Brazil
From 1965 to 1985, Brazil was organized as a military republic. During this time, the different military regimes established a health care system that was highly centralized. Throughout the 1970s, the public health system took shape under two ministries, the Ministry of Health and the Ministry of Social Security and Social Assistance. The Ministry of Health was responsible for coordinating national health policies, preventive medicine, and a network of hospitals as well as a network of health care facilities in poor municipalities. The Ministry of Social Security and Social Assistance was responsible for providing medical care to workers insured by social security. Under this system, medical services were offered by both public and private facilities. The National Institute of Medical Care and Social Security (INAMPS) was responsible for the public provision of health services. Meanwhile, the social security system contracted more and more with the private sector, so that by 1976 73% of Brazilian hospitals were private.
From 1965 to 1985, Brazil was organized as a military republic. During this time, the different military regimes established a health care system that was highly centralized. Throughout the 1970s, the public health system took shape under two ministries, the Ministry of Health and the Ministry of Social Security and Social Assistance. The Ministry of Health was responsible for coordinating national health policies, preventive medicine, and a network of hospitals as well as a network of health care facilities in poor municipalities. The Ministry of Social Security and Social Assistance was responsible for providing medical care to workers insured by social security. Under this system, medical services were offered by both public and private facilities. The National Institute of Medical Care and Social Security (INAMPS) was responsible for the public provision of health services. Meanwhile, the social security system contracted more and more with the private sector, so that by 1976 73% of Brazilian hospitals were private.
High inflation rates during the 1970s led to a deep recession in the early 1980s. This macroeconomic cycle brought efforts to reduce public-sector expenditures. During the first four years of the 1980s, public health expenditures decreased year over year. This experience led to the creation of the Integrated Health System (AIS) in 1982, which was an early attempt to decentralize the health system by off-loading health management and policy responsibilities to the states. Nevertheless, the federal government retained control over both the financing and the design of all health programs.
In 1987, continuing in the spirit of decentralization, the Unified Decentralized Health System (SUDS) was introduced. A carryover of the AIS, it augmented the state’s role in the management and regulation of health care and increased the scope of civil society participation in the policy-making process. However, the federal government retained control over the financing and administrative aspects of the system. Through 1988, social security revenues had been the primary source of financing for the health sector. Under SUDS, the states were given decision-making authority over whether to delegate administrative and policy responsibilities to the municipalities. It is important to note that prior to the SUDS, municipalities had never played a significant role in health care management.
Brazil
Historical Context
From 1965 to 1985, Brazil was organized as a military republic. During this time, the different military regimes established a health care system that was highly centralized. Throughout the 1970s, the public health system took shape under two ministries, the Ministry of Health and the Ministry of Social Security and Social Assistance. The Ministry of Health was responsible for coordinating national health policies, preventive medicine, and a network of hospitals as well as a network of health care facilities in poor municipalities. The Ministry of Social Security and Social Assistance was responsible for providing medical care to workers insured by social security. Under this system, medical services were offered by both public and private facilities. The National Institute of Medical Care and Social Security (INAMPS) was responsible for the public provision of health services. Meanwhile, the social security system contracted more and more with the private sector, so that by 1976 73% of Brazilian hospitals were private.
High inflation rates during the 1970s led to a deep recession in the early 1980s. This macroeconomic cycle brought efforts to reduce public-sector expenditures. During the first four years of the 1980s, public health expenditures decreased year over year. This experience led to the creation of the Integrated Health System (AIS) in 1982, which was an early attempt to decentralize the health system by off-loading health management and policy responsibilities to the states. Nevertheless, the federal government retained control over both the financing and the design of all health programs.
In 1987, continuing in the spirit of decentralization, the Unified Decentralized Health System (SUDS) was introduced. A carryover of the AIS, it augmented the state’s role in the management and regulation of health care and increased the scope of civil society participation in the policy-making process. However, the federal government retained control over the financing and administrative aspects of the system. Through 1988, social security revenues had been the primary source of financing for the health sector. Under SUDS, the states were given decision-making authority over whether to delegate administrative and policy responsibilities to the municipalities. It is important to note that prior to the SUDS, municipalities had never played a significant role in health care management.
The 1980s saw many health experts and health system reform advocates in Brazil holding key positions within the health services ministries. Naturally, these ministries began to implement the many reform proposals that had been discussed within what had been referred to as the Sanitary Reform Movement. Key among these proposals were the decentralization of the system and the unification of control at the municipal and state levels.
The 1980s saw many health experts and health system reform advocates in Brazil holding key positions within the health services ministries. Naturally, these ministries began to implement the many reform proposals that had been discussed within what had been referred to as the Sanitary Reform Movement. Key among these proposals were the decentralization of the system and the unification of control at the municipal and state levels.
