by Federal Law
9637 of 1998, a social organization is a fully autonomous entity managed by a certified
nonprofit organization to provide social services on behalf of the state. The São Paulo State
legislature immediately passed a law adapting the federal law, and the state government went
on to implement the new model. It was initially applied to 11 newly built hospitals, where the
new (private) managers hired staff based on the Private Employment Law.
Six features characterized the model as implemented in São Paulo: (a) state ownership of
buildings and equipment; (b) private management by a certified social organization with
recognized experience in hospital management; (c) public funding, but full financial and
managerial autonomy; (d) management contract signed by the government and the social
organization, with clear objectives, goals, and measurable targets; (e) staff hired under private
law; and (f) strong oversight and contract management from the state secretariat of health.
La Forgia and Couttolenc (2008) demonstrated that the São Paulo social organizations performed significantly better than similar hospitals under typical public management. Their score
for technical efficiency, which was computed using data envelopment analysis, was 50 percent
higher, reaching a level of efficiency comparable to that of private facilities under corporate
(for-profit) governance. They also had higher indicators of productivity and quality than a control group of public hospitals. After controlling for several factors, Matzuda et al. (2008) identified key factors contributing to the difference in performance, including a strong accountability
mechanism between provider (social organizations) and purchaser (state secretariat of health).
This mechanism included performance-based contracting and the ability of managers to hire
and fire personnel and thus define the appropriate mix of staff skills, which in turn improves
staff motivation.
In 2011, São Paulo Municipality deployed a broad strategy for improving autonomy and
governance at the facility level. It includes establishing and contracting with social
organizations to manage 5 hospitals, 15 emergency centers, and 5 diagnostic services in a
model similar to that of São Paulo State, signing management contracts with 327 primary
health care facilities, contracting with social organizations to manage regional networks, and
establishing public-private partnerships for constructing, expanding, and managing four new
hospitals.
Source: La Forgia and Couttolenc 2008.
decisions be made about what models may be appropriate for the very diverse
conditions in Brazil’s states and municipalities.
Notes
1.Law 8.080 states that the private sector is free to participate in the delivery of
health services, provided that it complies with ethical norms and government
­regulations. Furthermore, the law includes provisions for the SUS to rely on private
services in cases where adequate converge cannot be ensured, with preference given
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Have the SUS Reforms Transformed the Brazilian Health System?
to philanthropic or other nonprofit organizations. The law prohibits the SUS from
subsidizing or providing financial support to private for-profit providers.
2.The PACS covered about 16 million people in 1994, before the ESF was launched,
mostly in the states of Bahia, Ceará, and Maranhão. These areas reached high levels of
coverage (above 70 percent) in the early 2000s.
3.The Family Health Strategy was initially known as the Family Health Program. For
simplicity, this report calls it the Family Health Strategy or ESF throughout.
4.ESF “enrollment” is not based on individual choice; it is determined by whether a
person’s residence is within the ESF team’s catchment area. In heavily populated
areas, there may be more than one ESF team per health facility, but each team is
assigned a specific territory and has a list of which families it serves. Hence, in this
report, we refer to “ESF enrollees” as those people whose household is within the
catchment area of an ESF basic care unit and who therefore are on the list of families
for which that ESF unit is responsible. As with other services delivered by the SUS,
there are no user fees for services and most medications are delivered free of charge.
5.During 2002–06, expansion of the ESF in larger municipalities occurred at the same
pace as in smaller municipalities. The World Bank Family Health Strategy Project,
which aimed to expand coverage and strengthen the ESF in 187 large municipalities
(with more than 100,000 people), may have contributed to this trend (Ministry of
Health 2008; Facchini et al. 2006).
6.According to a Ministry of Health study, nearly two-thirds of ESF team professionals
in 2002 had been hired under temporary or short-term contracts (Ministry of Health,
CGPRH and Universidade Federal de Minas Gerais, NESCON 2002).
7.The national systems (Ministry of Health, Ministry of Education, and INAMPS) were
largely merged into one system, which in turn was integrated with state and municipal
systems (university hospitals continue to be managed by the Ministry of Education,
but are formally part of the SUS).
8.The series on government health spending are not fully consistent over time. In particular, there have been some changes in the treatment of government spending for
civil servants, the military, and teaching hospitals under the Ministry of Education.
Moreover, the expenditure data do not reflect subsidies to the private sector.
However, these gaps and inconsistencies in the data do not significantly change the
overall trend.
9.In 2002, there was a break in the series when transfer and payment mechanisms were
regrouped into five transfer blocks.
10.Some successful experiences of the ESF in larger municipalities have emphasized
restructuring the organization of and access to specialized care based on the Family
Health Strategy (Giovanella et al. 2009; Macinko 2011).
11.This issue is discussed in more detail in chapter 3.
12.These are not the only aspects of governance and accountability that are relevant to
the health sector. The last 20 years also saw significant measures to strengthen consumer protection (for example, the establishment of PROCON, a consumer protection agency), improve monitoring and reporting, and strengthen an increasingly
proactive Federal Audit Tribunal (Tribunal de Contas de União), to mention a few.
The report does not get into these broader institutional reforms.
13.Bilateral committees operate in each state and include representatives of state and
municipal health authorities (state and municipal health secretariats); the trilateral
committee also includes representatives from the Ministry of Health.
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Have the SUS Reforms Transformed the Brazilian Health System?
14.Financing was linked to the number of ESF teams in place and coverage of the PACS.
This incentive was instrumental in the rapid deployment of the two programs.
15.The municipalities of Aracaju, Belo Horizonte, and Curitiba, for instance, have
often been cited as successful and interesting models, but little systematic analytical
work has been done on the issue (one exception is Matzuda et al. 2008, which
analyzes the Curitiba experience). The implementation of local or regional health
care networks focusing on guidelines for care is the subject of the ongoing
Qualisus-Rede Project funded by the World Bank (see Ministry of Health 2006;
World Bank 2007).
References
CONASS (Conselho Nacional de Secretários de Saúde) and OPAS (Organização PanAmericana de Saúde). 2007. A gestão da saúde nos estados: Avaliação e fortalecimento
das funções essenciais. Brasilia.
Couttolenc, B. 2011. “Taking Stock of Performance Reforms at the Sub-National Level in
Brazil: Recent Performance Gains Achieved in the Health Sector, Hypotheses on
Possible Drivers of Good and Bad Performance.” Consultant report, World Bank,
Washington, DC.
de Sousa, M., and E. Hamann. 2009. “Programa Saúde da Família no Brasil: Uma agenda
incompleta?” Cien Saúde Coletiva 14 (Suppl 1): 1325–35.
Facchini, L., R. Piccini, E. Tomasi, E. Thumé, D. Silveira, F. Siqueira, and M. Rodrigues.
2006. “Desempenho do PSF no sul e no nordeste do Brasil: Avaliação institucional e
epidemiológica da atenção básica à saúde.” Universidade de Pelotas, Ciência & Saúde
Coletiva 11 (3): 669–81.
Giovanella, L., M. Mendonça, P. de Almeida, S. Escorel, C. Senna Mde, M. Fausto,
M. Delgado, C. de Andrade, M. da Cunha, M. Martins, and C. Teixeira. 2009. “Family
Health: Limits and Possibilities for an Integral Primary Care Approach to Health Care
in Brazil.” Cien Saúde Coletiva 14 (3): 783–94.
IBGE (Instituto Brasileiro de Geografia e Estatística). 2008. Pesquisa nacional por
amostragem de domicilios. Rio de Janeiro: IBGE.
———. 2010. Estatísticas da saúde: Assistência médico-sanitária (AMS) 2009. Rio de
Janeiro: IBGE.
Iglesias, R., P. Jha, M. Pinto, V. L. C. Silva, and J. Godinho. 2007. “Controle do tabagismo
no Brasil.” HNP Discussion Paper, World Bank, Washington, DC.
La Forgia, G. M., and B. F. Couttolenc. 2008. Hospital Performance in Brazil: In Search of
Excellence. Washington, DC: World Bank.
Macinko, J. 2011. “A Preliminary Assessment of the Family Health Strategy (FHS) in
Brazil.” Consultant report, World Bank, Washington, DC.
Matzuda, Y., J. Rinne, G. Shepherd, and G. Wenceslau. 2008. “Brazil: Enhancing
Performance in Brazil’s Health Sector: Lessons from Innovations in the State of São
Paulo and the City of Curitiba.” Brief Note 116, World Bank, Washington, DC,
February.
Medici, A. C. 1991. Perspectivas do financiamento à saúde no governo Collor de Mello. Série
Economia e Financiamento 2. Brasilia: OPAS.
Ministry of Finance, STN (National Treasury Secretariat). 2010. “Orçamentos fiscal e da
seguridade social.” Série Histórica da Consolidação das Contas Públicas, Brasilia.
Twenty Years of Health System Reform in Brazil • http://dx.doi.org/10.1596/978-0-8213-9843-2
55
56
Have the SUS Reforms Transformed the Brazilian Health System?
Ministry of Health. 2006. “QUALISUS: Projeto de investimentos para a qualificação do
Sistema Único de Saúde.” Documento do Projeto Revisado, Brasilia.
———. 2008. Saúde da família no Brasil: Uma análise de indicadores selecionados,
1998–2005/06. Brasilia.
———. 2011. “Programa de avaliação para a qualificação do Sistema Único de Saúde.”
Ministério da Saúde, Secretaria Executiva, Brasilia.
Ministry of Health, CGPRH (Coordenação Geral de Políticas de Recursos Humanos) and
Universidade Federal de Minas Gerais, NESCON (Núcleo de Educação em Saúde
Coletiva). 2002. “Agentes institucionais e modalidades de contratação de pessoal no
Programa de Saúde da Familia no Brasil.” Relatorio de Pesquisa, Universidade Federal
de Minas Gerais, Belo Horizonte.
Ministry of Health, DAB (Departamento do Atenção Básica). 2011. “Performance Data
on the Family Health Program.” Ministério da Saúde, Brasilia. http://dab.saude.gov.br/
abnumeros.php.
Paim, J., C. Travassos, C. Almeida, and J. Macinko. 2011. “O sistema de saúde brasileiro:
História, avanços e desafios.” Série Saúde no Brasil 1, thelancet.com (May 9): 11–31.
Pereira, A., A. de Sá Campelo, F. Cunha, J. Noronha, H. Cordeiro, S. Dain, and T. Pereira.
2006. “The Economic-Financial Sustainability of the PROESF in the States of Amapá,
Maranhão, Pará, and Tocantins.” Cien Saúde Coletiva 11 (3): 607–20.
Rocha, R., and R. Soares. 2009. “Evaluating the Impact of Community-Based Health
Interventions: Evidence from Brazil’s Family Health Program.” Discussion Paper 4119,
IZA, Bonn, Germany.
Schmidt, M., B. Duncan, G. Azevedo e Silva, A. Menezes, C. Monteiro, S. Barreto, D. Chor,
and P. Menezes. 2011. “Chronic Non-Communicable Diseases in Brazil: Burden and
Current Challenges.” thelancet.com 377 (May 9): 1949–61.
World Bank. 2007. “Health Network Formation and Quality Improvement Project
(Qualisus-Rede).” Project Appraisal Document, World Bank, Washington, DC.
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C h a pter 3
Have the SUS Reforms Led to Better
Outcomes?
While the Unified Health System (Sistema Único de Saúde, SUS) reforms
focused on transforming how the health system is financed and organized, the
ultimate goal was to universalize access to health services. This chapter assesses
the extent to which this goal has been achieved. It also looks at progress in relation to other intermediate goals, in particular, with regard to quality and
­efficiency. It then turns to achievements in meeting the ultimate goals of the
health system: improving health outcomes, reducing the financial burden of
health expenditures, and enhancing trust in and satisfaction with the system.
In doing so, it looks at how the SUS interfaces with private financing, the trends
and ­patterns in the volume of services provided by the SUS and the utilization
of services by households, and out-of-pocket payments on health. Beyond indicators related to coverage, the chapter also looks at trends in health outcomes and
the extent to which improvements in health can be attributed to the SUS.
Use of Health Services and Progress toward Universality
Universality was a key founding principle of the SUS. Universal access or
­coverage is typically understood to mean that all people have access to a full
spectrum of services without suffering undue financial hardship. Formally, the
SUS reforms achieved this goal by decree: the Constitution and supporting
­legislation define health as a right, and all Brazilian citizens are entitled to have
their health needs met by the SUS. To what extent has this formal entitlement
translated into increased access and enhanced financial protection in practice?
Given the inherent imprecision in the definition of “universal coverage,” this
question is difficult to answer. What should be included in a “full spectrum of
services”? At what point does the financial contribution required to pay for
­services become a “hardship”? There is no precise answer to these questions—­
coverage is inevitably a matter of degree. Nonetheless, we can derive at least a
partial picture of how coverage has evolved by piecing together data from
­various sources on the use of health services and spending on health.
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Have the SUS Reforms Led to Better Outcomes?
SUS “Coverage” and Fragmentation of the Health System
In assessing coverage of the SUS, the first question to answer is who is the system
intended for? In 1981, 49 percent of the population reported that Social Security
or the National Institute for Social Medical Assistance (Instituto Nacional de
Assistência Médica da Previdência Social, INAMPS) was their “regular source of
care,” while another 19 percent relied on the public system or free philanthropic
services (5 and 14 percent, respectively).1 In other words, around 68 percent of
the population relied on the elements of the system that were merged into the
SUS in 1988. The remainder either used private health insurance (10 percent) or
paid out-of-pocket for services delivered mostly by private providers
(20 percent).
Implicit in the universality principle was the notion that most of the population relying on private health insurance and paying for their own health care
would be brought into the integrated public system. If measured based on
­self-reported “regular sources of care,” this goal has not been achieved. Indeed, by
2008, only 58 percent of individuals reported that they regularly use the SUS—
lower than in 1981—while 26 and 19 percent reported that they rely primarily
on private health insurance and pay for their care out-of-pocket, respectively.2
While this decline in the share of population indicating that the public
­systems are their regular source of care is significant, the picture is less clear when
we look carefully at the patterns of use. In the same way that any regular users
of the SUS sometimes pay for some services in the private sector, many who
typically pay through private health insurance or pay out-of-pocket occasionally
turn to the SUS. Indeed, some researchers argue that nearly all Brazilians use SUS
services at some point. A 2003 survey lends credence to this view: it found that
28.6 percent of Brazilians were exclusive users of the SUS, 61.5 percent used
both the SUS and other systems, and only 8.7 percent never used SUS services
(CONASS 2003). More recent evidence suggests that reliance on the SUS
increased over the last decade, with 60 percent indicating that they only use the
public system (CNI 2012; figure 3.1), but these differences may be due at least
in part to how the questions were asked.
Other evidence suggests that individuals “pick and choose” service providers,
depending on the type of service and their circumstances. For instance, individuals use the SUS as the main source of both primary care (community health
worker activities, immunizations, and some outpatient procedures) and more
expensive services (hospitalization and high-cost therapies such as ­chemotherapy,
radiation, and dialysis), but use private financing for general consultations, dental
care, and diagnostic procedures (figure 3.2).
Even if most Brazilians use the SUS at some point, the apparent decline in the
share of those who use the system as their regular source of care is significant.
The fact that private health insurance and out-of-pocket expenditures continue
to account for a large share of total health spending indicates that coverage gaps
are present in the SUS or that concerns about quality and convenience lead those
who can afford to pay privately for services to do so.
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Have the SUS Reforms Led to Better Outcomes?
Figure 3.1 Use of Private and Public Providers of Health Care in Brazil, 2012
Only use private sector
Mainly use private sector
Use both SUS and private sector
Mainly use SUS
Only use SUS
0
10
20
30
40
50
60
Percentage of respondents
70
Source: CNI 2012.
Note: SUS = Sistema Único de Saúde.
Figure 3.2 Main Source of Care in Brazil, by Type of Service, 2008
100
Percentage of population
90
80
70
60
50
40
30
20
10
Co
Ge
ns
ne
ul
ta
ra
tio
l
n:
P
hy
Co
sic
ns
ia
ul
n
ta
tio
n:
De
Co
Pr
nt
ns
im
ist
u
ar
lta
yh
tio
ea
n:
Ot
he lth
he
c
al ar
r
th e/
w co
or m
ke m
r a un
Va ctiv ity
i
cc
in ty
at
io
n,
Ho
et
sp
c.
ita
la
dm
iss
Di
io
ag
n
no
Th
st
ic
er
ap
te
st
y:
s
Ca
nc
er
,d
ia
lys
is
0
Out-of-pocket
Private health insurance
SUS
Source: IBGE, PNAD for 2008.
