Overview of Brazil's Healthcare System

Main ideas, concepts, and lessons conveyed

1) Roadmap of the presentation

The video covers:

• An overview of Brazil’s healthcare system
• Key facts and comparisons (population health indicators vs. Canada)
• Strengths and weaknesses
• System organization, funding, regulation, and care delivery
• Major national health concerns (water/sanitation, dengue, Zika)
• Current pressures on the system (economic crisis, underfunding)

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2) Snapshot facts about Brazil’s population and health indicators (vs. Canada)

Population (July 2016)

• Brazil: >205 million
• Canada: >35 million

Infant mortality

• Brazil: ranked 94th, 18 deaths per 1,000 live births
• Canada: stated as 179, 4.6 deaths per 1,000 live births

Paternal mortality

• Brazil: 44 deaths per 100,000 (as stated)
• Canada: ranked 147th, 7 deaths per 100,000

Life expectancy

• Brazil: 73.8 years, ranked 127th
• Canada: 81.9 years, ranked 19th

Language, geography, and urbanization

• Official language: Portuguese
• Brazil: largest South American country and 5th largest in the world
• Urban population (2015):
  • Brazil: 85.7%
  • Canada: 81.8%

Socioeconomic indicators

• Below poverty line: 21.4%
• Unemployment: 9%
• Inflation: 9% in 2015 (with 6.3% in 2014 mentioned)

Health insurance context

• Brazil has a large health insurance sector:
  • ~25% of the population covered (2013)
  • Second largest in the Americas after the U.S.

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3) History and evolution of Brazil’s healthcare system (timeline)

• Early 1900s
  • Public health activities began via public health campaigns described as military-style
  • Lack of access and an autocratic approach led to resistance
• 1904
  • Official revolt after compulsory smallpox vaccination was imposed by “General of Public Health Oswald kurz” (as transcribed)
• 1920s–1930s
  • Policies based on job-related social/civil rights
• 1930s–1945 (President Vargas era)
  • Decision-making/management without public involvement
  • Little government investment in healthcare
  • Vulnerable groups under-served
  • Ministry of Health and Social Security described as underfunded
• 1964
  • Military takeover
  • Expansion of private healthcare in urban areas
• 1972–1974
  • Federal budget used to improve/build private hospitals
  • Promotion of expanded medical care
• 1988
  • Constitution of the Federative Republic of Brazil
  • Health declared a citizen’s right
  • State responsible for universal health care
  • Creation/establishment of SUS (Unified Health System)

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4) SUS (Sistema Único de Saúde): purpose, structure, pros/cons, stakeholder model

What SUS is and aims to do

• Universal health care established as:
  • A right of citizens
  • A responsibility of the government
• Administrative structure:
  • SUS planned and managed for both public and private health systems
  • Goal: decentralize responsibilities to states and municipalities

Growth in capacity (as stated)

• Health facilities increased:
  • 22,000 (1981) → 75,000 (2009)

Pros and benefits (as stated)

• Described as a large universal healthcare system
• Helps reduce outcomes such as:
  • maternal and child mortality
  • cardiovascular disease
  • death from influenza
• 1990: Health Council split into three levels:
  • federal, state, and municipal
• Stakeholder engagement emphasized

Cons / weaknesses (as stated)

• Largely decentralized, which can reduce efficiency in delivery/treatment
• “Family physicians only rich half are brazilians” (transcription unclear; appears to imply unequal access or uneven utilization)
• Underfunding

Health Council stakeholder composition (framework described)

Council membership requires a ratio:

• 50% users (e.g., neighborhood associations / patient interest groups)
• 25% healthcare professionals and academic professionals
• 25% healthcare providers (public/private firms, NGOs, and governments at different levels)

These stakeholders are responsible to:

• finance, monitor, deliver, and use health services (as stated)

Mission/mandate (as described):

• Achieve equitable access for all citizens
• Improve population health through partnerships (federal agencies, states, municipalities, private sector)
• Improve quality of life and “citizenship” (as phrased)

Vision (as described):

• “Health for all”, tied to Alma-Ata direction (1978)

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5) How Brazil’s healthcare system is classified (regulation, financing, provision)

Using a framework attributed to “Bohm at all” (transcription; likely “Bohm et al.”), systems are classified across three dimensions:

• Regulation
• Financing
• Service provision

Brazil is determined (per the narrator/framework) to be:

• A national health service
• Where the state has the highest power in:
  • regulation
  • financing
  • service provision

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6) System organization: geography and administrative units

• Brazil has 27 federative units:
  • 26 states + 1 Federal District
• Number of municipalities (as stated):
  • 5,570 municipalities
• Service delivery is strongly shaped by decentralization across government levels

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7) Funding sources and spending levels (SUS funding breakdown)

Funding for SUS (as stated)

• 47% publicly funded, including:
  • Social Security
  • federal government
  • Federal District
  • states and municipalities
• 36% privately funded via out-of-pocket expenses
• 17% from insurance companies

Social Security composition (as described)

• Contributions from:
  • employee and employer monthly contributions
• Plus:
  • general taxes and other social contributions designed for healthcare investment

Spending levels / GDP share (as stated)

• Brazil spent 8.3% of GDP (2014), up from 3.76% in 2010 (as transcribed)
• Mentions of tax revenue shares:
  • Federal District: 12% and 15% of tax revenues (as stated)
  • States: 12% of tax revenue
  • Each municipality: 15% of tax revenue (as stated)

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8) Care delivery structure: public vs private vs supplemental + levels of care

Types of healthcare access described

• Public healthcare: free and universal access
• Private healthcare: direct payment for services
• Supplemental healthcare: supplemental plans/insurance