Three interest groups had a particular stake in the reform process:
- Unions, professional associations, and federal councils supported health reform as a public and democratic system
- Private sector associations were opposed to any government control. The contracted private sector wanted the state to continue paying for services provided, but they did not want any technical or administrative interference. The voluntary private insurance sector, which was already sizable, wanted complete independence from the state.
- Representatives of health and social security bureaucracies wanted to keep control of medical care.
The gradual approach taken within the health sector reforms helped to guarantee political stability and governance within the process. The approach minimized conflict and resistance by health professionals. Health is the only social sector that has been supported by all political parties.
Brazil
Political Context
The 1980s saw many health experts and health system reform advocates in Brazil holding key positions within the health services ministries. Naturally, these ministries began to implement the many reform proposals that had been discussed within what had been referred to as the Sanitary Reform Movement. Key among these proposals were the decentralization of the system and the unification of control at the municipal and state levels.
Three interest groups had a particular stake in the reform process:
- Unions, professional associations, and federal councils supported health reform as a public and democratic system
- Private sector associations were opposed to any government control. The contracted private sector wanted the state to continue paying for services provided, but they did not want any technical or administrative interference. The voluntary private insurance sector, which was already sizable, wanted complete independence from the state.
- Representatives of health and social security bureaucracies wanted to keep control of medical care.
The gradual approach taken within the health sector reforms helped to guarantee political stability and governance within the process. The approach minimized conflict and resistance by health professionals. Health is the only social sector that has been supported by all political parties.
The 1988 constitution crystallized the movement toward democratization. One of the primary tenets of this new constitution was the de jure establishment of free, universal healthcare. Such a goal would be pursued through the Unified Health System (SUS), a newly established administrative body responsible for the stewardship of both the public and private health systems.
The 1988 constitution crystallized the movement toward democratization. One of the primary tenets of this new constitution was the de jure establishment of free, universal healthcare. Such a goal would be pursued through the Unified Health System (SUS), a newly established administrative body responsible for the stewardship of both the public and private health systems. The primary purpose of the SUS was to decentralize health policy down to the level of the state and municipality, with municipalities responsible for managing and providing primary health care services. States would assist in setting policy goals and provide technical and financial assistance. Under the new legislation, municipal health secretariats were the primary entities responsible for planning, managing, and administering most aspects of health care. Most federal hospital and ambulatory health services were transferred to both state and municipal secretariats, which now had to staff hospitals, contract out services to the private sector, and provide community outreach services. The majority of public hospitals run by municipalities tend to be small facilities, with larger hospitals being operated by the states and the largest teaching hospitals being operated by the federal government.
Implementation of the SUS has been piecemeal, as new legislative programs have been added to its initial 1988 framework. In 1991, the first Basic Operational Standards (NOB) were passed; the second and third NOBs were added in 1993 and 1996 respectively. The purpose of these legislative programs was to increase the involvement and capacity of state and municipal governments in health care management. Between 1996 and 2000, the number of municipalities deemed capable of managing the health system increased from 30% to 99%. This allowed for the direct transfer of resources from both federal and state funds into municipal funds. It is worth pointing out, however, that oftentimes the process of certifying a municipality as capable was political and did not in fact mean that the municipality was able to operate the local health system. To this day, many municipalities lack the capacity to operate an effective delivery system.
In 1994, the government created the Family Health Program (PSF) and the Community Health Agents Program (PACS). The PSF provides primary care services through medical teams consisting of a physician, a nurse, and community health workers. PACS provides a more restricted set of services than the PSF and employs primarily community health workers to deliver care. The last NOB in 1996 introduced financial incentives by the Ministry of Health for mayors to implement and manage the PSF and the PACS. Since then, implementation of these programs has expanded significantly.
The PSF is the program through which the government restructured the organization and delivery of publicly financed primary health care (it has recently taken on the role of covering chronic diseases). In essence, it has turned a passive, facility-based delivery system into an active, outreach model in which family health care providers deliver care to households and communities.
Brazil
Summary of Reforms
The 1988 constitution crystallized the movement toward democratization. One of the primary tenets of this new constitution was the de jure establishment of free, universal healthcare. Such a goal would be pursued through the Unified Health System (SUS), a newly established administrative body responsible for the stewardship of both the public and private health systems. The primary purpose of the SUS was to decentralize health policy down to the level of the state and municipality, with municipalities responsible for managing and providing primary health care services. States would assist in setting policy goals and provide technical and financial assistance. Under the new legislation, municipal health secretariats were the primary entities responsible for planning, managing, and administering most aspects of health care. Most federal hospital and ambulatory health services were transferred to both state and municipal secretariats, which now had to staff hospitals, contract out services to the private sector, and provide community outreach services. The majority of public hospitals run by municipalities tend to be small facilities, with larger hospitals being operated by the states and the largest teaching hospitals being operated by the federal government.
