This document reviews the gap between demand and access to medicines in Brazil's public health care system. It finds that while over 70% of medical consultations are publicly funded, around 70% of medicines are privately purchased due to high prices and limited availability in public pharmacies. This shifts the financial burden to users and disproportionately harms those who cannot afford treatment, increasing inequality. The document calls for improvements in budget forecasting, health planning, and data collection to better measure and address variations in access to medicines across regions and types of treatments.

1. Measuring the Gap between
Demand and Access in the Brazilian
Public Health Care System
Mariana Socal, MD, MPP
June 25, 2012

2. Background
• Around 76% of the Brazilian population
depends exclusively on the public health
system for obtaining health care services
• Insured patients may also resort to the public
health system in order to access treatments
and services not covered in their health plans
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3. Background
• The benefits package of the Brazilian Public
Health Care System includes free provision of
medicines.
• Insufficiencies in the provision of drugs may
harm patients by preventing the initiation of
treatment or by interrupting ongoing
regimens.
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4. Objectives
• To review the existing evidence on the gap
between demand and access to medicines within
the Brazilian public health care system.
• Estimating demand is the first step in order to
allow for improvements in budget forecasting and
public health planning.
• Ultimately, this work aims to inform the
development of tools to allow longitudinal and
comprehensive estimation of demand and access
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5. Method
• Review of the literature through the Medline
medical database (US National Library of
Medicine). Keywords:
Brazil, SUS, demand, access, utilization, medici
nes, drugs. Review of reference lists of the
identified articles.
• Most of the selected studies drew data from
national or regional population-based studies
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6. Results
• Near half of the adult population in Brazil utilizes
medicines (Carvalho, 2005)
• The utilization of medicines increases with age
reaching more than 70% of individuals aged 60 years
or older (Carvalho, 2005)
Age group (years) p value
18-39 38.9 0.000
40-59 54.0
60 and over 73.0
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7. Financing
• Medicines are prescribed in more than 60% of
medical consultations (Louvisson, 2008)
• Although 61% of health consultations are publicly
funded (Silva, 2011), around 70% of medicines are
privately purchased (Louvisson, 2008)
Medical
Medicines
Consultations
Public
Public
Private
Private
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8. Gap in access
• Around 8% of patients who receive a medical
prescription are entirely unable to obtain the
medicines they need (Louvisson, 2008).
• Most frequently reported reasons
(Carvalho, 2005):
lack of financial conditions to purchase drugs
(55%)
lack of availability of medicines in public
pharmacies (13%)
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9. Major Reason 1: Price
• Retail prices of essential medicines in Brazil:
 1.9 times more expensive than Sweden
13.1 times more expensive than international
unit-price indicators (Nóbrega, 2007)
• The mean private expenditure with medicines per
month compromises more than 20% of the income
for at least 50% of the elderly (Lima-Costa, 2003).
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10. Major Reason 2: Availability
• The median availability of essential drugs in public
pharmacies is 30% (Mendis, 2007). In private
pharmacies the same drugs have median availability
of 70%.
• 65% of the essential medicines (RENAME) do not
have a generic version available in the country
(Miranda, 2010).
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11. Equity Considerations
• Less educated individuals are less likely to
obtain treatment (Louvisson, 2008)
• Out-of-pocket expenditures disproportionally affect
the poorest (Ugá, 2007)
Income decile 1 5 10
OOP as fraction (%) of 6.76 5.26 3.08
income
Medicines as % of OOP 82.5 67.6 42
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12. Discussion
• The available evidence demonstrates limitations in the
provision of medicines by the Brazilian public health
care system.
• Lack of public availability of drugs shifts the financial
burden of medical treatment to users, compromising
significant amounts of household income.
• Individuals who cannot afford to buy medicines are
disproportionally harmed, contributing to increased
inequality.
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13. Limitations
• Nationwide data were not analyzed by region
• Comparisons between levels of complexity
(high-cost vs. essential medicines) or acute vs.
chronic treatments were not performed
• Cross-sectional data may limit the
understanding of patterns across time
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14. Conclusions
• In order to increase availability of drugs in the Brazilian
public health care system, improvements in budget
forecasting and health planning are needed
– Mechanisms for longitudinal data collection on access to
medicines should be developed
– Accounting for variations across regions, types of care and
treatment complexity should be incorporated
• Moving forward, empirical and epidemiologic evidence
should be combined in order to inform development and
implementation of pharmaceutical policies in the Brazilian
public health system
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