Note: SUS = Sistema Único de Saúde.
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Have the SUS Reforms Led to Better Outcomes?
What is the nature of these coverage gaps or quality issues? This is a critical
question to answer in assessing the extent to which universal coverage has been
achieved. If, on the one hand, the inability to pay for services privately (through
private health insurance or directly out-of-pocket) leads to significant inequalities
in access to necessary care and eventual health outcomes, the coverage gaps are a
matter of significant concern. If, on the other hand, the gaps are primarily in areas
with limited implications for health and well-being (for example, brand name
versus generic drugs or diagnostic and treatment procedures with limited ­efficacy),
they may have important implications for efficiency, but are less of a concern from
the perspective of coverage and equity. We return to this issue below, although it
is not a question that can be fully settled with available data and evidence.
The Volume of Services Provided by SUS
Given that the majority of the population uses the SUS at some point, the
­volume of services provided by SUS facilities provides a good indication of realized access. The expansion of the network of facilities over the last two decades,
documented in the previous chapter, has been accompanied by a large increase
in the supply of services by the public system—INAMPS and then the SUS. The
number of medical consultations per capita increased 70 percent between 1990
and 2009 (figure 3.3), and the volume of basic care procedures increased even
more—from around 2.5 per capita in 1990 to more than 8 per capita in 2009.3
Figure 3.3 Medical Consultations, Basic Care Procedures, and Hospital Admissions per
Capita in Brazil, 1980–2009
9
120
100
7
6
80
5
60
4
3
40
2
20
Number of hospital admissions per
1,000 population
Number of consultations and basic
procedures per capita
8
1
0
1980
1985
1990
Admission rate
1995
2000
Basic care procedures
2005
Consultations
0
2010
Sources: IBGE, AMS surveys (IBGE 2002, 2006, 2010); Ministry of Health DATASUS data.
Note: Changes in the list of procedures recorded in SUS information systems and their definition make comparisons over
time imprecise; the figure for primary health care in 1990 is from IBGE AMS surveys and may not be strictly comparable to the
figures for later years, which are from Ministry of Health data, but this is unlikely to change dramatically the general trend.
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Have the SUS Reforms Led to Better Outcomes?
In the later years of this period, much of this increase was due to the rapid
deployment of the Family Health Strategy (ESF). In contrast, the quantity of
hospitalizations provided by the SUS or INAMPS remained stagnant at around
11.5 million, reaching a peak of 14.8 million in 1993. This translates into slightly
declining hospital admission rates.
The composition of SUS service provision by type of provider also changed
substantially, reflecting a change in the allocation of resources in favor of
public providers and away from private contracted providers. This is especially apparent in the case of hospital care (figure 3.4). However, while hospitalizations in the SUS have been relatively stable, even falling between 1992
and 2009, hospitalizations in the private non-SUS sector have doubled, and
by 2005 the private sector accounted for almost the same number of hospitalizations as the SUS. This raises important questions about whether constraints in SUS hospital capacity have resulted in rationing, with an overflow
into the private sector, or whether other factors are at play.
Survey data corroborate administrative data on the volume and composition
of services. For instance, the percentage of individuals who reported seeking some
form of health care in the last two weeks increased nearly 30 percent between
1986 and 2008, from 11.3 to 14.4 percent. The type of services used by households also changed over time, with preventive visits and dental consultations
accounting for a growing share of all visits to health care providers ­(figure 3.5).
Moreover, the restructuring of health care provision and the strengthening of
primary health care changed how Brazilians seek and use health care services.
Up to the 1980s, hospitals were the preferred source of care for most Brazilians;
20 years later, more Brazilians use basic care units (and, to a lesser extent, private
practice offices and clinics) as their main source of care (figure 3.6).
Number of admissions (millions)
Figure 3.4 Hospital Admissions in Brazil, by Type of Provider, 1985–2009
25
20
15
10
5
0
1985
1990
1992
Brazil
Private SUS
1999
2005
2009
Private non-SUS
Public
SUS
Sources: IBGE, AMS surveys (IBGE 2002, 2006, 2010); Ministry of Health DATASUS data.
Note: SUS = Sistema Único de Saúde. The line for Brazil includes public and private (SUS and non-SUS providers); the SUS line
includes most admissions in public facilities and admissions in private facilities under SUS contract (private SUS).
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Have the SUS Reforms Led to Better Outcomes?
Figure 3.5 Health Services Used by Households in Brazil, 1986 and 2008
100
Percentage of all visits to health
care providers
90
80
70
60
50
40
30
20
10
0
1986
Other
Dental
2008
Check-up/
prevention
Illness or
accident
Source: Based on data from IBGE, PNAD for 1986 and 2008.
Figure 3.6 Source of Care in Brazil, by Type of Facility, 1981–2008
Percentage of visits to a health facility
100
90
80
70
60
50
40
30
20
10
0
1981
1986
1998
Hospital or
Private practice
emergency room
or clinic
2008
Health
center or post
Source: Based on IBGE, PNAD for 2008.
Utilization Rates across States and Socioeconomic Groups
The gradual equalization of the availability of services across states, achieved by
restructuring the hospital system and focusing the ESF rollout on the poorer
states, has helped to reduce geographic disparities in utilization, although the
picture is not entirely clear. By 2009, all states had achieved rates of at least 2.35
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Have the SUS Reforms Led to Better Outcomes?
consultations per capita per year (figure 3.7). Increases in utilization were greater
in low-income states, such that the relationship between average income and
utilization was somewhat weaker (figure 3.8). In the case of hospitalizations,
most states saw a reduction in admission rates (figure 3.7). Nonetheless,
90 ­percent of states achieved a hospital admission rate within the Ministry of
Health (Ministério da Saúde) parameter of 7–9 percent per year (the exceptions
are Alagoas, Amazonas, and Sergipe); the national average for 2008 was
9.0 ­percent. These rates are much lower than in Organisation for Economic
Co-operation and Development (OECD) countries (6.8 percent for consultations and 15.8 percent for hospitalizations, respectively), but around or above
those of most middle-income countries (2.5 and 5.5 percent, respectively, for
Mexico) and significantly higher than those of China, Peru, and Thailand.4
Although geographic disparities in utilization have declined somewhat, a significant income gradient remains in average utilization rates across states in Brazil
(figure 3.8).
Moreover, notable disparities are still evident across income groups, with
higher levels of utilization among high-income groups. For instance, household
survey data indicate that utilization rates are around 50 percent higher for the
top two deciles than for the bottom two (figure 3.9). The better off are also using
SUS services at a much lower rate than those at the lower end of the income
distribution.
Figure 3.7 SUS Consultations per Capita and Hospitalizations per 100 Persons in Brazil, by State,
1995 and 2008 (or 2009)
a. SUS consultations
Number of SUS consultations per capita
7
6
5
4
3
2
1
M
ar
an
hã
o
Pi (22
a
4
Ce uí ( )
ar 237
á
To Bah (30 )
ca ia 5)
nt (3
S
Pe er ins 11)
rn gi (31
am pe 1)
b (3
Ri
Pa uco 19)
o
r
Gr
a (
an Ala íba 335
de go (3 )
do as 48)
No (35
rt 1)
Pa e (3
r
M G á ( 59)
at oi 41
o ás 4
Am Gro (45 )
az sso 8)
M
on (4
at
o
Gr Am as ( 82)
os a 49
M so pá ( 5)
in do 50
Es as G Su 7)
pí e l (
rit ra 51
o is 8
Sa (5 )
Pa nto 18)
ra (5
ná 3
4
Ro Acr (60 )
Sa n e 8)
d
nt ô (61
a C ni 7
Ri
at a (6 )
o
a
gr Ro rin 37)
an râ a (
Ri de ima 67
o d ( 8)
de o 68
J Su 9
Di S ane l (6 )
st ão iro 97
rit P
o au (77 )
Fe lo 9
de (8 )
ra 62
l( )
1,
06
8)
0
State (income per capita, R$)
1995
2008
figure continues next page
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Have the SUS Reforms Led to Better Outcomes?
Figure 3.7 SUS Consultations per Capita and Hospitalizations per 100 Persons in Brazil, by State, 1995 and 2008
(or 2009) (continued)
b. SUS hospitalizations
Number of SUS hospital admissions
per 100 persons
16
14
12
10
8
6
4
2
M
ar
an
hã
o
Pi (22
au 4)
Ce í (
ar 237
á
To Bah (30 )
ca ia 5)
nt (3
Pe Ser ins 11)
rn gi (31
am pe 1)
b (3
Ri
Pa uco 19)
o
r
Gr
a (
an Ala íba 335
de go (3 )
do as 48)
No (35
rt 1)
Pa e (3
M G rá ( 59)
at oi 41
o ás 4
Am Gro (45 )
az sso 8)
M
on (4
at
o
Gr Am as ( 82)
os a 49
M so pá ( 5)
in do 5
Es as G Su 07)
pí e l (
rit ra 51
o is 8
Sa (5 )
Pa nto 18)
ra (5
ná 3
4
Ro Acr (60 )
Sa n e 8)
d
(
nt ô 61
a C ni 7
at a (6 )
Ri
o
a
gr Ro rin 37)
an râ a (
d
Ri e ima 67
o d ( 8)
de o 68
J Su 9
Di S ane l (6 )
st ão iro 97
rit P
o au (77 )
Fe lo 9
de (8 )
ra 62
l( )
1,
06
8)
0
State (income per capita, R$)
1995
2009
Source: Based on Ministry of Health, DATASUS data.
Note: SUS = Sistema Único de Saúde. States are ranked by average income per capita (IPEAData).
Figure 3.8 SUS Consultations per Capita and Hospitalizations per 100 Persons in Brazil,
by State Income per Capita, 1995 and 2008 (or 2009)
Number of SUS consultations per capita
a. SUS consultations
7
6
5
4
3
2
1
0
1,500
0
500
1,000
State (average monthly income per capita, R$)
1995
2008
figure continues next page
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Have the SUS Reforms Led to Better Outcomes?
Figure 3.8 SUS Consultations per Capita and Hospitalizations per 100 Persons in Brazil,
by State Income per Capita, 1995 and 2008 (or 2009) (continued)
b. SUS hospitalizations
Number of SUS hospital admissions
per 100 persons
18
16
14
12
10
8
6
4
2
0
0
500
1,000
1,500
State (average monthly income per capita, R$)
1995
2009
Sources: Based on Ministry of Health, DATASUS data; IPEAData from IBGE for state income levels.
Note: SUS = Sistema Único de Saúde.
20
100
18
90
16
80
14
70
12
60
10
50
8
40
6
30
4
20
2
10
0
0
1
2
3
4
5
6
Income decile
7
8
9
10
Percentage of those who used SUS (2008)-right axis
Percentage of sought care (2008)
Percentage of sought care (1986)
Source: IBGE, PNAD for 2008–09.
Note: SUS = Sistema Único de Saúde. Income decile is defined relative to mean household income per capita.
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Percentage of population who used the SUS in
the last two weeks
Percentage of population who sought care
in the last two weeks
Figure 3.9 Percentage of the Population Who Sought and Used Care in Brazil, by Income Decile,
1986 and 2008
66
Have the SUS Reforms Led to Better Outcomes?
Are Health Care Needs Being Met?
Trends and patterns in the use of health services provide a good indication of
realized access. As noted, the last 20 years have seen a steady increase in the use
of many types of health services, as well as a reduction in geographic and socioeconomic disparities. However, simple utilization rates do not shed much light
on whether individuals are able to access the preventive, diagnostic, and curative services they need in a timely manner, even though this is a critical element
in assessing progress toward improving access and achieving universal
coverage.
One way to address this question is to look at coverage of health interventions
with a clearly defined target group. This can be done, for instance, with maternal
and child health interventions, such as immunizations, antenatal care, and
­hospital deliveries. Where data are available and the target population has been
clearly defined, it is also possible to look at coverage rates for routine screening
or disease management programs. As shown below, coverage of key maternal and
child health interventions in Brazil has increased over the last couple of decades
and is now nearly universal; fewer data are available on coverage of disease
screening and other interventions.
Another approach is to look at self-reported unmet need. Household survey
data in Brazil show a reduction in self-reported unmet need as well as a shift in
the reasons reported for not using health services when needed. One of the
­limitations of self-reported problems with access is that questions tend to be
concerned only with the use and nonuse of services. However, many care-­
seeking experiences involve multiple providers and services (general practice,
specialist care, diagnostic services), with effective access depending not only on
the availability of services, but also on the organization and coordination of care,
referral arrangements, and so forth. Access is harder to assess in relation to these
types of services, but is increasingly important as basic health care needs are
being met and the burden of chronic conditions increases. Although limited,
available ­evidence from Brazil points to important weaknesses in the system and
also highlights the need for more systematic data on these aspects of
performance.
Coverage of Key Health Services and Interventions
Even prior to the extension of primary health care through the ESF, immunization coverage had increased significantly, from around 50 percent in 1980 to
nearly 100 percent in the early 2000s (figure 3.10). This trend was similar to that
in many developing countries and somewhat weaker than in some middle- and
low-income countries; for example, India, Malaysia, Mexico, Peru, and Thailand
expanded coverage at a faster pace.
Coverage of antenatal care also improved. Between 1996 and 2006, the
­proportion of pregnant women having no prenatal consultation dropped from 26
to 1.3 percent (Ministry of Health 2010b) the mean number of consultations rose
from 1.2 to 6.2, and the share of women with at least four visits during p
­ regnancy
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Have the SUS Reforms Led to Better Outcomes?
Percentage of population who are immunized
Figure 3.10 Immunization Coverage in Brazil and Other Developing Countries, 1980–2009
120
100
80
60
40
20
0
1980
1985
1990
1995
2000
2005
2009
Brazil
Upper middle-income countries
Latin America and the Caribbean
Sources: Ministry of Health and World Bank data.
increased from 76 to 89 percent, which was higher than that in other countries
with available data.
At the other end of the spectrum, the Program on HIV/AIDS (human immunodeficiency virus/acquired immunodeficiency syndrome) has been very successful and one of the few programs to offer nearly universal access to AIDS
medications and treatment (box 3.1). The program’s success was also due to a
strong health education initiative conducted through the media, which induced
significant change in health and sexual behavior.
Trends and Patterns in the Use and Nonuse of Services
Another indicator of access is the proportion of people reporting that they did not
seek health services when they perceived a need for care.5 While there has been
no clear trend in the nonuse of services for individuals who reported an episode
of illness over the last decade, there has been an important shift in the relative
importance of the reasons for not seeking care. In particular, the share of households reporting lack of money (for services or transportation) as a reason for not
using services declined over the last two decades, in particular among households
at the lower end of the income distribution (figure 3.11). Similarly, the expansion
of infrastructure and staffing has translated into improved availability of services,
with fewer households reporting access or transportation as a reason for not
­seeking care.
Meanwhile, facility-related reasons (lack of or unfriendly staff, inadequate
scheduling, long waiting times) have increased, becoming the chief reasons for
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Have the SUS Reforms Led to Better Outcomes?
Box 3.1 Brazil’s Program on HIV/AIDS
The Brazilian Program on HIV/AIDS (human immunodeficiency virus/acquired immunode­
ficiency syndrome) was launched in 1986 in response to the rapid expansion of the epidemic in
the country. By then, Brazil counted 1,537 reported cases, a number that was more than
doubling every year. The HIV/AIDS policy ultimately combined several key strategies: (a) mass
media information campaigns, (b) wide availability of diagnosis, (c) free distribution of
antiretroviral drugs to all patients, (d) close collaboration with nongovernmental organizations
and patients’ rights organizations, (e) focus on and support for high-risk groups, and
(f) negotiations with pharmaceutical companies to reduce prices under the threat of breaking
patents. The following are the key milestones of the program:
• 1984. The Health Secretariat of São Paulo establishes the first AIDS control program;
Montagnier isolates the retrovirus causing the infection: 220 cases reported (prevalence).
• 1985. The first nongovernmental organization in Latin America is founded in Brazil (Grupo
de Apoio à Prevenção à AIDS, GAPA): 678 cases.
• 1986. The national Program on HIV/AIDS is established: 1,537 cases.
• 1988. The federal government starts distributing drugs against opportunistic infections:
6,029 cases.
• 1991. The Ministry of Health starts distributing free antiretroviral drugs: 18,487 cases.
• 1992. The Ministry of Health launches a large education campaign and begins to reimburse
treatment under the SUS: 25,186 cases.
• 1994. A World Bank support project is initiated: 38,015 cases.
