MFC Background paper by Abhay shukla universal access to health care

1. 12/4/2010
Brazil: A Country of
Inequalities
100
1188
467
Among the highest 90
283
Brazil: in income
80
126
70
concentration 60
A System for Universal Access to Gini = 60.7 50
58
Health Care Important 40
differences across 30
29
economic levels in 20
Compiled by Abhay Shukla 10
<abhayshukla1@gmail.com> health 13
0
based on various articles and documents education
Centiles of income distribution in Brazil.
employment Values in US dollars.
Earlier Model – Three Sub
Systems Social Security
Until the 1960s, health care services Social security - the state began to
participate in the financing of public and
in Brazil were organized according to private companies’ social security benefits, to
three subsystems, provide health care to workers and their
dependants.
Social security Social security institutions were organized
according to professional categories and
The Ministry of Health and according to a classic insurance model:
benefits depended on the ability of the
The private sector category of employee to pay.
Social security became the dominant system
for providing health care services in the
country
Ministry of Health Private Sector
The Ministry of Health, organized in a The private sector, was independent of
parallel structure, was responsible for the main subsystems and limited to
preventive care. (vaccination services provided by autonomous
campaigns, sanitation, and so forth) physicians through direct payment
In terms of medical care, the Ministry
was responsible only for the creation
and maintenance of chronic care
facilities
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Pre-reform Situation Growing Privatisation
Contributed to the creation of a specific model Relationship between the public and private
of health care in the 1970s, with basic sectors was restricted almost exclusively to
characteristics that would become the contracting, based on fee-for-service payment,
with no control over the kind of medical care
principal targets of health reform. provided.
• high level of centralization Thus, medical care was characterized by high-
• dichotomy of institutions within the health cost, specialized, curative, and hospital-based
care system treatment.
• growth in coverage through private The absence of policies based on the actual
provision of health care epidemiological profile and health needs of the
population meant that services concentrated in
• incomplete coverage the more profitable regions, causing an imbalance
• regressive financing in supply
Social Security Supporting Privatisation An Inequitable Health System
The National Institute of Medical Care and Health System was highly privatized, already
Social Security contracted more and more established as a medico-industrial complex,
often with third parties to care for the Preeminently curative, concentrated in urban
increasing clientele. nuclei and only in high-income neighborhoods.
This gave the private sector a progressively Access was unequal, as were the services
more important role in service provision. offered.
As a result, the publicly owned network Services were not available in all regions nor
shrank and deteriorated. By 1976, for were they prioritized.
example, only 27% of all hospital beds Main feature of health care management was
were public, while 73% belonged to the the non-existence of any public control over
private sector health policy.
Social Security Crisis In
1980s The Health Movement
Proliferation of expensive medical care The Health Movement strategically associated the
without a corresponding change in the demand for health care services with the demand for
method of financing; a democratic regime.
A method of paying the private sector that
stimulated an increase in expensive The main principles of the Health Movement were that
specialized procedures, as well as fraud; health is a right of all citizens, to be provided by the
state through a universal health system based on
Difficulty in controlling finances because of integrity and equity in health care
the disorganized structure of the system;
Deterioration in the quality of services; The effectiveness of the Movement required the
A national economic crisis allied to a construction of a political strategy that encouraged
broader crisis of international scope. civil-society organizations to demand the universal
right to health as an obligation of the state
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Mobilisation on Two Fronts
Mobilisation on Two Fronts
Mobilisation proceeded along two broad fronts. Second front consisted of the mobilization of
those organized sections of society for the
First front was the production of knowledge, democratization of health care.
dedicated to promoting the political
struggle, to the elaboration of case studies This proceeded along various lines of action, ranging
from those professional areas linked to health care and
about the inequities of access to health education, to unions, religious social groups, social
care in Brazilian society and the inequities movements, and popular organizations
of the country’s health system.
Led essentially, by two political forces –
A Marxist perspective in health studies; the
importance of Latin American Social The clandestine PCB (Brazilian Communist Party)
Medicine The recently formed PT (Workers´ Party) - a mass left
political party
Some Demands for Reform 8th National Health Conference
restructuring financing mechanisms to In 1986 at the 8th National health
broaden the support base beyond the conference the reform became a policy
payroll;
reversing the process of privatization and This brought together not only broad sectors
establishing ways for the public sector to of civil society and representatives of the
control the private sector; most important institutions in the sector,
giving greater decision-making and but also professional groups and political
financing autonomy to the states and parties.
municipalities; and
introducing the participation of social The conference differed from previous ones in
organizations in formulating and its participatory nature
implementing health policies.
Guiding Principles of the Guiding Principles of the Health
Health Care Reform Care Reform
Health as a right of citizenship. All Brazilian Integrated and hierarchical health care organized to
citizens acquired the right to health care provided by provide integrated care; activities had to be based on the
epidemiological profile of the population. Provision of
the state, thereby characterizing health as an activity services had to be arranged with respect to the health care
of public relevance. hierarchy and had to provide people with universal access
Equal access. All citizens should have equal access to all levels of care.
to health services, with no discrimination of any kind. Social control and social participation. The system had
to be governed according to democratic criteria, and the
Health as a component of social welfare. The participation of civil society in its decisions was of
health sector had to be integrated with the social paramount importance.
welfare system, Decentralization and regionalism led to a redistribution
of the responsibilities between levels of government.