Implementation of the SUS has been piecemeal, as new legislative programs have been added to its initial 1988 framework. In 1991, the first Basic Operational Standards (NOB) were passed; the second and third NOBs were added in 1993 and 1996 respectively. The purpose of these legislative programs was to increase the involvement and capacity of state and municipal governments in health care management. Between 1996 and 2000, the number of municipalities deemed capable of managing the health system increased from 30% to 99%. This allowed for the direct transfer of resources from both federal and state funds into municipal funds. It is worth pointing out, however, that oftentimes the process of certifying a municipality as capable was political and did not in fact mean that the municipality was able to operate the local health system. To this day, many municipalities lack the capacity to operate an effective delivery system.
In 1994, the government created the Family Health Program (PSF) and the Community Health Agents Program (PACS). The PSF provides primary care services through medical teams consisting of a physician, a nurse, and community health workers. PACS provides a more restricted set of services than the PSF and employs primarily community health workers to deliver care. The last NOB in 1996 introduced financial incentives by the Ministry of Health for mayors to implement and manage the PSF and the PACS. Since then, implementation of these programs has expanded significantly.
The PSF is the program through which the government restructured the organization and delivery of publicly financed primary health care (it has recently taken on the role of covering chronic diseases). In essence, it has turned a passive, facility-based delivery system into an active, outreach model in which family health care providers deliver care to households and communities.
Some challenges remain within the Brazilian health system. Because many different populations are now covered for health services to which they did not previously have access, financial sustainability is an ever-present concern.
Some challenges remain within the Brazilian health system. Because many different populations are now covered for health services to which they did not previously have access, financial sustainability is an ever-present concern. There is constant conflict over resources between primary health care programs and hospitals, municipalities are struggling with increased costs, and the Family Health Program (PSF) has increased secondary care services such as lab tests without corresponding federal resource transfers. Furthermore, from 2001 to 2008 the percentage of doctors that were paid more than 15 times the minimum wage has decreased from 90% to 26%, raising concerns about a shortage of health professionals in the public sector due to migration to the private sector. Thus, it is clear that difficult decisions remain ahead.
In terms of the PSF, five important issues remain. (1) There is a challenge of providing quality and effective care in light of a lack of clinical guidelines; (2) there are problems of integrating the PSF into the broader health system, especially when it comes to effective referral mechanisms; (3) there is high staff turnover; (4) there is a lack of reliable costs information; (5) and there are limited resources for scaling up successful experiences.
The hospital sector is also experiencing important challenges. Spending on hospital care is high; however there remain a large number of facilities that are plagued by low quality and high inefficiency. The primary drivers for these poor outcomes are rigid and unaccountable hospital governance structures, weak coordination and distorted capacity configuration, passive and diluted funding, a lack of systematic programs to enforce standards and measure quality, and a lack of information for decision making. The years ahead will see a need to seriously address these issues.
Brazil
The Way Forward
Some challenges remain within the Brazilian health system. Because many different populations are now covered for health services to which they did not previously have access, financial sustainability is an ever-present concern. There is constant conflict over resources between primary health care programs and hospitals, municipalities are struggling with increased costs, and the Family Health Program (PSF) has increased secondary care services such as lab tests without corresponding federal resource transfers. Furthermore, from 2001 to 2008 the percentage of doctors that were paid more than 15 times the minimum wage has decreased from 90% to 26%, raising concerns about a shortage of health professionals in the public sector due to migration to the private sector. Thus, it is clear that difficult decisions remain ahead.
In terms of the PSF, five important issues remain. (1) There is a challenge of providing quality and effective care in light of a lack of clinical guidelines; (2) there are problems of integrating the PSF into the broader health system, especially when it comes to effective referral mechanisms; (3) there is high staff turnover; (4) there is a lack of reliable costs information; (5) and there are limited resources for scaling up successful experiences.
The hospital sector is also experiencing important challenges. Spending on hospital care is high; however there remain a large number of facilities that are plagued by low quality and high inefficiency. The primary drivers for these poor outcomes are rigid and unaccountable hospital governance structures, weak coordination and distorted capacity configuration, passive and diluted funding, a lack of systematic programs to enforce standards and measure quality, and a lack of information for decision making. The years ahead will see a need to seriously address these issues.
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