• 1996. The Program on HIV/AIDS launches the first national consensus for AIDS treatment;
the free distribution of antiretroviral drugs is established by law: 56,605 cases.
• 1998. Treatment coverage is mandated for private insurers; the Ministry of Health begins to
distribute 11 drugs: 91,916 cases.
• 2001. Brazil threatens to break patents and negotiates a significant reduction in the price of
antiretroviral drugs: 139,573 cases.
• 2007. Survival rates improve significantly; the Ministry of Health establishes a database on
violations of HIV/AIDS patients’ rights: 474,273 cases since 1980.
• 2008. Brazil invests US$10 million in a factory producing antiretroviral drugs in Mozambique.
The program managed to change sexual behavior through information campaigns,
achieved nearly universal free treatment, was a leader in negotiating significant reductions in
drug prices, and ultimately controlled expansion of the epidemic and reduced mortality from
HIV/AIDS (mortality peaked in 1995, reaching 12.2 deaths out of 100,000 population and then
dropped to half by 1998).
Source: Ministry of Health, Departamento de DST, AIDS e Hepatites Virais website (http://www.aids.gov.br).
not seeking care. These data strongly suggest that access to services has improved,
but that the problems with quality and responsiveness of services have worsened
(or expectations have risen).6 This is also apparent from the increase in the share
of households that report seeking care but not being able to access it
(figure 3.12).
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Have the SUS Reforms Led to Better Outcomes?
Figure 3.11 Reasons Given for Not Seeking Care in Brazil, by Income Decile, 1986 and 2008
a. Lack of money
20
Percentage of respondents
18
16
14
12
10
8
6
4
2
0
1
2
3
4
5
6
7
Income decile
8
9
10
9
10
b. Lack of access or transport
18
Percentage of respondents
16
14
12
10
8
6
4
2
0
1
2
3
4
5
6
7
Income decile
1986
8
2008
Source: IBGE, PNAD for 1986 and 2008.
Access to Specialist Care and Waiting Times
Data from household or patient surveys on the nonuse of services can provide
important insights into access problems. In many cases, such data refer to primary
contacts in the event of illness or need (as perceived by the respondent). Yet, as
illustrated in figure 3.13, many health needs require services and clinical
decisions from multiple providers, and problems with access and delays in
­
­receiving care can arise at various points in this process.
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Figure 3.12 Share of Persons Reporting That They Sought Care but Did Not Receive It in
Brazil, by Income Decile, 1986 and 2008
Percentage of respondents who sought
care but did not receive it
8
7
6
5
4
3
2
1
0
1
2
3
4
5
6
7
Income decile
1986
8
9
10
2008
Source: IBGE, PNAD for 1986 and 2008.
Figure 3.13 Patterns of Care and Possible Points of Delay in Accessing Health Care in Brazil
Onset of
disease
Seek medical
advice
Receive
primary
medical care
Receive a
specialist
referral
Receive
specialist care
Need further
specialist
care (such as
surgery)
Receive
further
specialist
care
Primary care
management
Possible points of delay
Source: Authors
Given the significant diversity of health needs and the complex pattern of
health care provided to patients, access problems along this chain are hard to
capture in simple indicators. One common approach is to assess the performance
of health systems through data on waiting times, typically for elective procedures.
Indeed, waiting times are one of the most important health system problems in
many OECD countries (OECD 2003). While there is no established consensus
on what represents an “excessive” waiting time, many countries have established
targets for maximum waiting times, on the grounds that longer waiting times are
unpopular and can lead to adverse consequences (such as deterioration in the
condition, anxiety, increase in the cost of the procedure, and loss of income
from work).
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Have the SUS Reforms Led to Better Outcomes?
There is ample evidence that long waiting times are a source of considerable frustration among users of the SUS. However, systematic data are scarce
on how long patients are waiting for specialist assessments and care. A recent
study of cancer care by the Federal Audit Tribunal (Tribunal de Contas da
União, TCU 2011) represents an important effort to compile data on delays
in diagnosis and treatment that illustrate broader challenges in the health
system. Cancer is now the second most important cause of mortality in Brazil,
and demand for both diagnostic and treatment services is increasing rapidly.
Using administrative data on payments for high-complexity procedures from
2010, the study found that, as a result of problems accessing diagnostic procedures and specialist care, 60 percent of cancer patients were diagnosed at a
very late stage (stage three or four), reducing the prospects of effective treatment and survival.7 There are no directly comparable data from multicountry
studies, but in the United States, only 7 percent of cancer patients were diagnosed at stage three or four according to a recent study (Legorreta et al.
2004).
The problem of late diagnosis is compounded by delays in accessing treatment. The report uses both administrative data on authorized payments for
radiation and chemotherapy and hospital cancer registries to assess the delay
from diagnosis to treatment. Payment data indicate that median waiting time for
chemotherapy was 76.3 days in 2010, with only 35.6 percent of patients receiving treatment within 30 days of diagnosis. In the case of radiation therapy, the
corresponding figures were 113.4 days and 15.9 percent of patients.8 There are
no national guidelines or targets against which to assess these numbers. However,
as a point of comparison, the report notes that in Canada and the United
Kingdom most patients receive treatment within 30 days (88 and 99 percent,
respectively), with a median waiting time ranging from 5 to 25 days depending
on the type of treatment.
The report notes that delays in diagnosis and treatment are inconsistent with
the goals established in Law 8.080 and the National Cancer Policy (Portaria
GM/MS 2.439/2005). Several factors contribute to the problem, including a
lack of capacity in the system, insufficient staff with qualifications in relevant
specialties (such as pathologists), weaknesses in the referral and counterreferral
systems, and payment rates that do not always match the costs of services.9
More and better data are needed on waiting times and outcomes (such as survival rates).
Another effort to assess unmet need is a recent study focusing on the demand
for specialist, diagnostic, and surgical procedures in Rio Grande do Sul
(CNM 2011). The study collected data on all referrals for which the service had
not yet been provided to the patient and found that, for the state as a whole, with
a population of 10.6 million people, there was an unmet need of nearly 500,000
consultations or procedures.10 Specialist consultations (orthopedic and opthalmology were the most important) accounted for more than half of these, while
diagnostic procedures accounted for 30 percent. In the case of hospital admissions, nearly all of the unmet need was for psychiatric care. These problems are
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Have the SUS Reforms Led to Better Outcomes?
attributed to a lack of physical capacity, inadequate financing by the state, and
weaknesses in the referral and counter-referral systems.
Data on waiting lists and access to specialist care are limited in Brazil.
Nonetheless, many patients clearly have difficulty navigating the health system,
which explains the comparatively high levels of dissatisfaction with the SUS.
The Quality Dimension: A Missing Piece of the Puzzle?
Discussions of coverage tend to focus on access to and cost of services for different groups. However, this concept of “coverage” does not adequately capture
quality and the extent to which improvements in coverage of health services
translate into better health outcomes. In other words, it is not only access to
services that matters for realizing potential health gains, but also the extent to
which those services are appropriate and well delivered.11
Although enhanced effectiveness was an important goal, the SUS reform did
not focus explicitly on quality. This may be due to the fact that the quality of
health services is inherently difficult to measure. Indeed, the quality of services
in the Brazilian health system has only recently been reported or monitored
and even then only partially. While long-term comparisons are difficult to
make, quality has been a long-standing concern. For instance, a report from
1994 found that, in the early 1990s, little systematic information or rigorous
assessment of the quality of care was available, and a huge contrast existed
between world-class quality in complex services, such as cardiac surgery and
transplants, and generally inadequate quality in the most-used basic services,
such as maternal and child care (World Bank 1994). Among other things, the
report noted (a) inappropriate patterns of staffing and work; (b) inadequate
patterns of drug prescription and use, with few facilities using a list of essential
or standardized drugs; (c) high rates of Cesarean sections; (d) lack of standard
treatment protocols; (e) high infection rates among surgical procedures and
inpatient care in general (6.5–15 percent) and high mortality rates (13.9 percent in private hospitals under contract with INAMPS and 6.7 percent in
public hospitals in Rio de Janeiro); (f) limited use of quality assurance programs; and (g) weak channels for reporting malpractice or consumer
dissatisfaction.
Almost 15 years later, in their review of the hospital sector, La Forgia and
Couttolenc (2008) found that progress had been slow and limited, in spite of the
multiplication of quality assurance initiatives.12 The study found several frequent
quality issues that can be grouped into the following: errors or delays in diagnosis;
failure to follow recommended procedures; failure to carry out operations and
examinations using appropriate procedures; failure to select and administer
­treatments properly; mistakes in dosage or method of using or administering
drugs; unnecessary delays in providing treatment or sharing test results; use of
incorrect or inappropriate treatment; failure to use recommended prophylactic
treatments; lack of a monitoring, revision, and control system; problems with
availability and use of equipment; and lack of a staff training system (La Forgia
and Couttolenc 2008).
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Have the SUS Reforms Led to Better Outcomes?
Similar concerns have also been raised by other studies. For instance, a 2003
survey of more than 1,000 public and private hospitals in São Paulo State found
that 52.5 percent—47.6 percent of public and 53.9 percent of private ­hospitals—
did not comply with minimum requirements for licensing by state and national
standards (CREMESP 2004) and that two-thirds had incomplete medical
records. The Ministry of Health’s Program for Evaluation of Health Services
(Programa Nacional de Avaliação de Serviços de Saúde), in its 2005 report, found
that, of the 6,030 SUS-funded hospitals surveyed, 40 percent did not respond
and 37 percent were not compliant; among those that were rated, only 16 ­percent
were deemed as providing good or superior quality of care, while 37 percent
were seen as providing unacceptable or very unacceptable quality (Ministry of
Health 2006). Clearly, quality concerns are related to weak design or implementation of regulatory and quality assurance systems, but provider payment
arrangements and patient expectations also come into play. This is evident, for
example, in the very high rates of Cesarean sections in Brazil (box 3.2).
But there are also indications of improvements. For instance, two recent
­studies used the Primary Care Assessment Tool of the Ministry of Health (2010a)
to assess the quality of the ESF relative to the traditional approach to providing
facility-based primary health care services and found that in all of the qualityrelated functions considered, the ESF was significantly superior to the traditional
approach (Macinko 2011; Macinko, Almeida, and de Sá 2007; figure 3.14).
Other studies have focused on hospitalization for conditions that can be
­managed effectively in a primary care setting (with high hospital admission rates
for these conditions indicating poor quality of primary care). The proportion of
admissions for conditions sensitive to primary care was estimated in the early
2000s at 27 percent in Minas Gerais (SES-MG 2005) and at 30 percent in Brazil
as a whole (La Forgia and Couttolenc 2008). However, during 1999–2007
hospitalizations for chronic diseases that are sensitive to outpatient care
­
(­cardiovascular disease, stroke, and asthma) fell at a rate greater than hospitalizations for other reasons. Moreover, the ESF had a lower proportion of avoidable
admissions (Macinko 2011), as illustrated in figure 3.15. Similarly, a study by
Dourado et al. (2011) looking at national, regional, and state-level data found
that greater ESF coverage at the state level was associated with lower hospital
admissions for conditions sensitive to primary health care, after controlling for
confounding variables.
Health System Efficiency
The concept of efficiency is concerned with the relationship between inputs
and outcomes or outputs. At the broadest level, an efficient health system is
one that produces the greatest improvement for a given level of spending.
Given the ­variegated influences on health outcomes, efficiency is difficult to
determine at this high level. For these reasons, assessments of efficiency tend to
focus on specific links in the chain from spending to outcomes, including the
extent to which resources are allocated appropriately across programs or
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Have the SUS Reforms Led to Better Outcomes?
Box 3.2 Cesarean Sections in Brazil
The proportion of Cesarean sections in Brazil has been among the highest in the world for
many years and now averages 43 percent nationally. It has been increasing in all regions since
the 1970s: from 15 percent in the early 1970s to 30–35 percent in the 1980s, 40 percent in the
late 1990s, and 49 percent in 2008 (Victora et al. 2011). However, SUS (Sistema Único de Saúde)
rates remain much higher in the rich states of the southeastern and southern regions (33–35
percent) than in the northern and northeastern regions (28 percent in 2007). The mean rate for
Brazil is higher than in any other country and twice the 22 percent average for high-income
countries (WHO 2008); it is much higher than the upper limit recommended by the World
Health Organization (15 percent). Cesarean sections may be more convenient for physicians
and many mothers, but they also carry increased risks for women and newborns.
The SUS, which is responsible for about 80 percent of deliveries, has been moderately
­successful at curbing the trend within its system, through changes in payment levels in the
early 1980s and other policies in the 1990s; the rate would probably be much higher if the SUS
had not implemented policies to reduce it.13 The rate is much higher in the private sector (covered by health insurance plans), at more than 80 percent, than in the SUS (IBGE 2009). But the
effects of SUS policies have been short-lived, as apparent in figure B3.2.1. Particularly worrisome is the 44 percent increase in the SUS rate since 2000 (32 percent increase in the private
sector rate).
Figure B3.2.1 Rates of Cesarean Section for Brazil as a Whole and for INAMPS/SUS,
1970–2009
Percentage of all deliveries
60
50
40
30
20
10
0
1970
1975
1980
1985
1990
INAMPS/SUS
1995
2000
2005
2009
Brazil
Sources: Ministry of Health data; Ministry of Health, SVS 2011; ANS 2011.
Note: INAMPS = Instituto Nacional de Assistência Médica da Previdência Social, SUS = Sistema Único de Saúde.
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Have the SUS Reforms Led to Better Outcomes?
Figure 3.14 Quality of Care in the ESF and the Traditional Primary Health Care System in
Petropolis, Brazil, 2003
1.0
Quality of care score
0.8
0.6
0.4
0.2
Pr
re a
co
ov
id
er
s
ity a
m
m
un
To
ta
ls
Co
Co
or
Fa
m
ily a
di
en
eh
pr
Co
m
na
siv
tio
n
ea
y
lit
na
di
itu
ng
Lo
Ga
te
ke
ep
Ac
in
ce
ss
ga
0
ESF
Traditional
Source: Macinko, Almeida, and de Sá 2007.
a. Difference between reformed (ESF) and traditional clinics is statistically significant at less than 5 percent.
Figure 3.15 Potentially Avoidable Hospital Admissions for Chronic Diseases and ESF Coverage in Brazil,
1997–2007
Adjusted prevalence ratio
Diabetes
Chronic obstructive
pulmonary disease
Stroke
Hypertension
Other
cardiovascular disease
Asthma
0.75
0.80
0.85
ESF quintile 5
0.90
ESF quintile 4
0.95
1.00
ESF quintile 3
1.05
ESF quintile 2
Source: Macinko 2011.
Note: ESF (Family Health Strategy) quintiles are based on a ranking of municipalities by level of ESF coverage, with quintile 1 being the
municipalities with the lowest level of coverage and Q5 being the municipalities with the highest.
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Have the SUS Reforms Led to Better Outcomes?
interventions (allocative efficiency) and the extent to which the greatest volume and quality of health services are produced for the available inputs (technical efficiency).
While there were no explicit goals in relation to efficiency, the SUS reforms
were expected to enhance health system efficiency through a range of measures,
including increased integration and coordination, enhanced focus on primary
care, provider payment reform, and stronger governance and accountability.
Many of these specific reforms, particularly in the areas of provider payment and
governance, were implemented only partially; although gains in efficiency can be
expected due to the strengthening of primary care, these gains are likely to be
relatively small.
Few indicators of efficiency are available for an extended period of time in
Brazil’s health care system. The few studies on the issue are cross-sectional and
focus on particular aspects of efficiency. However, some available indicators and
a review of the literature can provide direct and indirect evidence that the SUS
and the Brazilian health sector in general operate at low levels of efficiency. It is
difficult, however, to make conclusions about trends over time.
Allocative Efficiency
Few studies have been conducted of allocative efficiency in the Brazilian health
system. However, government spending has been reallocated toward primary
care, with the share allocated to basic care increasing from 10 percent in the
1970s to around 20 percent in 2010, while medium- and high-complexity care
continues to account for the largest share of spending. Nonetheless, the changes
in resource allocation are bringing Brazil more in line with OECD countries,
where inpatient, including long-term, care accounts for 41 percent of health
expenditure, ranging between 34 and 52 percent, and outpatient, including
­primary and secondary, care accounts for 31 percent, ranging between 23 and
46 percent (figure 3.16).14
Figure 3.16 Distribution of Health Spending in OECD Countries, 2007
Collective services,
7%
Medical supplies,
21%
Inpatient,
29%
Long-term,
12%
Outpatient,
31%
Source: OECD 2011.
