The first paper (Professor Jairnilson Pain, Instituto de Saúde Coletiva, Salvador, Brazil, and colleagues) analyses the history of Brazilian health. By far the most important development in terms of improving access has been the creation of the Unified Health System (Sistema Único de Saúde /SUS), created in 1988. In addition, the country has a thriving private health system. In tandem with SUS, key improvements in infrastructure have been made over the past few decades. For example, in 1970 only a third of homes had indoor water; by 2007, this had risen to 93%.
Other improvements, such as increased connection to sewerage, more homes with electricity and a better social security system have led to marked improvements in a wide range of Brazilian health indicators, including life expectancy (now 72 years), and large reductions in child mortality. Smoking rates in 2007 (17%) were half what they were in 1989 (34%).Yet as everywhere else, Brazil's population is aging, and by 2020 there are expected to be 68 adults over aged over 60 years to every 100 children and adolescents. The country is also getting fatter, with obesity levels rising (almost half of men in state capitals report being overweight). 40% to 50% of Brazilians aged over 40 years have high blood pressure, and 6 million of the country's 191 million inhabitants are known to be diabetic. Yet encouragingly, the gap between the country's richest and poorest is narrowing.
Some of the factors that have been big success stories for Brazil, including improved tobacco control, and the world's largest free HIV/AIDS drug distribution system, are discussed more fully in later papers.
Around a quarter of all Brazilians have some form of private health insurance, with some two thirds of these policies concentrated in the relatively affluent Southeast region. The private sector in Brazil is well supported by government, and frequently provides services contracted by the SUS. Yet the Series authors are concerned that costs associated with subsidising the private sector are threatening to undermine efforts at universal health provision via SUS. As in the US, Brazil has a system that encourages intense use of diagnostic and therapeutic procedures, when in many cases they are not appropriate. The authors believe political will is the only way to bring the private health sector back under manageable constraints.
Despite these limitations, the SUS has managed to vastly improve access to primary and emergency care, reach universal coverage of vaccination and prenatal care, and invest heavily in the expansion of human resources and technology, including major efforts to produce the country's most essential pharmaceutical needs. Health-care service use has increased 174% from 1981 to 2008. However, the proportion of the population that consulted a doctor in 2008 was 68%, lower than the 80% or more seen in many high-income countries. And at 1.9 public hospital beds per 1000 population, Brazil has fewer beds per head than any other OECD country apart from Mexico. So work still needs to be done.
The authors conclude: "Ultimately, to overcome the challenges that Brazil's health system faces, a revised financial structure and a thorough reassessment of public-private relations will be needed. Therefore, the greatest challenge facing the SUS is political."
Professor Jairnilson Pain, Instituto de Saúde Coletiva, Salvador. T) +55 71 3283-7442 E) jairnil@ufba.br
Journal
The Lancet