A single administration for the public system. Provision of health services had to become the
creation of a single system to aggregate all health responsibility of municipal governments, aided financially by
services provided by federal, state, and municipal the federal government and the states
public institutions
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The Brazilian “Unified Health Three Health Care Delivery
System” (SUS) Systems
Presently, three main care health delivery systems
Created by the 1988 Constitution coexist in the country:
Universal system the SUS, which provides free care to all residents in
the country (covers 75% of population)
covering everyone independent of the Supplementary Health System (SHS) run by
contribution private healthcare insurance companies or health
cooperatives (covering 35 million paying members)
offering preventive and curative care, the Private Health System (PHS), totally private, used
dealing with simple and complex only by the highest-income population
problems
decentralized at municipal level Health care funding in Brazil is drawn from various
sources; two thirds are public and one third private
Funding for SUS Sources of Funds
Funding for the SUS is guaranteed by Federal Government still provides
a Constitutional Amendment, over 70 per cent of funding for the
approved in 2000, according to which health sector, with States providing
Federal funds should increase at a 20 per cent and municipalities 10 per
rate of 5% a year and States and cent or less.
municipalities are obliged to spend Funds are collected through taxation.
12% and 15% of their respective A tax levied on money transfers into
revenues on health bank accounts was introduced to
Total national health expenditure is benefit the health sector.
estimated at US$250 per capita.
Social and Health Expenditure - Brazil Private Sector has Higher
1980-81 1982-89 1990-95
Costs
Education
In 2007, the budget of the Ministry of Health
% GNP 2.9 3.5 4.6
was R$40 billion. This financed a system
Per capita 33.5 57.7 100.5 that potentially covered about 143 million
Health beneficiaries of public health care
Around 40 million Brazilians have some type
% GNP 3.2 3.5 4.6
of private health insurance, R$60 billion
Per capita 36.3 58.5 100.5 were spent by those affiliated to the private
Social security health care system.
% GNP 6.4 6.6 8.5 It is therefore a myth that privatization
reduces costs
Per capita 73.3 108.8 185.6
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Distribution of Care Family health program - PSF
Seventy-five per cent of the population is
Health facility with clear geographic
covered by the SUS services.
coverage
Public institutions provide 75 per cent of
Team formed by
SUS out-patient care.
full-time general practitioner
Between 70 and 80 per cent of SUS in-
registered nurse
patient care is provided by contracted
nurse
private services.
4 community health workers
University hospitals are mainly public and
Looks after 1000 families (~3000 people)
provide half of public hospital care.
Competitive salary levels
Large Scale People’s
PSF implementation Participation
A landmark of SUS is community participation,
Initially deployed in guaranteed by a network of over 5,000
areas not covered by a health center Municipal Health Councils, 27 State Health
poorest areas Councils, and the National Health Council,
Next, existing health centers turned involving some 100,000 individuals in this
into PSF units voluntary work.
Eventually, all primary health care Most of the decisions on healthcare such as
to be based on PSF budget, construction of health facilities,
implementation of health programs, etc.,
Ministry of Health estimate:
must be approved by health councils
~35% population covered
Health Councils Twelfth National Health Conference
All social sectors are represented in The participatory process reaches its peak
during the National Health Conferences: the
these councils: latest, held in December 2003, involved
clientele or community approximately 300,000 people at three
representatives (50%) levels: municipal, State, and national
The Twelfth National Health Conference
health providers plus health was held in 2003 on the theme
managers / officials (25%) "Health is a Right for All and the Duty of
healthcare workers (25%) the State – the Health We Have and the
SUS We Want"was attended by nearly
5,000 people
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Trends in the Health
Mechanisms for Transferring
Movement Funds
Disagreements over the manner in which public Mechanisms for transferring funds from the
participation is being institutionalized and
bureaucratized have led to divisions in the people's federal to state and municipal levels –
movement for health.
An MOP faction has defended creation of a People's
Previously such transfers were based on
Health Council as an autonomous forum to replace calculation – either of existing
the State Health Council. infrastructure or service capacity and
The dilemma of the people's movements in playing the
role of State's opponent while interacting with the provision.
State; when the councils were created, some Starting in 1998 the transferring of funds
movements, upon being called, refused to have
institutionalized participation became automatic and based on a fixed
In 1992, at the Ninth National Health Conference, per capita value for basic health services
social movement members decided to create and
maintain autonomous forums in order to preserve — either individual or collective.
their independence and avoid the possibility of the
forums being treated as instruments.
Distribution of Health Care Facilities
Public Private
Two Types of Transfers
With the creation of the PSF (Family Health Classes n % n %
Care Program) two components, Basic units 6 038 98.0 131 2.0
a fixed one (based on a set per capita
calculation), Health 14 129 98.5 189 1.5
a variable component which allowed the centres
transfer of federal funds to priority
Polyclinics 2 126 25.5 6 170 74.5
programs. These include the PSF, the
Pharmaceutical Assistance Program and the
Program for Controlling Nutritional Emergencies 188 65.5 98 34.5
Deficiencies.
Hospitals 1377 21.0 5 155 79.0
Total 23 858 67% 11 843 33%
Human Resources - Brazil
Shift from Private to Public
1976 1992
In 1995 the relation of public hospital
beds per thousand people was 0.71
while that of private hospital beds Public Private Public Private
was 2.29/1,0000
In 2005 these proportions had changed Physician 54 201 62 259 65 205 106 356
to 0.84 and 1.19 – trend of increase s
in public beds compared to private
Nurses 30 833 40 200 46 785 48 242
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Organogram
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