Note: OECD = Organisation for Economic Co-operation and Development.
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Have the SUS Reforms Led to Better Outcomes?
Medical Technology and Allocative Efficiency at the Facility Level
Brazil is an avid adopter of medical technologies. However, a substantial
­proportion of high-complexity equipment is adopted without considering its
implications for the cost, quality, and effectiveness of care. In 2002, Brazil as a
whole had a density for computerized tomography (CT) and magnetic resonance
imaging (MRI) scanners higher than that of the lowest quartile of OECD countries, which includes countries from Eastern Europe, and close to that of a group
of five rich countries that are relatively low users of medical technology and have
established systems to regulate the adoption of new technology (Australia,
Canada, France, the Netherlands, and the United Kingdom; figure 3.17).
The availability of equipment is much lower in the SUS than in Brazil as a
whole, because the larger part is offered by the private (not-for-SUS) sector,
where supply is much higher than in most OECD countries. In addition, the
allocation of high-cost medical equipment in Brazil is largely irrational and
­inefficient: an analysis of density by municipality in 2002 revealed that, of the
100 municipalities with the highest density, 70 percent had fewer than 30,000
inhabitants and had densities more than 10 times higher than among OECD
countries (Couttolenc, Dias, and Nicolella 2004). This means that a substantial
proportion of high-cost equipment is installed in municipalities that have neither
the size nor the role (within the health system) to host them.
However, the supply of diagnostic equipment tends to generate demand for it,
at a high cost to the health system. SUS supply is in line with Ministry of Health
standards but relatively high in comparison to that of most upper-middle-income
countries (typically the lowest quartile of OECD countries). No established
­system for regulating and organizing the adoption and supply of medical technology is yet in place, although partial initiatives have been undertaken by the
Ministry of Health, such as the establishment of a specific department and
financing of some studies on the issue.
Another indicator of the supply and use of technical inputs is the mean
number of diagnostic tests per medical consultation. This number increased
­
80 ­percent between 1995 and 2008, from 0.1 to 0.18 (Ministry of Health,
DATASUS data). However, some studies indicate that up to 60 percent of
­diagnostic tests are unwarranted and useless: they reveal little that could not be
revealed by a simple examination of the patient and add little value to diagnosis
and treatment (Santos 2006). This also reflects the low use of treatment
­guidelines in Brazil.
Hospital Efficiency
Efficiency in hospital care can be measured in several ways, such as bed
occupancy rate, staff productivity, and use of hospital infrastructure. Most
­
Brazilian hospitals operate at a very low level of efficiency. Using data envelopment analysis for a sample of 428 hospitals, La Forgia and Couttolenc (2008)
found that the average score for technical efficiency in 2002 was 0.34 on a scale
of 0 of 1, which means that the average hospital could produce three times more
output if it were as efficient as the most efficient hospital in the sample. Public
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Have the SUS Reforms Led to Better Outcomes?
Figure 3.17 Density of Technology Use in Brazil and OECD Countries, 1985–2009
Number of CT scanners per million population
a. CT scanners
25
20
15
10
5
0
1985
1992
1999
2009
1999
2009
b. MRIs
Number of MRIs per million population
12
10
8
6
4
2
0
1985
1992
Brazil
SUS
MOH standard
OECD (all)
OECD (five rich countries)
OECD (poorest quartile of countries)
Sources: Couttolenc, Dias, and Nicolella 2004, with data from AMS surveys (IBGE 2002, 2006, 2010); (OECD 2011) IBGE 2009.
Note: CT = computerized tomography, MOH = Ministry of Health, MRI = magnetic resonance imaging, OECD = Organisation
for Economic Co-operation and Development, SUS = Sistema Único de Saúde.
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hospitals were less efficient than private ones (mean score of 0.29 and 0.39,
respectively), but both were, on average, quite inefficient. The main factors contributing to inefficiency were small scale of operations, high use of human
resources, and low use of installed capacity and technical resources. The
­governance model and payment mechanisms also affected efficiency.
Most Brazilian hospitals are too small to operate efficiently: 65 percent have
fewer than 50 beds, and only 13 percent have 100 beds or more, while the international literature and La Forgia and Couttolenc (2008) have found that efficient
hospitals tend to be have more than 200 beds. The large number of small
­hospitals in Brazil is to some extent the result of a deliberate SUS policy to
extend access to hospital care in smaller cities by building a large number of
small municipal hospitals. Between 1985 and 1999, some 1,200 new public
­hospitals were built—mostly municipal—and the average size dropped from 94
to 55 beds (IBGE 2002, 2006, 2010).
The mean bed occupancy rate in Brazil is very low and an important source
of inefficiency and waste. La Forgia and Couttolenc (2008) found that the bed
occupancy rate among SUS hospitals was 37 percent for acute care hospitals and
45 percent for all hospitals (compared with the level recommended by the
Ministry of Health of 75–85 percent and international averages of around
70–75 percent). Many hospitals had a bed occupancy rate below 25 percent. As
shown in figure 3.18, low bed occupancy rates have been an issue in SUS
­hospitals for many years, although they improved gradually in the 2000s.
Hospital technical resources are also underutilized. For instance, the mean
number of surgeries performed per operating theater in Brazil was 0.66 per
working day (La Forgia and Couttolenc 2008); this means that operating rooms
Figure 3.18 Bed Occupancy Rate in SUS Hospitals in Brazil, 1992–2010
50
40
30
20
10
09
20
08
20
07
20
06
20
05
20
03
20
02
20
01
20
00
20
99
20
98
19
97
19
96
19
95
19
94
19
93
19
19
0
92
10
19
Percentage of all beds occupied
60
Source: Ministry of Health, DATASUS data.
Note: SUS = Sistema Único de Saúde. Figure is for all SUS hospitals, both acute and chronic care; the rate for acute care
hospitals is about 10 percentage points lower.
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Have the SUS Reforms Led to Better Outcomes?
in the typical Brazilian hospital are not used 85 percent of the time. In fact, such
low use of available infrastructure and resources hides two quite different realities: a small number of large referral hospitals are heavily used, as reflected in
long lines and crowded rooms and corridors, while most small hospitals are
hardly used at all. Since most Brazilians tend to bypass small local hospitals and
seek care at large regional facilities, the policy to extend access through a large
network of small hospitals has proved ineffective and costly.
It is unclear whether the bed occupancy rate was affected by the expansion
and strengthening of primary health care in the mid-1990s and the ceiling
defined for inpatient admissions, since at the same time some 500 new—mostly
small—hospitals were built. Also, part of hospitals’ inefficiency is a result of
­ineffective primary care and poor referral mechanisms. For instance, two studies
estimated the proportion of hospital admissions for conditions sensitive to
­outpatient care within the SUS at close to 30 percent; in comparison, studies in
Spain and the United States found much lower proportions (8–18 and
13–16 percent, respectively).15 The use of hospital infrastructure for unneeded
admissions is clearly related to the absence of functioning, effective health care
networks.
Has the Health System Improved Health Outcomes?
Ensuring broad-based access to effective health services was a key concern of the
SUS reforms. However, as noted in chapter 1, the ultimate goal of health systems
is to improve the level and distribution of health outcomes, to ensure that financing of health care is affordable and equitable, and to achieve high levels of
responsiveness and satisfaction.
While the SUS founding legislation did not define any specific target for
health outcomes, the reforms were expected to improve health outcomes and
reduce inequalities. Available data suggest that many health outcomes have
indeed improved over time and that outcomes have converged across geographic
areas and socioeconomic groups.
Improved Health Outcomes, with Some Caveats
First, life expectancy at birth increased 9.8 years or 15.5 percent,16 from
63.3 years in 1985 to 73.1 in 2009 (figure 3.19). Second, infant mortality
decreased 71.3 percent, from 60.3 to 17.3 deaths per 1,000 live births. Child
mortality (deaths of children under age five per 1,000 live births) dropped
57.6 percent between 1990 and 2008, and mortality from acute diarrhea among
children younger than five years old dropped 71.5 percent between 1990 and
2007 (from 12.3 to 3.5 deaths per 1,000 live births; figure 3.20). According to
Ministry of Health projections, Brazil should achieve the Millennium
Development Goals for infant and child mortality three years ahead of the 2015
deadline (Ministry of Health 2010b).
Comparing the progress in outcome indicators with that of other countries
sheds additional light on the issue. Since 1985, life expectancy and infant
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Life expectancy at birth (years)
80
140
SUS
70
120
60
100
50
80
40
60
30
40
20
20
10
0
1960
1970
1980
1985
1990
Life expectancy
1995
2000
Infant mortality
2005
2009
Number of infant deaths per 1,000
live births
Figure 3.19 Long-Term Trends in Life Expectancy and Infant Mortality in Brazil, 1960–2009
0
Sources: IBGE 2009 Ministry of Health, SUS 2011.
Note: SUS = Sistema Único de Saúde.
Figure 3.20 Child Mortality and Mortality by Acute Diarrhea among Children Younger Than
Five Years Old in Brazil, 1990–2008
Number of deaths per 1,000 live births
60
50
40
30
20
10
0
1990
1995
Child mortality
2000
2005
Mortality by acute diarrhea
2007–08
Sources: Ministry of Health data (Ministry of Health, SVS 2011) for mortality by diarrhea and World Health Organization health
statistics (WHO 2010) for child mortality.
mortality have improved more than twice as much as in the average country in
Latin America and the Caribbean (table 3.1). Among select countries of similar
income level,17 only Peru and Turkey increased life expectancy and reduced
infant mortality more (around 16.5 percent for life expectancy and 76 percent
for infant mortality).
However, other indicators paint a less positive picture. For maternal mortality,
official figures indicate a high and stagnant rate in the last 20 years, around 50
deaths per 100,000 live births, in a country where more than 90 percent of births
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Table 3.1 Change in Health Outcomes in Brazil and Comparable Countries, 1985–2009
percentage change
Country or group of countries
Brazil
Latin America and the Caribbean
Middle-income countries
China and India
Best performers in groupa
Life expectancy
Infant mortality
15.5
7.1
6.1
11.1
16.5
−71.3
−33.2
−28.5
−60.5
−76.3
Sources: IBGE 2004; Ministry of Health data (Ministry of Health, SVS 2011); World Bank 2011.
a. Best performers are Peru and Turkey.
Number of maternal deaths per 100,000
live births
Figure 3.21 Maternal Mortality in Brazil and Latin America and the Caribbean, 1990–2009
160
140
120
100
80
60
40
20
0
1990
1995
2000
Latin America and the Caribbean average
Ministry of Health estimate
2005
2009
World Bank estimate
Reported
Sources: Ministry of Health, SVS 2011 and previous years; World Bank 2011.
take place in a hospital setting. In comparison with other countries, Brazil’s
adjusted rate runs below the regional average, but is twice as high or more as in
Chile and Turkey (26), Malaysia (31), or China and the Russian Federation
­(38–39).18 Brazil is unlikely to meet the Millennium Development Goal for
maternal mortality (35 deaths per 100,000 live births). However, focused studies
suggest that the apparent stagnation of the maternal mortality rate may be the
result of improvements in the identification and recording of maternal deaths.19
Adjusted estimates based on regression techniques, by both the Ministry of Health
and the World Bank, show significant reductions in maternal deaths over the last
20 years, from 140 to 75 deaths per 100,000 live births (figure 3.21).20 However,
even based on these estimates, the maternal mortality rate remains r­ elatively high.
Some preventable causes of mortality or morbidity are on the rise. Dengue
and malaria, for instance, fluctuate widely year-to-year without showing signs of
being under effective control. Mortality from traffic accidents declined between
1996 and 2000, but has remained stable or increased since then, at around
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Have the SUS Reforms Led to Better Outcomes?
18.5 deaths per 1 million population (Ministry of Health 2010b). Mortality from
homicides doubled, from 14 deaths per 100,000 population in 1980 to 28 in
2006 and has decreased slightly since then.
Inequalities in Health Outcomes
Life expectancy, infant mortality, and other outcomes improved substantially in
all states, but at quite different speeds. Geographic inequalities in health outcomes were significantly reduced, with northeastern states benefiting the most
(Bahia, Ceará, Pernambuco, Piauí, and Rio Grande do Norte). These states had
the lowest baseline values. Gains in life expectancy varied from 6.2 years in
Pernambuco to 3.3 in Amapá, with an average of 4.6 (figure 3.22). The mean
deviation in life expectancy decreased from 2.35 years to 1.90. The same is true
of infant mortality, although the best-performing states are not exactly the same.
The reduction in mean deviation was even greater: from 14.49 to 6.05 deaths
per 1,000 live births. The poorer northeastern and northern regions experienced
the largest reductions, although they continue to have higher rates (figure 3.23).
The achievement of nearly full child immunization coverage in all regions,
improvements in child nutrition (which were more pronounced in the
Northeast), and implementation and coverage of the ESF and other programs
that prioritized poor regions and population groups contributed to this trend, as
mentioned elsewhere in this report.
Figure 3.24 further illustrates these trends, this time across regions. The difference between the regions with the highest and the lowest infant mortality
rates—Northeast and South—dropped from 3:1 to 2:1 during the period.
Disparities in health outcomes have been reduced not only geographically, but
also across socioeconomic groups. For instance, figure 3.25 shows that the
reduction in the infant mortality rate was much greater among low-income
­
groups, contributing to the convergence of different income groups to around
20 deaths out of 1,000 live births by the mid-2000s.
Has the SUS Contributed to Improved Health Outcomes?
While the improved outcomes and lower inequalities in health are good news,
these gains are attributable at least in part to developments outside the health
system: access to safe water and sanitation, quality food and education, and the
economic situation of households.21 Nearly a quarter of the population is
­covered by private insurance and another 15 percent do not use the SUS as their
regular source of care, which complicates the picture further. Finally, several
broad public health programs that are linked only partially to the SUS reforms
have also contributed to improvements. These include, for example, a Ministry of
Health program promoting breast-feeding, which was initiated in 1981. As a
result of this program, the mean duration of breast-feeding increased from
2.5 months in the mid-1970s to 14 months in 2006–07 (Victora et al. 2011).
Have the SUS reforms contributed to improving health outcomes? This is
very difficult to answer with certainty because reforms were implemented
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83
an
hã
o
Pi (2
au 24
Ce í (2 )
ar 37
á )
To Bah (30
ca ia 5)
nt (3
Pe Se ins 11)
rn rgi (3
am pe 11
bu (3 )
Ri
o
Pa co 19)
Gr
an A raíb (335
de lag a ( )
do oa 348
No s (3 )
rte 51
)
Pa (35
rá 9)
M
G
at o (4
o iá 14
G
Am ros s (4 )
5
M
az so 8)
at
on (48
o
Gr A as 2
os m (4 )
s a
M o d pá 95)
in o (5
Es as Su 07
pí Ge l ( )
rit ra 51
o is 8)
Sa (5
n 1
Pa to 8)
ra (53
ná 4
)
Sa Ro Acr (608
nt nd e ( )
a C ôn 61
at ia 7)
Ri
a (
o
Gr Ro rin 637
an râ a ( )
Ri de im 678
o d a( )
de o 68
S
Di S Jan ul (6 9)
st ã ei 9
rit o ro 7)
o Pa (7
Fe u 7
de lo 9)
ra (86
l ( 2)
1,
06
8)
ar
M
Number of deaths per 1,000 live births
hã
o
Pi (2
au 24
Ce í (2 )
ar 37
á )
To Bah (30
ca ia 5)
nt (3
Pe Se ins 11)
rn rgi (3
am pe 11
bu (3 )
Ri
o
Pa co 19)
Gr
an A raíb (335
de lag a ( )
do oa 348
No s (3 )
rte 51
)
Pa (35
rá 9)
M
G
at o (4
o iá 14
G
Am ros s (4 )
5
M
az so 8)
at
on (48
o
Gr A as 2
os m (4 )
s a
M o d pá 95)
in o (5
Es as Su 07
pí Ge l ( )
rit ra 51
o is 8)
Sa (5
n 1
Pa to 8)
ra (53
ná 4
)
Sa Ro Acr (608
nt nd e ( )
a C ôn 61
at ia 7)
Ri
a (
o
Gr Ro rin 637
an râ a ( )
Ri de im 678
o d a( )
de o 68
S
Di S Jan ul (6 9)
st ã ei 9
rit o ro 7)
o Pa (7
Fe u 7
de lo 9)
ra (86
l ( 2)
1,
06
8)
an
ar
M
Life expectancy at birth (years)
84
Have the SUS Reforms Led to Better Outcomes?