Regulation body

• Ministry of Health (federal branch agency)
  • Consolidates health practices in Brazil
  • Composed of seven departments
  • Includes an office/secretariat described as:
    • “Office of Health Services / Secretariat of Health”

Role of evaluation and councils

• A National Health Council evaluates services using stakeholder input to identify gaps

Decentralized management

• “All levels of government work together”
• Municipalities largely manage healthcare services

Dentistry/optometry/pharmaceuticals

• Stated as mostly privately funded

Three tiers of healthcare (as detailed)

• Primary care
  • First contact; central to the system
  • Implemented via the Family Health Program
  • Public responsibility providing care through:
    • home visits
    • clinics
    • hospitals
  • Coverage stated: 54.8% of the population
  • Community participation highlighted:
    • community input → municipal health councils
  • Referrals to secondary care
• Secondary care
  • Provided by professionals who generally don’t have first-contact role
  • Usually delivered in hospitals
  • Many hospitals described as privately owned
  • Equity concern:
    • hospitals may take more from the supplemental system since insurance pays more than government funding
• Tertiary care
  • Specialized consultative care
  • Dependent on privately owned facilities
  • Examples listed:
    • organ transplants and donations (guidelines)
    • oncology
    • cardiac surgeries
  • Provided by private groups and paid for by the government (as stated)

System capacity and spending figures (as stated)

• 7,500 hospitals
• 443,210 beds
• 2,812 public hospitals (as stated)
• 1.95 doctors per 1,000 people (stated as an average)
• Health spending:
  • $224 billion total
  • $5 billion on pharma
  • $0.55 billion on energy (as transcribed)

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9) National health status issues: water/sanitation, dengue, Zika

Water and sanitation

• Brazil has 12% of the world’s freshwater
• Despite this:
  • 1/3 of the rural population lacks safe drinking water/sanitation
• Drought (2015 mentioned)
  • Reduced water flow via city pipelines
  • Anecdote: hospital lacked water; staff couldn’t wash hands; bedding reused
• Policy/history mentioned:
  • 1934: water code prioritizing water usage for energy (not broadly for other aspects)
  • 1980/1990: water management concerns resurfaced
  • 1997: Congress passed a law focusing on preserving water and making it available
  • National Water Agency created to aid management/protection (2007–2014)
  • “Rio Grande and Nord States water security project”:
    • built water supply systems in 33 rural communities
    • 3,700 beneficiaries
    • installed 125 desalination units
    • supported 8,900 families (as stated)

Dengue

• Dengue described as viral disease transmitted by mosquito bites
• Endemic since 1981
• 2015: rainy season was dry → drought → people stored water in open containers
  • creates breeding grounds for mosquitoes
• Response measures described:
  • improve surveillance (decentralized vector control)
  • lab diagnosis
  • “drug tents” for treatment in high-risk areas
  • door-to-door education by health officials:
    • fill potted plants with sand
    • keep containers dry
    • cover swimming pools
    • place mosquito nets over open tanks
  • education campaign had limited success due to residents’ reluctance to open doors
  • soldiers trained to do door-to-door education to improve trust and cooperation

Zika

• Zika transmitted by mosquitoes; also stated as sexually transmissible
• Reported impacts (as stated):
  • affects up to 20% of pregnancies
  • can cause “brain damage” to baby
  • can cause microcephaly in ~1% of Zika-affected pregnancies
• International partnership:
  • CDC and WHO partnered with Brazil to:
    • develop testing to confirm Zika early in illness
    • improve diagnosis of prior infection
    • develop a vaccine for at-risk groups, especially pregnant people
• Prevention continues via municipal mosquito-control efforts

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10) Current challenges and system stressors (economic crisis and policy shifts)

• The video links healthcare stress to Brazil’s economic crisis and recession:
  • government declared state of emergency
  • budget cuts to public healthcare
  • public hospitals run with minimal staff and treat mostly life-threatening cases
  • job losses reduce private health insurance coverage
  • increased demand on the public system
  • government struggles to meet citizen needs
• Currency weakness increases costs:
  • treatment and imported drugs/equipment become more expensive
• Access delays:
  • patients may wait several months for appointments/procedures (public system described as “poor”)

Public vs private role changes and legal shifts

• Historically:
  • until 2013, only Brazilian companies could provide healthcare services in the country
  • foreign capital allowed only in specific cases
• Early 2015 law:
  • allowed foreign capital/investment with fewer restrictions
  • sectors covered (as listed):
    • hospitals
    • human genetics
    • medication manufacturing and supply
    • clinical pathology
    • medical imaging laboratories
• Government acknowledgment (as stated):
  • new measures and private money would help an overloaded public system
• Local hospitals shutting down less profitable units (e.g., maternity/pediatrics)
  • creating space for new companies in mainstream and non-traditional fields

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11) Claimed outcomes / closing assessment of SUS

Despite limitations, SUS is said to:

• improve access to primary and emergency care
• provide universal coverage of vaccinations and prenatal care
• invest heavily in expansion of:
  • human resources
  • technology
• make major efforts to produce essential pharmaceutical needs domestically

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Speakers or sources featured (as mentioned in the subtitles)

• General of Public Health Oswald kurz (referenced in historical context)
• President Vargas (referenced as a historical figure)
• “Bohm at all” (framework/citation for healthcare system dimensions; full name not provided in subtitles)
• Alma-Ata Declaration (1978) (goal-setting framework referenced)
• CDC (Centers for Disease Control and Prevention; partnered on Zika testing)
• WHO (World Health Organization; partnered on Zika testing)
• Government of Brazil / Ministry of Health (institutions referenced; no individual speaker named)