Figure 3.22 Life Expectancy and Infant Mortality in Brazil, by State, 1994 (or 1995) and 2007 (or 2009)
a. Life expectancy
80
70
60
50
40
30
20
10
0
State (average income per capita, R$)
1995
2009
b. Infant mortality
90
80
70
60
50
40
30
20
10
0
State (average income per capita, R$)
1994
2007
Source: Couttolenc 2011, based on Ministry of Health data.
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Figure 3.23 Link between Health Outcomes and Average Income per Capita in Brazil,
1994 (or 1995) and 2007 (or 2009)
a. Life expectancy
Life expectancy at birth (years)
78
76
74
72
70
68
66
64
62
60
0
500
1,000
1,500
Average monthly income per capita (R$)
1995
2009
Number of deaths per 1,000 live births
b. Infant mortality
90
80
70
60
50
40
30
20
10
0
500
1,000
1,500
Average monthly income per capita (R$)
1994
2007
Sources: Ministry of Health, DATASUS data for life expectancy and infant mortality; IPEAData from IBGE for state income.
nationwide and the quality and consistency of administrative data from the
­program are problematic. There is, however, some convincing evidence from
studies of avoidable mortality and evaluations of the ESF that the SUS has played
an important role in improving health outcomes.
Avoidable Mortality
One way to identify the contribution of the health system in improving health
outcomes is to look at trends in avoidable (or amenable) mortality—that is,
deaths that could have been avoided in the presence of timely and effective
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Number of deaths per 1,000 live births
Figure 3.24 Infant Mortality in Brazil, by Region, 1997–2007
55
50
45
40
35
30
25
20
15
10
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Northeast
North
Brazil
Center-West
Southeast
South
Source: Rocha 2011, based on Ministry of Health data.
Figure 3.25 Infant Mortality in Brazil, by Income Group, 1990–2006
Number of deaths per 1,000 live births
10
8
6
4
2
0
1990
1992
1994
1996
1998
Less than 0.5 times the minimum wage
0.5–1 times the minimum wage
1–3 times the minimum wage
2000
2002
2004
2006
3–5 times the minimum wage
5 or more times the minimum wage
Source: IBGE, PNAD for various years.
health care. This approach is based on data from national death registers, which
record the cause of death based on standardized classifications of disease.22
Mortality from specific conditions is then defined as avoidable, and this permits
an analysis of trends and patterns (for example, variation between countries or
regions) of mortality that could have been avoided. The premise of this analysis
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Have the SUS Reforms Led to Better Outcomes?
is that improvements or spatial differences in the coverage or effectiveness of the
health system over time will be reflected in the data on avoidable mortality.23
Various studies of avoidable mortality in Brazil suggest that the SUS has
played an important role in improving outcomes. For instance, Malta et al.
(2010) examined trends in avoidable mortality in infants (children under one
year of age) during the period of 1997–2006. They found a significant decline
in both avoidable deaths (37 percent) and deaths from ill-defined causes
(75 percent), indicating improved access to health care, but stable mortality
from other causes (a reduction of 2.2 percent). This is likely to be driven at
least in part by improvements in coverage and quality of the health system. For
instance, mortality from pneumonia fell 52.7 percent, with effective primary
care likely to have played an important role. However, other factors, particularly improvements in living conditions and public health interventions that
affect the incidence of ­different health conditions, are also likely to have played
a role. While the study presents a positive picture of the health system overall,
it also reports an increase of 28 percent in mortality avoidable through adequate prenatal care. This is hard to reconcile with improvements in coverage of
prenatal care, but the authors speculate that poor quality of prenatal care may
have played a role.24
Along similar lines, Abreu, Cesar, and Franca (2007) studied trends in avoidable mortality for children and adults between 1983 and 2002, using data from
117 municipalities. Comparing the periods 1983–92 and 1993–2002, they found
that avoidable mortality declined significantly, while mortality from other causes
remained stable. They also noted a significant difference between women and
men, with ischemic heart disease accounting for most of this difference (there is
also a large gender difference in mortality from other causes, most likely the
result of different rates of death due to violence and accidents; see also Abreu,
Cesar, and Franca 2009).
The studies of avoidable mortality in Brazil are unfortunately not comparable
with the studies from OECD countries, so international comparisons are not
possible at this point. However, the significant decline in avoidable mortality over
the last couple of decades indicates that the geographic expansion of the health
system and the increased focus on primary care are contributing to improved
health outcomes, although other factors may also be playing a role.
Impact of the ESF on Health Outcomes
Evaluations of the ESF provide another piece of the puzzle. An early evaluation
of the ESF (Ministry of Health 2000), which surveyed the 1,219 municipalities
that had implemented the program as of 1998, found that the ESF was associated with a dramatic increase in health promotion and prevention activities,
including prenatal care, family planning, cancer screening, and chronic disease
management.25 However, simple comparisons between municipalities with and
without ESF are problematic, as the rollout and expansion of the program have,
to some extent, been systematically related to local conditions (health needs,
economic development, political circumstances, and so forth). Moreover, the
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Have the SUS Reforms Led to Better Outcomes?
impact of the program is likely to depend on how long it has been implemented
and the level of coverage achieved.
World Bank (2002) made an early attempt to deal with these issues in evaluating the impact of the ESF. The study compared changes in outcomes between
1995 and 1998 for municipalities with and without the ESF, finding some evidence that the ESF was reducing infant mortality rates and hospital
admissions.
More recent studies have been able to achieve larger samples and use longer
time periods to study the program. For instance, Macinko et al. (2006) found that
implementation of the ESF was associated with significant reductions in infant
mortality, diarrhea incidence among children, hospitalization for strokes, and
acute respiratory infections in the period between 1990 and 2002. For example,
a 10 percent increase in ESF coverage was associated with a 4.5 percent decrease
(p < 0.01) in the infant mortality rate. Along similar lines, Aquino, Oliveira, and
Barreto (2009), using data from 1996 to 2004, found reductions in the infant
mortality rate ranging from 13 to 22 percent depending on the level of coverage
(coverage of less than 30, 30–69.9, or 70 percent or more).
Rocha and Soares (2009) used both administrative and survey data to study
the impact of the ESF on health outcomes (mortality) and household behaviors
(schooling, fertility, and labor supply). They also found a significant impact on
health, with eight years of implementation being associated with a 20 percent
reduction in infant mortality. They reported notable heterogeneity in impact,
with large and significant reductions in infant mortality in the North and
Northeast and no significant impacts in other parts of the country.26
Given how the ESF has been implemented, it is impossible to determine the
impact of the program with certainty. Nonetheless, taken together, these studies
provide a strong indication that the rollout of the ESF has contributed to a reduction in mortality, in particular among children and in the North and Northeast.
Out-of-Pocket Payments and Financial Protection
The principle of universality is related not only to the use of services, but also to
the extent that individuals are able to access services without financial distress.
Hence, effective financial protection is considered an important goal and one of
the criteria against which the performance of a health system is typically measured.
Progress with regard to financial protection is typically assessed using data on
household health spending over a defined period (for example, one month)
based on household surveys that record expenditures on both private health
insurance and direct out-of-pocket payments for drugs, health services from
private providers, or copayments in public facilities (in cases where such
­
­co-payments are levied).
As noted in chapter 2, private spending still accounts for a significant share of
overall health spending. While the share of private spending on health is an
important variable, it is not necessarily the best guide for assessing the burden
that households face in paying for health care. For this, detailed analysis of
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Have the SUS Reforms Led to Better Outcomes?
Figure 3.26 Share of the Household Budget Spent on Health in Brazil, 1987–2003
a. Household spending
Health care as a percentage of household
consumption spending
Health care as a percentage of total
household spending
7
6
5
4
3
2
1
0
1987/88
1995/96
2002/03
2008/09
11 metropolitan areas
National sample
11 metropolitan areas excluding private plans
b. Consumption spending
8
7
6
5
4
3
2
1
0
1
2
3
4 5 6 7 8
Income decile
1987/88
1995/96
9 10
2002/03
Sources: Estimates from 11 metropolitan areas and disaggregations by decile are from Diniz et al. 2007; National estimates are from POF
survey reports (IBGE 2002, 2010).
­ ousehold survey data provide a more meaningful perspective, as it allows an
h
assessment of how health expenditures relate to income and how they are distributed across households.
Available household survey data (Pesquisa dos Orçamentos Familiares, POF),
which offer data points ranging from 1987 to 2008, suggest that there has been
little change over time in the share of total household spending dedicated to
health, with estimates ranging from 5 to 7 percent (figure 3.26). There was a
notable increase in the burden of spending between 1987 and 1995, but this
trend was reversed between 1995 and 2002. While the share of total household
spending dedicated to health was similar across the income distribution in
1987–88 and 1995–96, the share of household spending on health at the lower
end of the income distribution declined notably in 2002–03.
While household spending on health remained stable as a share of the
­household budget over the last 20 years, the composition of spending changed
dramatically (figure 3.27). Charges for services (consultations, hospitalization,
and dental care) accounted for more than half of spending in 1987–88, but this
share declined to 20 percent in 2008–09. Over the same period, spending on
private plans (in particular between 1987 and 1995) and on drugs rose. Indeed,
the rise in spending on private plans accounts for most of the rise in the share of
the household budget spent on health in the early 1990s, with drugs playing an
important role in the late 1990s and 2000s.
Of course, the composition of household spending on health and its change
over time vary significantly across socioeconomic groups. For the bottom deciles
of the income distribution, spending on drugs accounts for between 60 and
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Figure 3.27 Composition of Household Spending on Health in Brazil, 1987–2009
Percentage of household health spending
50
40
30
20
10
0
1987/88
1995/96
Drugs
Dental care
Consultation, outpatient
2002/03
2008/09
Other
Health plans
Hospitalization, surgery
Sources: All estimates are from the Pesquisa dos Orçamentos Familiares (POF). Data for 1987–88 and 1995–96 are from Medici
2003; data for subsequent years are from POF survey reports (IBGE 2002, 2010).
70 percent of total health spending, while spending on private health plans
accounts for only 5–10 percent. Conversely, at the upper end of the income
distribution, 35–45 percent of total health spending is on private health plans,
while only 25–35 percent is on drugs (figure 3.28). While the share of health
spending on private plans has a strong income gradient, it increased notably
across the income distribution between 1987 and 1995.
The average share of health spending in total consumption provides an
­important perspective on the burden of health expenditures for households, in
particular, on whether a large share of it is in the form of out-of-pocket spending.
However, the distribution of spending across households also matters, in particular, the extent to which some households spend a very large share of their income
on health (referred to as “catastrophic health expenditures”).27 Because estimates
of catastrophic spending depend critically on methodological choices (how
income or disposable income is defined and the cutoff for catastrophic spending
that is applied) and on the data at hand (in particular the comprehensiveness of
income and health spending measures), there is a wide range of estimates for Brazil.
Perhaps the most systematic effort to assess the incidence of catastrophic
health is a study by Diniz et al. (2007), based on data from the POF.28 Using a
cutoff of 40 percent and total income minus food expenditures as a measure of
disposable income, they found an incidence of catastrophic spending of
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Figure 3.28 Household Spending on Drugs and Private Health Plans in Brazil,
by Income Distribution, 1987–2003
a. Drugs
Percentage of total health spending
90
80
70
60
50
40
30
20
10
0
1
2
3
4
1987/88
5
6
7
Income decile
1995/96
8
9
10
2002/03
b. Private health plans
50
Percentage of total health spending
45
40
35
30
25
20
15
10
5
0
1
2
3
4
1987/88
5
6
7
Income decile
1995/96
8
9
10
2002/03
Sources: Diniz et al. 2007, based on the Pesquisa dos Orçamentos Familiares (POF) (using a consistent subsample from
11 metropolitan areas).
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Figure 3.29 Incidence of Catastrophic Spending on Health in Select Latin American
Countries, Various Years, 2002–08
Catastrophic spending as percentage
of household spending
16
14
12
10
8
6
4
2
ru
ua
Ar dor
Do
ge
m
nt
in
ica
in
a
n
Re
pu
Ni bl
ca ic
ra
gu
Gu
a
at
em
al
a
Ch
ile
Pe
Ec
bi
a
Bo
liv
ia
ico
om
il
az
ex
Br
M
Co
l
Co
st
aR
ica
0
Source: Data from Knaul et al. 2011.
Note: Data for Brazil are for 2002–03. Data for other countries are for various years ranging from 2002 to 2008.
2.2 ­
percent if all household health spending is considered and 1.9 percent
if spending on private plans is excluded. No studies provide evidence on how
the incidence of catastrophic spending has evolved over time.
Using the same data for Brazil, but a slightly different approach, Knaul et al.
(2011) compared the incidence of catastrophic spending in 12 countries in the
Latin America and Caribbean region. They found that Brazil has one of the
­lowest levels of catastrophic spending in the region (figure 3.29). Similar to many
other countries in the region, catastrophic spending is significantly higher among
poorer households and households with elderly members.
The finding of comparatively low levels of catastrophic spending in Brazil is
in stark contrast to that of an earlier study by Xu et al. (2003), which found that
the incidence of catastrophic spending in Brazil—estimated at 10.3 percent—
was the second highest among the 59 countries in the study. This high level of
catastrophic spending is likely to be an artifact of the data used, and subsequent
studies have been unable to replicate the findings using nationally representative
data (see Diniz et al. 2007).29 Hence, there are good reasons to believe that catastrophic health spending in Brazil is low both in absolute terms and relative to
that of other countries in the region.30
Overall, there is no clear evidence that the share of health in total household
spending has been declining over time. The incidence of catastrophic spending
appears to be relatively low in Brazil, but health spending undoubtedly continues
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to be a significant burden for many Brazilian households. A large share of this
burden is due to spending on private health plans and drugs.
In the case of private health plans, these expenditures are voluntary and
comprise a prepayment of health expenditures incurred at a later date.
However, households with insurance plans do not necessarily have a lower
incidence of catastrophic health spending; if anything, the opposite is true
(Barros, Bastos, and Damaso 2011; Bos and Waters 2008; Knaul et al. 2011).
The primary function of private plans seems to be to ensure timely access to
health services and perhaps higher quality. High demand for private plans indicates that the SUS is failing to deliver on some of its promises and raises important equity concerns. Private plans may also suffer from moral hazard on both
the demand and supply sides, such that not all services provided are appropriate and necessary. Insofar as this is the case, high levels of private spending on
health plans raise efficiency concerns.
The government has taken many measures to reduce household spending on
drugs, introducing the National Medicines Policy in 1998, gradually expanding
the Popular Pharmacies Program since 2004, and steadily increasing government
spending on pharmaceuticals (Vieira 2009). These strategies appear to be working. In real terms, household spending on drugs declined between 1995 and 2002,
from R$73 to R$53, and then increased slightly to R$59 in 2008 (Garcia et al.
2011).31 Moreover, at least in areas where the population has good access to the
SUS, the SUS provides a large share of the drugs consumed. For instance, in a
study of households covered by the ESF in Porto Alegre, Rio Grande Sul, the SUS
provided for free nearly 70 percent of all the medicine consumed (80 percent for
the bottom quintile; 31 percent for the top two quintiles; Bertoldi et al. 2011).
Nonetheless, high levels of household spending on drugs persist for a range of
reasons. First, availability of drugs in public pharmacies remains a problem
(Bertoldi et al. 2012), and studies have found that sometimes as high as 40 percent
of the drugs prescribed in public primary care were not available when needed
(Naves and Silver 2005; Santos and Nitrini 2004). Evidence from the Pesquisa
Nacional por Amostra de Domicílios (PNAD) also suggests that, although the
supply of free drugs in the SUS has increased over time, in 2008, more than half
of the drugs prescribed by SUS providers were not received for free (figure 3.30).
Second, much of drug expenditures appear to be for drugs that are not on the
SUS list of essential drugs, typically prescribed by non-SUS providers or
­self-medicated (Bertoldi et al. 2009, 2011; figure 3.31). This raises important
questions about whether the rationing of drugs in the SUS is rational and whether
drugs not on the list have demonstrated health benefits. Finally, drug prices for key
drugs appear to be comparatively high in Brazil (Bertoldi et al. 2012).
Public Perceptions of and Satisfaction with the Health System
The primary goals of the health system are to improve health outcomes and
provide financial protection. However, most people (and policy makers) also
consider satisfaction and responsiveness important intrinsic objectives. Although
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Figure 3.30 Access to Dental Care and Medications from the SUS in Brazil, 1981–2008
Percentage of population who sought care
50
40
30
20
10
0
1981
1986
1998
Dental care by SUS last year
2008
Access to free drugs
Source: IBGE, PNAD for 1981–2008.
Note: SUS = Sistema Único de Saúde. Access to dental care is defined as the proportion of individuals seeking dental care
during the previous year who were treated by an SUS dental facility or professional; access to free drugs is defined as the
proportion of SUS users prescribed medications during their last consultation who received their medications free either fully
or in part.
Figure 3.31 Drugs Paid for Out-of-Pocket in Brazil, by SUS List, Type of Prescriber, and
Use, 2008
Percentage of all purchased
medicines
70
60
50
40
30
20
10
Prescriber
In SUS list
Chronic
Acute
Included
Not included
Self
Other physician
ESF physician
0
Type of use
Source: Data from Bertoldi et al. 2009.
Note: ESF = Family Health Strategy, SUS = Sistema Único de Saúde. Percentage of all purchased medicines (which account for
41 percent of all medicines consumed), based on a sample of 2,988 individuals in Porto Alegre (30-day recall).
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important, satisfaction and responsiveness are difficult to measure in systematic
and consistent ways.
This section does not aim to provide a comprehensive review of the literature
on satisfaction with the health system in Brazil. However, recent opinion polls
provide an important perspective on current health system challenges. For
instance, a study by the National Confederation of Industry (Confederação
Nacional da Indústria, CNI) reports that 61 percent of the population consider
public health services to be bad or terrible, with 85 percent seeing no change or
a worsening over the last three years (CNI 2012).32 The problems that are most
commonly reported are delay in access or treatment and lack of doctors. The
main strike against public hospitals, which were rated worse than private
­hospitals, is waiting times for consultations and for exams.
A recent survey by Datafolha reached similar conclusions (Folha de São Paulo
2012). According to the study, a growing share of the population considers
health to be the “main problem in the country” (39 percent), up from 28 percent
in 2010 and significantly higher than in the early 2000s.33
In contrast, a study by the Institute of Applied Economic Research (Instituto
de Pesquisa Econômica Aplicada, IPEA) (IPEA 2011) provides a more positive
assessment, with only 28.5 percent of users thinking that SUS services are bad or
very bad (28.9 percent found them good or very good). The study found some
variation across different parts of the SUS, with the ESF receiving the most positive assessment and basic care units and emergency care being considered the
worst. In terms of key problems, the survey responses resonate with the findings
of other studies, highlighting the lack of doctors and long waiting times for hospital or referral services as key concerns. However, the survey also found that
many individuals consider having a private health plan as very important, with
getting more rapid access to services being the most important reason. A similar
finding was reported in a study that sampled 1,626 individuals with health plans
and 1,627 individuals without plans (IESS 2011). Nearly all sampled individuals
without health plans (88 percent) considered having a plan as “important” or
“very important.” When asked to rank health plans among 12 other assets, goods,
or services, health plans were ranked second, ahead of a car, life insurance, new
household appliances, and a computer, with “own house” being the only item
ranked as more important.
Opinion polls are often based on relatively small samples, and answers tend to
be very sensitive to how questions are asked. Results should therefore be treated
with some care. Moreover, some surveys are not able to distinguish dissatisfaction
with the SUS from satisfaction with the broader health system, including private
health plans and providers. Nonetheless, the findings from several polls reveal a
high level of dissatisfaction with the SUS and highlight problems related to
access and long waiting times as key issues, factors that contribute to the
continued (perhaps growing) demand for private health insurance.34 These
­
results have to be contrasted with more positive assessments in other surveys.
Of course, given the nearly limitless demand for health care, all countries
struggle to meet expectations. Yet dissatisfaction with the health system is
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Figure 3.32 Satisfaction with the Health System in Select Countries, by GDP per Capita, 2010
100
Percentage of respondents saying they are
satisfied with the health system
90
80
Thailand
Philippines
Malaysia
Uruguay
Korea, Rep.
70 Nicaragua
Argentina
El
Salvador
Portugal
Vietnam
Turkey
60 Honduras
Guatemala Ecuador
Colombia
South Africa
BoliviaParaguay China
Mexico
50
Poland
Pakistan
Brazil Chile
Peru
India
40
Russian Federation
30
20
10
0
800
3,200
12,800
51,200
GDP per capita in 2010 (US$), logarithmic scale
Sources: Data on satisfaction with the health system from the Gallup World Poll; data on GDP from World Bank 2010.
Note: GDP = gross domestic product.
­ articularly high in Brazil.35 In a recently conducted round of the Gallup World
p
Poll, which asked randomly selected households across a wide range of countries
about their satisfaction with public services and other issues, only 40 percent of
Brazilians were satisfied with the health system. This is significantly lower than
in many other middle-income countries that have achieved or made significant
strides toward universal coverage in recent years (for example, Malaysia,
Thailand, Turkey, or Uruguay; figure 3.32).
Notes
1.Through the 1970s and 1980s, INAMPS gradually expanded its coverage from the
initial target group of workers employed in the urban formal sector by including rural
workers (1969–71) and then domestic and self-employed workers (1972–73) and by
dropping the requirement to present a Social Security card to be treated in its
network.
2.There are large variations in the data regarding coverage over the years. For example,
data on private health insurance fluctuated when the regulatory agency (Agência
Nacional de Saúde Suplementar, ANS) was established and began collecting sector
data in 2000; the ANS does not collect data on self-managed plans offered directly by
employers through their human resource or other department. These types of plans
largely cover civil servants, who account for some 10 million workers and dependents.
Another discontinuity in the data appears in the proportion of out-of-pocket expenditures between 1981 and 1986 (20 and 34 percent, respectively).
3.The figures for medical consultation and basic care are not exactly comparable over
time due to changes in classification in SUS information systems; however, these
changes do not affect significantly the general trends observed. The high and rising
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number of primary health care procedures per capita reflects not only the increase in
coverage and supply, but also the increasing detail in recording and counting the
­different types of services provided. More than 1,000 procedures are recorded and
counted, including medical and other professional consultations, home visits and
outreach activities, treatments and therapies, drug administration, immunizations,
diagnostic tests, and others. The list was substantially changed in 1999, which makes
comparisons over time imprecise.
4.OECD health data for 2011 and Word Bank, World Development Indicators for
­various years.
5.IBGE’s annual household survey (Pesquisa Nacional por Amostra de Domicílios,
PNAD) is the main source of data on this issue, but they suffer from some inconsistency in the definition of variables over the years. Specifically, computing and comparing the proportion of people seeking (or not seeking) care when ill is not possible
since the PNAD of 1986 defined sickness as “having a health problem in the last two
weeks,” while the surveys since 1998 defined it as “having to interrupt daily activities
due to a health problem.” To address this problem, we computed the proportion of
people who did not seek care when they felt they needed it, excluding those who
did not seek care because they felt they did not need it; although this approach is
not rigorous or precise, it provides the best approach to estimating general difficulties related to access. For a detailed discussion, see Osorio, Servo, and Piola (2011).
6.The relative importance of these reasons varies widely across states. For instance, distance and transportation are important in the low-density states of the northern
region, while economic reasons are more important in poorer states (but this is where
they decreased most in importance). Reasons related to facility characteristics were
consistently more important in the richer states of the Southeast, South, and
Center-West.
7.Late diagnosis (stages three and four) was even more common for certain forms of
cancer, such as lung cancer.
8.Hospital registry data present a slightly different picture, with a median waiting time
of 70.3 days and 38.4 percent of patients waiting less than 30 days. The registries are
intended to be national in scope, but currently only cover certain states and selected
hospitals. More than 80 percent of the data come from Minas Gerais, Paraná, Rio de
Janeiro, Rio Grande do Sul, and Santa Catarina. There are also serious data quality
issues.
9.Based on norms established in Portaria SAS/MS 741/2005, indicating the expected
number of cancer patients requiring surgery, chemotherapy, and radiation therapy, the
report finds a deficit in treatment capacity, with significant geographic differences.
The volume of services is also lower than needed as defined by the norms, with the
SUS only supplying 66 percent of needed radiation therapy procedures and 34.5
percent of needed cancer surgeries.
10.At one level, this is likely to be an overestimate, as some patients may have been waiting for a shorter period. However, the data do not include patients who were unable
to secure a referral or who gave up trying to access specialist care.
11.The concept of “effective coverage” has been coined to capture both the access and
quality dimensions, referring to the extent to which potential health gains are
realized.
12.Quality assurance programs are numerous in Brazil. For instance, several major
­hospital accreditation systems are in place: the National Accreditation Organization
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(Organização Nacional de Acreditação); the hospital quality assurance initiative
sponsored by the Medical Association of São Paulo (Controle da Qualidade
­
Hospitalar); the Brazilian accreditation initiative (Consórcio Brasileiro de Acreditação)
supported by the U.S. Joint Commission on Accreditation of Healthcare Organizations;
and the National Quality Award (Premio Nacional da Qualidade), a multisector quality assurance initiative of the National Quality Foundation. In addition, the country
has among the largest number of hospitals in the United Nations Children’s Fund’s
Baby Friendly Hospital Initiative. However, quality assurance efforts tend to be unsystematic and fragmented, and there have been few evaluations of their effectiveness to
date. Currently, less than 5 percent of existing hospitals are accredited by any of these
systems. Such low buy-in appears to be related to the absence of strong incentives for
hospitals to engage in systematic quality improvement and accreditation and to the
absence of systematic and coherent national policies on the issue.
13.In 1980, INAMPS reduced the amount reimbursed for a Cesarean section, which used
to be higher than for normal deliveries; the SUS established a ceiling of 40 percent in
the proportion of Cesarean sections in 1998 and then reduced it to 30 percent in 2000
(Victora et al. 2011).
14.There are, of course, broader allocative issues—for example, concerning the balance
between prevention (including activities outside the health sector) and curative
­services. This issue is difficult to tackle at the health system level, but can usefully be
addressed in relation to specific conditions or health risks. It is not addressed in this
report given the limited evidence that is available.
15.For Brazil, Couttolenc, Dias, and Nicolella (2004); La Forgia and Couttolenc (2008);
and SES-MG (2005). For Spain, Caminal, Starfield, and Sanchez (2004). For the
United States, Vali (2001) and Axene and McQuillian (1999).
16.Using data from the World Bank (2010) changes the numbers a bit (an increase of
12.8 percent), but not the trend.
17.The reference countries include five from Latin America (Argentina, Chile, Colombia,
Mexico, and Peru), the other emerging BRICS (Russia, India, China, and South
Africa), and two Asian countries (Malaysia and Thailand).
18.WHO, Healthstats estimates.
19.In recent years, technical committees for the review of deaths of women in reproductive years have been established in all states, covering 40 percent of all deaths in 2009;
this effort is likely to improve reporting.
20.World Bank estimates offer rates of 120 deaths per 100,000 live births in 1985 and
58 in 2009, a decline of 51.7 percent.
21.For instance, access to safe water increased steadily from 57.8 percent of the population in 1981 to 91.5 percent in 2007, while access to sanitation increased from 37.6
to 71.6 percent during the period. Economic conditions also improved substantially
in spite of several economic crises, with mean household income per capita increasing
50.9 percent in real terms from 1981 to 2009 (from R$467,75 to R$705,72). Perhaps
more important, the proportion of individuals living in poverty (that is, with less than
one minimum wage salary per month) nearly halved.
22.The list of conditions for which mortality is considered amenable has varied significantly over time and across studies. In part, this reflects the introduction of new
technology, but also the extent to which studies have focused on personal health care
services alone or have also taken into account broader primary prevention interventions. For details, see Nolte and McKee (2003).
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23.Of course, changes in avoidable mortality reflect both changes in incidence and effectiveness of health care (treatment as well as secondary and tertiary prevention). Some
care is needed in interpreting the data. Nolte and McKee (2003) note, “Avoidable
mortality was never intended to be more than an indicator of potential weaknesses in
health care that can then be investigated in more depth.”
24.Two recent studies focusing on a cohort of children in Pelotas (Gorgot et al. 2011;
Santos et al. 2011) found that most of the mortality in children was avoidable, largely
through adequate maternal care during pregnancy (70 percent of deaths), and that
most deaths occurred in the first year of life (92 percent). The increase in premature
deaths and poor prenatal care were contributing factors. They also documented a
socioeconomic gradient, with children born to women in the lowest quintile having a
three times higher probability of dying from avoidable causes than those born to
women in the highest quintile, in part because preterm births are nearly twice as high
in the lowest quintile. Effective cessation of smoking and provision of progesterone to
high-risk women could help to reduce mortality. The increase in mortality that could
be avoided through effective prenatal care may also be partly due to an increase in
maternal conditions that affect the fetus (for example, diabetes) and improved diagnosis and more accurate classification of deaths.
25.Similar findings were reported in Ministry of Health (2008).
26.For the Northeast (and, to a lesser extent, the North), they also found a significant
impact on mortality for other age groups. Moreover, the program was associated with
significant increases in schooling and labor market participation.
27.There are various approaches to measuring the incidence of catastrophic spending
(O’Donnell et al. 2008). Xu et al. (2003) considers health spending to be catastrophic
if it accounts for more than 40 percent of disposable income, with disposable income
defined as total consumption minus spending on food (or an estimated “subsistence”
amount for households with low food spending). Other studies use total income or
consumption as a denominator, but apply a different cutoff point (typically between
5 and 20 percent). While most studies consider only direct out-of-pocket spending in
estimates of catastrophic spending, some include spending on health plans on the
grounds that these expenditures contribute to the overall burden of health spending
(for example, Bos and Waters 2008).
28. Diniz et al. (2007) is based on data for 1987–88, 1995–96, and 2002–03, but the
authors only estimate the incidence of catastrophic spending for 2002–03. The sample
design changed significantly between rounds. The 1987–88 and 1995–96 rounds
sampled the population in 11 metropolitan areas that account for approximately 30
percent of the Brazilian population; the 2002–03 sample is nationally representative.
There were also differences in the timing (and reference periods) of the different
surveys. Finally, the 2002–03 survey questionnaires included a more detailed aggregation of health spending and also captured nonmonetary spending. In order to ensure
that the data from the respective rounds were comparable, the authors worked with
a subsample of the 2002–03 survey, transformed all amounts into real values, and
mapped the spending categories in the 2002–03 survey and those used in earlier
rounds.
29.The estimates of Xu et al. (2003) are based on the 1996–97 Living Standards Survey,
which surveyed around 5,000 households in 10 geographic areas. The sample is
­considerably smaller than for the POF, and the survey is not nationally representative.
Furthermore, the measures of total consumption (denominator) only include
­expenditures; they do not capture imputed rent, home production, and other in-kind
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elements of consumption. Using the methodology of Xu et al. (2003), but with total
consumption and a 40 percent cutoff, Diniz et al. (2007) found that only 0.6 percent
of households have catastrophic spending. Using monetary income as a proxy for
expenditure—the closest they can get to the denominator used by Xu et al. (2003),
catastrophic spending is estimated at 6 percent.
30.Other studies using the same data have reached different conclusions. These differences are largely due to the way in which income (and disposable income) is
­measured. For instance, Campino (2011) found that 7 percent of households in the
lowest-income quintile had catastrophic health expenditures in 2002–03 (defined
as expenditures of 20 percent or more of household available income after
deduction of food expenditure). The proportion was higher (8 percent) in the
­
­second lowest quintile and then decreased with income to 5.7 percent in the highest
­quintile; the national average was 6.7 percent. When available income is defined as
income above the poverty line, 17 percent spend more than 20 percent of their
available income.
31.All amounts are in constant 2009 (January) prices.
32.Among those who used the SUS in the previous year, only 22 percent said that the
service was bad or terrible.
33.Security and unemployment were14 and 9 percent, respectively. As the study reports
the relative ranking of different issues, the higher ranking of health as a key problem
may reflect improvements in other areas rather than a worsening of the health
system.
34.Although some studies point in this direction, they are difficult to reconcile with
other studies that point to high levels of satisfaction. For instance, in the nationally
representative PNAD, 16 percent of those obtaining care from the SUS said that it
was “very good” and 64 percent that it was “good.”
35.While many studies tend to focus on the public system, dissatisfaction with private
plans is also high, but for different reasons. This suggests the need for effective oversight and regulation.
References
Abreu, D., C. Cesar, and E. Franca. 2007. “The Relationship between Deaths That Are
Avoidable with Adequate Health Care and the Implementation of the Unified Health
System in Brazil.” Revista Panamericana de Salud Pública 21 (5): 282–91.
———. 2009. “Gender Differences in Avoidable Mortality in Brazil (1983–2005).”
Cadernos de Saúde Pública 25 (12): 2672–82.
ANS (Agência Nacional de Saúde Suplementar). 2011. “Cadernos de informação da saúde
suplementar.” ANS, Brasilia, March.
Aquino, R., N. Oliveira, and M. Barreto. 2009. “Impact of Family Health Program on
Infant Mortality in Brazilian Municipalities.” American Journal of Public Health 99
(January): 87–93.
Axene, D., and S. McQuillian. 1999. Analysis of Potentially Avoidable Inpatient Services.
Research Paper. Radnor, PA: Milliman and Robertson.
Barros, A., J. Bastos, and A. Damaso. 2011. “Catastrophic Spending on Health Care in
Brazil: Private Health Insurance Does Not Seem to Be the Solution.” Cadernos de
Saúde Pública 27 (Suppl 2): S254–62.
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Have the SUS Reforms Led to Better Outcomes?
Bertoldi, A., A. Barros, A. Camargo, P. Hallal, S. Vandoros, A. Wagner, and D. Ross-Degnan.
2011. “Household Expenditures for Medicines and the Role of Free Medicines in the
Brazilian Public Health System.” American Journal of Public Health 101 (5): 916–21.
Bertoldi, A., A. Barros, A. Wagner, D. Ross-Degnan, and P. Hallal. 2009. “Medicine Access
and Utilization in a Population Covered by Primary Health Care in Brazil.” Health
Policy 89 (3): 295–302.
Bertoldi, A. D., A. P. Helfer, A. L. Camargo, N. U. Tavares, and P. Kanavos. 2012. “Is the
Brazilian Pharmaceutical Policy Ensuring Population Access to Essential Medicines?”
Global Health 8 (1): 6.
Bos, A. M., and H. Waters. 2008. “The Financial Protection Impact of the Public Health
System and Private Insurance in Brazil.” CEPAL Review 95 (August): 125–39.
Caminal, J., B. Starfield, and E. Sanchez. 2004. “The Role of Primary Care in Preventing
Ambulatory Care Sensitive Conditions.” European Journal of Public Health 14 (3):
246–51.
Campino, A. C. 2011. “Gastos catastróficos, iniquidade e proposta de reformulação do
sistema de saúde.” In Brasil: A nova agenda social, edited by E. Bacha and
S. Schwartzman, 104–08. Rio de Janeiro: Long Term Care.
CNI (Confederação Nacional da Indústria). 2012. Retratos da sociedade brasileira: Saúde
pública. Pesquisa CNI-IBOPE. Brasilia: CNI.
CNM (Confederação Nacional de Município). 2011. Pesquisa da CNM sobre a demanda
reprimida em saúde no Estado do Rio Grande do Sul. Brasilia.
CONASS (Conselho Nacional de Secretários de Saúde). 2003: A saúde na opinião dos
brasileiros: Um estudo prospectivo. Série Progestores. Brasilia: CONASS.
Couttolenc, B. 2011. “Taking Stock of Performance Reforms at the Sub-National Level
in Brazil: Recent Performance Gains Achieved in the Health Sector, Hypotheses on
Possible Drivers of Good and Bad Performance.” Consultant report, World Bank,
Washington, DC.
Couttolenc, B., L. Dias, and A. Nicolella. 2004. “Estudo de custos, eficiência e mecanismos
de pagamento. Fase II: Eficiência e mecanismos de pagamento. Em busca da excelência: Fortalecendo o desempenho hospitalar no Brasil.” Consultant report, World Bank,
São Paulo.
CREMESP (Conselho Regional de Medicina do Estado de São Paulo). 2004. Avaliação
das condições de funcionamento dos hospitais e pronto-socorros, 2001–2003. São Paulo:
CREMESP.
Diniz, B., L. Servo, S. Piola, and M. Eirado. 2007. “Gasto das famílias com saúde no Brasil:
Evolução e debate sobre gasto catastrófico.” In Gasto e consumo das famílias brasileiras
contemporáneas, edited by F. Faiger, L. Servo, T. Menezes, and S. Piola, 143–60. Brasilia:
Instituto de Pesquisa Econômica Aplicada.
Dourado, I., V. Oliveira, R. Aquino, P. Bonolo, M. Lima-Costa, M. Medina, E. Mota,
M. Turci, and J. Macinko. 2011. “Trends in Primary Health Care–Sensitive Conditions
in Brazil: The Role of the Family Health Program (Project ICSAP-Brazil).” Medical
Care 49 (6): 577–84.
Folha de São Paulo. 2012. “Insatisfação com a saúde sobe 11 pontos em um ano (2012).”
Folha de São Paulo, January 25.
Garcia, L., M. Stivali, L. Santana, A. Pacheco Aurea, and L. Magalhaes. 2011. “Gastos das
famílias brasilieras com medicamentos: Analyise dasa Pesquisas de Orcamentos
Twenty Years of Health System Reform in Brazil • http://dx.doi.org/10.1596/978-0-8213-9843-2
101
102
Have the SUS Reforms Led to Better Outcomes?
Familaries de 1995–1996, 2002–2003 e 2008–2009.” Presentation at the Tenth
Encontro Nacional da Economia de Saúde, Porto Alegre, October 26–28.
Gorgot, L., I. Santos, N. Valle, A. Matijasevich, A. Barros, and E. Albernaz. 2011. “Avoidable
Deaths until 48 [Corrected] Months of Age among Children from the 2004 Pelotas
Birth Cohort.” Revista de Saúde Pública 45 (2): 334–42.
IBGE (Instituto Brasileiro de Geografia e Estatística). 2002. Estatísticas da saúde:
Assistência médico-sanitária (AMS) 2002. Rio de Janeiro: IBGE. http://www.ibge.
gov–br/home/estatistica/populacao/condicaodevida/ams/ams2002.pdf.
———. 2004. “Projeção da população do Brasil por sexo e idade para o período
­1980–2050.” Revised. Diretoria de Pesquisas, Coordenação de População e Indicadores
Sociais, Gerência de Estudos e Análises da Dinâmica Demográfica, Rio de Janeiro.
———. 2006. Estatísticas da saúde: Assistência médico-sanitária (AMS) 2005. Rio de
Janeiro: IBGE. http://www.ibge.gov.br/home/estatistica/populacao/condicaodevida/
ams/2005/ams2005.pdf.
———. 2009. Indicadores sociodemográficos e de saúde no Brasil. Rio de Janeiro: IBGE.
———. 2010. Estatísticas da saúde: Assistência médico-sanitária (AMS) 2009. Rio de
Janeiro: IBGE.
———. Various years (1982–2009). Pesquisa Nacional por Amostra de Domicílios (PNAD).
Brasilia: Ministério da Fazenda, Secretaria de Política Econômica.
IESS (Instituto de Estudos de Saúde Suplementar). 2011. “Pesquisa IESS/Datafolha
aponta que o plan de saúde é uma necessidade e desejo do brasileiro.” Saúde
Suplementar em Foco, Informativo Eletrônico 2 (13).
IPEA (Instituto de Pesquisa Econômica Aplicada). 2011. Sistema de indicadores de percepção social: Saúde. Brasilia: IPEA.
Knaul, F., R. Wong, H. Arreola-Ornelas, and O. Mendez. 2011. “Household Catastrophic
Health Expenditures: A Comparative Analysis of Twelve Latin American and
Caribbean Countries.” Salud Pública Mexicana 53 (Suppl. 2): S85–95.
La Forgia, G. M., and B. F. Couttolenc. 2008. Hospital Performance in Brazil: In Search of
Excellence. Washington, DC: World Bank.
Legorreta, A., H. Chernicoff, J. Trinh, and R. Parker. 2004. “Diagnosis, Clinical Staging, and
Treatment of Breast Cancer: A Retrospective Multiyear Study of a Large Controlled
Population.” American Journal of Clinical Oncology 27 (2): 185–90.
Macinko J. 2011. “A Preliminary Assessment of the Family Health Strategy (FHS) in
Brazil.” Consultant report, World Bank, Washington, DC.
Macinko, J., C. Almeida, and P. K. de Sá. 2007. “A Rapid Assessment Methodology for the
Evaluation of Primary Care Organization and Performance in Brazil.” Health Policy
and Planning 22 (3): 167–77.
Macinko, J., F. Guanais, M. de Fatima, and M. de Souza. 2006. “Evaluation of the Impact
of the Family Health Program on Infant Mortality in Brazil, 1990–2002.” Journal of
Epidemiology and Community Health 60 (1): 13–19.
Malta, D., E. Duarte, J. Escalante, M. Almeida, L. Sardinha, and E. Macario. 2010.
“Avoidable Causes of Infant Mortality in Brazil, 1997–2006: Contributions to
Performance Evaluation of the Unified National Health System.” Cadernos de Saúde
Pública 26 (3): 481–91.
Medici, A. 2003. Family Spending on Health in Brazil: Some Indirect Evidence of the
Regressive Nature of Public Spending in Health. Technical Paper Series. Washington,
DC: Inter-American Development Bank, Sustainable Development Department.
Twenty Years of Health System Reform in Brazil • http://dx.doi.org/10.1596/978-0-8213-9843-2
Have the SUS Reforms Led to Better Outcomes?
Ministry of Health. 2000. Avaliação da implementação e funcionamento do Programa de
Saúde da Familia. Ministério da Saúde, Secretaria de Assitencia da Saúde, Coordinação
de Atenção Básica, Brasilia.
———. 2006. Programa Nacional de Avaliação de Serviços de Saúde (PNASS): Resultado
do processo avaliativo 2004–2006. Brasilia: Ministério da Saúde.
———. 2008. Saúde da família no Brasil: Uma análise de indicadores selecionados,
­1998–2005/06. Brasilia.
———. 2010a. “PCA-Tool.” Ministério da Saúde, Brasilia.
———. 2010b. Saúde Brasil 2009: Uma análise da situação de saúde e da agenda nacional
e internacional de prioridades em saúde. Brasilia.
Ministry of Health, SVS (Secretariat of Health Surveillance). 2011. “Sistema de informações sobre mortalidade.” Ministério da Saúde, Brasilia.
Naves, O., and L. Silver. 2005. “Evaluation of Pharmaceutical Assistance in Public Primary
Care in Brasilia, Brazil.” Revista de Saúde Pública 39 (2): 223–30.
Nolte, E., and M. McKee. 2003. “Measuring the Health of Nations: Analysis of Mortality
Amenable to Health Care.” British Medical Journal 327 (7424): 1129.
O’Donnell, O., E. Van Doorslaer, A. Wagstaff, and M. Lindelow. 2008. Analyzing Health
Equity Using Household Survey Data: A Guide to Techniques and Their Implementation.
Washington, DC: World Bank.
OECD (Organisation for Economic Co-operation and Development). 2003. OECD
Reviews of Health Care Systems: Korea. Paris: OECD.
———. 2011. Health at a Glance 2011. Paris: OECD.
Osorio, R., L. Servo, and S. Piola. 2011. “Unmet Health Care Needs in Brazil: An
Investigation about the Reasons for Not Seeking Health Care.” Cien Saúde Colet 16
(9): 3741–54.
Rocha, R. 2011. “Equidade no sistema de saúde brasileiro.” Consultant report, World Bank,
Washington, DC.
Rocha, R., and R. Soares. 2009. “Evaluating the Impact of Community-Based Health
Interventions: Evidence from Brazil’s Family Health Program.” Discussion Paper 4119,
IZA, Germany, Bonn.
Santos, I., A. Matijasevich, A. Barros, E. Albernaz, M. Domingues, and N. Valle. 2011.
“Avoidable Deaths in the First Four Years of Life among Children in the 2004 Pelotas
(Brazil) Birth Cohort Study.” Cadernos de Saúde Pública 27 (Suppl. 2): S185–97.
Santos, J. Jr. 2006. “Avaliação médica: O consumo na medicina e a mercantilização da
saúde.” Revista Brasileira de Coloproctologia 26 (1): 70–85.
Santos, V., and S. Nitrini. 2004. “Prescription and Patient-Care Indicators in Health Care
Services.” Revista de Saúde Pública 38 (6): 819–26.
SES-MG (Secretaria de Estado da Saúde de Minas Gerais). 2005. “Caracterização da rede
hospitalar do Sistema Único de Saúde em Minas Gerais: Estudos de políticas de saúde
e de avaliação econômica do SUS-MG.” Serviços Hospitalares 3, SES-MG, Belo
Horizonte.
TCU (Tribunal de Contas da União). 2011. Política nacional de atenção oncológica. Brasília:
TCU, Secretaria de Fiscalização e Avaliação de Programas de Governo.
Vali, F. 2001. Access to Primary Care in New Jersey: Geographic Variation of Hospitalizations
for Ambulatory Care Sensitive Conditions in 1995 and 1997. Princeton, NJ: Health
Research and Educational Trust of New Jersey.
Twenty Years of Health System Reform in Brazil • http://dx.doi.org/10.1596/978-0-8213-9843-2
103
104
Have the SUS Reforms Led to Better Outcomes?
Victora, C., E. Aquino, M. Leal, C. Monteiro, F. Barros, and C. Szwarcwald. 2011. “Saúde
de mães e crianças no Brasil: Progressos e desafios.” Série Saúde no Brasil 2. thelancet.
com (May 9): 32–46.
Vieira, F. S. 2009. “Ministry of Health’s Spending on Drugs: Program Trends from 2002 to
2007.” Revista de Saúde Publica 43 (4): 674–81.
WHO (World Health Organization). 2008. World Health Statistics 2008. Geneva: WHO.
———. 2010. World Health Statistics 2010. Geneva: WHO.
World Bank. 1994. “The Organization, Delivery, and Financing of Health Care in Brazil:
Agenda for the 1990s.” Report 12655-BR, World Bank, Washington, DC.
———. 2002. “Brazil: Maternal and Child Health.” Report 23811-BR, World Bank,
Washington, DC.
———. 2010. World Development Indicators. Washington, DC: World Bank.
———. 2011. World Development Indicators. Washington, DC: World Bank.
Xu, K., D. B. Evans, K. Kawabata, R. Zeramdini, J. Klavus, and C. J. Murray. 2003.
“Household Catastrophic Health Expenditure: A Multicountry Analysis.” Lancet 362
(9378): 111–17.
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CHAPTER 4
Conclusions
Over the last 20 years, Brazil has experienced impressive improvements in health
outcomes, with dramatic reductions in child and infant mortality and increases
in life expectancy. Equally important, geographic and socioeconomic disparities
in outcomes have become far less pronounced. Needless to say, these achievements cannot be attributed solely to improvements in the health system. Indeed,
the last 20 years have also seen continued urbanization, improved access to water
and sanitation, and, at least in the last decade, rapid economic growth and lower
income inequality.
Yet there are good reasons to believe that changes in the Unified Health
System (Sistema Único de Saúde, SUS) have played an important role. The rapid
expansion of primary care has changed the patterns of use, with a growing share
of contacts taking place in health centers and other primary care facilities. The
use of health services has risen, and the share of households reporting problems
in accessing health care for financial reasons has declined. Moreover, this report
has presented evidence that improvements in health can be attributed at least in
part to the health system, with the expansion of primary care bringing about
impressive reductions in mortality that is amenable to health care and in child
mortality. In short, the SUS reforms have at least partially achieved the goals of
universal and equitable access to health care.
Yet the report also has highlighted many challenges that remain in the SUS
and the health system more broadly. Perhaps the most significant of these relate
to the quality and coordination of care, gaps in coverage of primary care, barriers
to accessing specialist and high-complexity care, and continued high reliance on
private spending to finance health care. For instance, the expansion of primary
care coverage has stagnated in recent years, and delays in the diagnosis and treatment of various forms of cancer reflect broader problems facing large segments
of the population in trying to access specialist care. Moreover, quality is a concern
throughout the system, with evidence that prenatal care is often not achieving its
potential with regard to reducing maternal and infant deaths and that compliance with clinical protocols and approaches to improving quality are often weak.
Partly as a result of remaining access and quality issues, Brazil still has significant
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ground to cover with respect to health outcomes; in spite of recent progress, the
country still ranks around 95 out of 213 countries for both life expectancy and
infant mortality.
At the same time, similar countries have achieved better health outcomes at
similar or lower expenditure levels, suggesting that there is scope for improving
the efficiency of Brazil’s public health system.1 Problems related to access and
quality also contribute to the continued demand for private health plans and
reliance on out-of-pocket expenditures to access care outside the SUS, undermining the goals of universality and equity. They are also the key factors
explaining high and seemingly rising levels of public dissatisfaction with the
health system.
These challenges are likely to get bigger in the future, as the health system has
to deal with the consequences of a rapidly aging population and rising expectations. The ratio of elderly (over 65) to population in the productive ages in Brazil
is expected to increase from 11 percent in 2005 to 49 percent in 2050, and life
expectancy is likely to rise to 81 years over the same period (Gragnolati et al.
2011; IBGE 2004). Aging and lifestyle changes mean that a growing share of the
burden of disease is the result of noncommunicable diseases.2 These changes
imply a need to move from a passive, curative pattern of care to one based on
managing and controlling risk factors and modifying health habits, with implications for how the health system is organized, the skills that are needed, and the
costs of delivering on the commitments of the SUS.3 In summary, the rapid
­process of population aging presents the SUS—and the health sector in general—
with a double challenge. First, it places greater financial pressure on the SUS, at
a time when the system is facing mounting resistance to mobilizing additional
resources under the current pattern of financing. Second, it creates pressure to
reorganize the delivery of health care to deal more effectively with chronic
­diseases of the elderly.
Both the achievements and the challenges can be traced back, at least in
part, to recent changes in how the health system is financed and organized.
The establishment of the SUS represented an important break from the past.
Yet, as noted in the report, the formal establishment of the SUS through the
1988 Constitution and subsequent legislation represents the culmination of a
series of steps and movements toward universal coverage during the 1970s
and 1980s. Moreover, while political policy and legislation are important,
transforming the health ­system is a long process. Although 1988 was a critical
juncture for health in Brazil, the impact of the reform is difficult to discern
given the continuity with the past and the slow and gradual process of
implementation.
Nonetheless, many of the structural reforms that were envisaged at the
­conception of the SUS have been achieved. In particular, there have been a
­dramatic decentralization of responsibilities for both financing and delivering health services; a deliberate reorientation of the health system toward
primary care; a gradual shift of hospital services toward public sector providers; an increase in government spending on health, particularly in recent
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Conclusions
years; and establishment of robust and innovative mechanisms for social
­participation and intergovernmental coordination in the health sector. But
the agenda is ­unfinished. Looking ahead, this report has highlighted five
primary challenges.
Sustaining Improvements in Access to Health Care
The report has described the rapid and impressive expansion of access to primary care in Brazil and the impact that this expansion has had on the use of
health services and health outcomes. Yet costs, lack of qualified staff, and other
factors have slowed the pace of expansion in recent years, with the Family
Health Strategy (ESF) reaching 50 percent of the population. As Brazil continues its effort to fill these gaps, parallel efforts will be needed to improve the
quality of primary care. However, diverse models of primary care are currently
in use, and it will be important to reach some consensus on their relative merits
(and costs).
While the path for sustaining improvements in the coverage of primary care
is relatively clear, efforts to achieve true “integrality” of care are likely to meet
with more challenges. Problems with coordination of care and access to specialist, diagnostic, and hospital services have multiple and complex causes, including
lack of infrastructure and human resource capacity, inadequate payment rates
(incentives) for some procedures, complex contracting arrangements with private sector providers, and weak referral and counterreferral systems. Many initiatives are under way to address these challenges: investment and upgrading of
capacity, review of payment rates, implementation of clinical guidelines, investment in systems for referrals and electronic medical records, and so forth. In most
cases (with the possible exception of large metropolitan areas), these reforms
require effective coordination across municipalities and are best implemented in
the context of regional health care networks. Even then, they are complex and
expensive reforms that need to be sequenced appropriately and coordinated.
Many important lessons can be learned from the Organisation for Economic
Co-operation and Development (OECD) and other middle-income countries in
this regard. It will also be important to establish mechanisms for monitoring and
evaluating reforms in Brazil and for sharing experiences across states and municipalities so that lessons are learned along the way.
As part of this process, it will be important to address the lack of integration
between the SUS and the private sector and to define their roles clearly.
Competition and lack of coordination between the two sectors result in duplications of efforts and resources, conflicts over who should pay for what, and difficulty in addressing systemwide problems. Under the SUS, an important step was
taken in establishing a regulatory framework, albeit one with gaps and unresolved
issues. But coordination between the two sectors remains very weak, and inconsistencies between SUS basic legislation, which confers a marginal role on
the private sector, and the existence of a strong dynamic private sector need to
be reconciled.
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Improving Efficiency and Quality of Health Care Services
The report has highlighted challenges pertaining to quality and efficiency in the
delivery of some services as well as important capacity gaps in some specialist
and high-complexity areas. The SUS reforms did not include specific goals or
targets in relation to how service delivery was to be organized, but the public
sector was expected to take on an increasingly important role in the delivery of
health services. This is what has happened, in particular in the hospital sector.
Yet in the face of persistent concerns about efficiency and quality, many states
and municipalities are experimenting with new models for providing services.
For instance, São Paulo has pioneered the contracting of hospital services from
nonprofit organizations (organizações sociais). Rio de Janeiro is using a similar
approach for primary care, and many other states and municipalities are following suit. While these contracting arrangements tend to be very collaborative in
nature, they require explicit performance standards and government capacity to
monitor and enforce contracts—requirements that put significant new demands
on the state and municipal health secretariats.
In many parts of Brazil there is also increased experimentation with publicprivate partnerships, in both the construction and the management of public
facilities. For instance, Bahia recently implemented a public-private partnership
for the Hospital do Subúrbio in Salvador. Such partnerships can bring important
benefits to the health sector, but only if the government chooses the right projects and has the capacity to design, monitor, and enforce contracts.
Separate from new models for contracting or partnering with the private sector, both the federal Ministry of Health and local governments are working on
approaches to stimulate improvements in efficiency and quality by setting more
explicit standards for services and creating financial incentives for providers. For
instance, the Ministry of Health is about to roll out a National Program for
Improvement of Access and Quality in Primary Care (Programa Nacional de
Melhoria do Acesso e da Qualidade da Atenção Básica, PMAQ), which will define
performance indicators and targets and provide incentives for municipalities to
achieve these targets. New modalities for contracts between the federal government and regional health care networks (tripartite agreements between federal,
state, and municipal governments) also entail an increased focus on results.4
The establishment of new contracting models will provide an opportunity to
change how providers are financed and how levels of government relate to one
another. However, outside of these experiences, an important factor that contributes to inefficiency and poor quality is the weakness of current mechanisms for
paying providers. Even when an originally adequate design has been adopted, as
with the inpatient care information and billing system of the SUS (autorização
de internação hospitalar, AIH), distortions have accumulated; current payment
methods do not provide appropriate incentives to service providers. Correcting
existing distortions and adopting methods that give providers clear incentives to
contain costs and improve quality will make more effective use of available
resources and further improve the performance of the health system.
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Conclusions
However, payment reform will have to go hand-in-hand with measures to
increase the financial and managerial autonomy of hospitals if the paymentrelated incentives are to have an impact on performance.
Overall, Brazil has undertaken extensive experimentation with approaches to
improve efficiency and quality in service delivery. Many of these hold promise,
but there clearly are no silver bullets. Moreover, in many cases, implementation
of reforms has been piecemeal and on a limited scale. It will be important to
ensure that these experiences are evaluated systematically and that the lessons
from these evaluations are shared widely among stakeholders in Brazil. In some
areas, meaningful reforms will require strong federal leadership. This is the case,
for instance, with provider payment reform and implies the need for significant
changes from current modalities for financing medium- and high-complexity
services. Similarly, federal initiatives such as PMAQ, with national support for
coordination and implementation, robust monitoring and reporting arrangements, and rigorous evaluation, can have a profound impact on the quality of
primary care. The ongoing efforts to establish regional networks may provide
opportunities for establishing similar initiatives to improve the efficiency and
quality of specialist and hospital services.
Clarifying Roles and Relationships across Levels of Government
Decentralization of the health sector has expanded the role of both municipalities and states in the financing and delivery of health services. This has brought
many benefits, such as increased accountability, tailoring of the system to local
needs, coordination with other public services, and so forth. Yet many municipalities lack the scale and technical capacity to manage a health system involving
all levels of care and complex support services, and many states have not played
the requisite role in coordination and support. Moreover, even with a growing
share of municipal spending allocated to health, complementary financing by the
state and federal governments is needed, both to achieve equity and to promote
higher-level goals and objectives. A well-functioning system will depend on effective coordination and collaboration across municipalities, in particular when it
comes to specialist and high-complexity services, referral systems, and medical
logistics (for example, patients and medical supplies). It will also depend on
robust institutions and approaches for contracting and financing across levels of
government.
In both of these areas, Brazil has made significant strides in recent years, with
new legislation to support the establishment of regional networks (comprising
several municipalities), a framework for contracting between federal government
and health regions, and institutional mechanisms for coordinating between
municipalities, states, and federal government. However, implementation of this
legislation will inevitably raise many political and practical challenges relating to
the process of regional planning, management, and coordination of “shared” services, how to finance investments in systems and capacity to support regional
networks, how to share financing responsibilities across levels of government,
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Conclusions
and so forth. Different states will proceed at different speeds, and it will be
important to study and learn from the early adopters.
Determining the Right Level of Health Spending and Improving
Efficiency
Although there is continued pressure from the health establishment to increase
public health funding to allow the SUS to fulfill its mandate, a key question is
whether a higher level of public financing is needed at all. That is, is the level of
public spending on health in Brazil adequate, in relation both to SUS constitutional responsibilities and to expectations of the population? The report has presented data showing that spending increased significantly over the last 20 years in
absolute terms (and to a lesser extent as a share of gross domestic product, GDP).
However, the growth in spending was slower than in many other middle- and highincome countries, in particular, those that have experienced a rapid expansion in
coverage (for example, the Republic of Korea, South Africa, Thailand, and Turkey).
Moreover, the increase in spending did not keep up with the rapid expansion of
the system and the volume of services provided, in particular, if cost increases associated with the introduction of new drugs and procedures are also considered.
More government spending on health would undoubtedly help to finance
more health system resources (facilities, equipment, staff), medical supplies, and
services. Yet the report has shown that the lack of resources and supplies often is
not a binding constraint to improving access and quality. For instance, La Forgia
and Couttolenc (2008) found that hospitals operate at a high level of inefficiency
and that the average Brazilian hospital could produce three times its current
output with the same amount of inputs if it were as efficient as the most efficient
hospitals. Hospital beds and operating theaters are largely underused, and expensive diagnostic equipment is oversupplied in many regions. And at least to some
extent, problems of access to diagnostic and specialist care have more to do with
how the health system is organized (weak management, lack of functioning
referral systems) than with a lack of resources per se.
Hence, although the debate over whether the public system is “adequately” or
“sufficiently” funded has raged since before its foundation, there is no clear and
scientific way to determine whether this is the case. In Brazil, the health system
clearly could produce more health services and better health outcomes with the
same level of resources if it were more efficient. For instance, significant gains
could be achieved by aligning hospital capacity more closely with need, enhancing technical efficiency of hospitals through better management and incentives,
reducing waste and misuse of funds, and so forth. Gains could also be realized
through improved prioritization in the allocation of government spending
(a shift toward services and interventions that are more cost-effective), which in
turn would require a more robust process for making decisions about the introduction and management of existing and new technologies (drugs and procedures). There are no simple solutions for dealing with these issues, but there is
a wealth of international experience on which to draw.
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Conclusions
At the same time, even with improvements in efficiency, spending pressures
are unlikely to abate in coming decades. As a share of GDP, government spending
on health in Brazil (around 4.5 percent) is less than half the OECD average. In
part, the higher government spending in many OECD countries is explained by
the fact that health is an inherently labor-intensive sector, and the relative cost of
health services tends to rise as GDP grows. But it is also explained by differences
in demographics and the coverage and quality of services provided.
As Brazil continues to grow and develop, the combination of unmet need in
both primary and specialist care, the introduction of new technology (drugs and
procedures), growing demand for health care associated with noncommunicable
diseases, and higher use associated with an aging population is likely to put significant pressure on public health spending in the decades to come. As in other
advanced health systems around the world, it will be essential to enhance efficiency and improve prioritization, but it will also be important to prepare for
significant and sustained increases in government health spending and put in
place mechanisms for managing the cost pressures that are already evident in the
system. This is likely to include more robust systems for assessing and managing
the introduction and use of new technologies in the form of hardware, procedures, and pharmaceuticals.
Conducting More and Better Health System Monitoring and Research
Brazil has a strong tradition of evidence-based policy making in the health sector
and a vibrant health research community. The report has highlighted the need to
build on these strengths to support continued health system reform. For instance,
although vast amounts of administrative data on health outcomes, delivery of
health services, and health financing are publicly available, problems often plague
the quality of data, consistency of definitions, and structure of data over time and
space. This makes it difficult to benchmark performance over time, across space,
and internationally in some areas. Data are missing on many important dimensions of performance, including waiting times for elective procedures, quality of
chronic disease care, and survival rates for specific conditions such as cancer and
heart attacks. Data on these types of indicators have played a very important role
in understanding and addressing health system challenges in OECD countries
and will gain importance as Brazil grapples with issues relating to access, quality,
and coordination of care. Despite the valid methodological concerns that have
been raised, the Ministry of Health’s initiative to define a new set of indicators
for monitoring and benchmarking performance (Índice de Desempenho do SUS,
SUS Performance Indicator, IDSUS) represents an important step toward
addressing this gap.
Beyond the monitoring of health system performance, the report has highlighted several areas where in-depth research is warranted. What are the costs
and relative merits of different primary health care models? What are the
impacts of the approaches to improving quality and improving efficiency that are
being considered? What are the advantages and risks associated with public
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111
112
Conclusions
contracting of health care from nonprofit providers? How can the high levels of
out-of-pocket spending on medicines be reduced? How does the establishment
of regional networks affect the structure, organization, and performance of local
health systems? How do different models of health system governance and
financing, including across levels of government, affect the performance of the
system? These are merely some of the questions that rigorous research and evaluation, based on strong partnerships between policy makers and the research
community, can help answer and, in that way, contribute to making the Brazilian
health system more efficient, effective, and equitable.
Notes
1.Ranking is based on the most recent data in the World Bank, World Development
Indicators database.
2.Noncommunicable diseases already account for about two-thirds of the burden
of ­disease in Brazil, compared with 24 percent from communicable diseases and
10 ­percent from injuries.
3.For instance, a recent study by the Instituto de Pesquisa Econômica Aplicada found
that 71 percent of Brazilian municipalities did not have any institution for elder care
and that existing institutions—two-thirds of which were not-for-profit ­organizations—
cared for only 0.5 percent of the elderly population (IPEA 2011).
4.The model is based on the organizational contract for public action in health (contrato
organizativo da acão pública da saúde).
References
Gragnolati, M., O. H. Jorgensen, R. Rocha, and A. Fruttero. 2011. Getting Old in an Older
Brazil: Implications of Population Aging on Economic Growth, Poverty Reduction, Public
Finance, and Service Delivery. Directions in Development Series. Washington, DC:
World Bank.
IBGE (Instituto Brasileiro de Geografia e Estatística). 2004. “Projeção da população do
Brasil por sexo e idade para o período 1980–2050.” IBGE, Diretoria de Pesquisas,
Coordenação de População e Indicadores Sociais, Gerência de Estudos e Análises da
Dinâmica Demográfica, Rio de Janeiro.
IPEA (Instituto de Pesquisa Econômica Aplicada). 2011. “Condições de funcionamento e
infraestrutura das instituições de longa permanência para idosos no Brasil.”
Comunicados IPEA 93, Série Eixos do Desenvolvimento Brasileiro, IPEA, Brasilia.
La Forgia, G., and B. Couttolenc. 2008. Hospital Performance in Brazil: In Search of
Excellence. Washington, DC: World Bank.
Twenty Years of Health System Reform in Brazil • http://dx.doi.org/10.1596/978-0-8213-9843-2
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Twenty Years of Health System Reform in Brazil • http://dx.doi.org/10.1596/978-0-8213-9843-2
More than 20 years have passed since the Brazilian Sistema Único de Saúde (Unified Health System or SUS)
was formally established by the 1988 Constitution. The SUS reforms established health as a fundamental
right and duty of the state and started a process of fundamentally transforming Brazil’s health system to
achieve this goal.
Twenty Years of Health System Reform in Brazil asks what has been achieved and what challenges remain in
accomplishing the goals that were established in 1988. Specifically, it assesses whether the SUS reforms have
transformed the health system as envisaged and whether they have improved access to services, financial
protection, and health outcomes.
The report finds that the health system reforms provided the foundation for the improved health system that
Brazil has today. These improvements include an impressive expansion of utilization and access to primary
care, a profound restructuring of the health system, the steady decentralization of responsibilities to
municipalities, and a growth in government health care spending.
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