Analysis BMJ Glob Health: first published as 10.1136/bmjgh-2018-000829 on 3 July 2018. Downloaded from The Brazilian health system at crossroads: progress, crisis and resilience Adriano Massuda,1 Thomas Hone,2 Fernando Antonio Gomes Leles,3 Marcia C de Castro,1 Rifat Atun1 To cite: Massuda A, Hone T, ABSTRACT Leles FAG, et al. The Brazilian The Unified Health System (Sistema Único de Saúde Summary box health system at crossroads: (SUS)) has enabled substantial progress towards Universal Brazil has made good progress towards achieving progress, crisis and Health Coverage (UHC) in Brazil. However, structural ► resilience. BMJ Glob Health Universal Health Coverage (UHC) with improvements weakness, economic and political crises and austerity 2018;3:e000829. doi:10.1136/ in population health, but shortages in public funding, policies that have capped public expenditure growth are bmjgh-2018-000829 suboptimal resource allocation and weaknesses in threatening its sustainability and outcomes. This paper healthcare delivery persist. analyses the Brazilian health system progress since 2000 Handling editor Valery Ridde From 2000 to 2014, total health expenditure rose and the current and potential effects of the coalescing ► from 7.0% to 8.3% of gross domestic product and economic and political crises and the subsequent austerity Received 13 March 2018 population coverage with the Family Health Strategy Revised 4 June 2018 policies. We use literature review, policy analysis and rose from 7.6% to 58.2%. Accepted 5 June 2018 secondary data from governmental sources in 2000–2017 Since 2015, public health expenditure per capita has to examine changes in political and economic context, ► declined in real terms, while 2.9 million people lost health financing, health resources and healthcare service private health plan coverage, violent deaths have in- coverage in SUS. We find that, despite a favourable creased and there have been outbreaks of infectious context, which enabled expansion of UHC from 2003 diseases. to 2014, structural problems persist in SUS, including Economic and political crises, combined with aus- gaps in organisation and governance, low public funding ► terity policies, pose a major risk to UHC and health and suboptimal resource allocation. Consequently, large gains achieved Brazil, and elsewhere, with detri- regional disparities exist in access to healthcare services mental impact on the poorest and the most vulnera- and health outcomes, with poorer regions and lower ble populations, and require development of resilient socioeconomic population groups disadvantaged the most. health systems. These structural problems and disparities will likely worsen with the austerity measures introduced by the current http://gh.bmj.com/ government, and risk reversing the achievements of SUS in improving population health outcomes. The speed at been widely acknowledged as an example which adverse effects of the current and political crises of successful health system reform in Latin are manifested in the Brazilian health system underscores America,4 and has played a major role in the the importance of enhancing health system resilience to redemocratisation of Brazil and in the re-es- counteract external shocks (such as economic and political on September 25, 2021 by guest. Protected copyright. tablishment of citizens’ rights.5 Reforms in © Author(s) (or their crises) and internal shocks (such as sector-specific employer(s)) 2018. Re-use austerity policies and rapid ageing leading to rise in health system governance and major expan- permitted under CC BY-NC. No disease burden) to protect hard-achieved progress towards sion of primary healthcare (PHC) have commercial re-use. See rights UHC. contributed to major improvements in health and permissions. Published by service coverage and access,6 and health BMJ. 7 8 1 outcomes. Harvard TH Chan School INTRODUCTION However, Brazilian health reforms were of Public Health, Harvard University, Boston, After 30 years of progress towards Universal incomplete, and did not fully address struc- 1 Massachusetts, USA Health Coverage (UHC), Brazil’s Unified tural weaknesses in the health system— 2Public Health Policy Evaluation Health System (Sistema Único de Saúde namely, challenges at the state government Unit, School of Public Health, (SUS)) is under major threat from a combi- level, inadequate financing and inequitable Imperial College London, nation of economic recession, political crisis, resource allocation.9 Consequently, dispar- London, UK 2 3Pan-American Health ill-conceived austerity policies and political ities in access to effective care, financial 10 Organization (PAHO)/World decisions aimed at reversing the right to protection and health outcomes persist. Health Organization in Brazil, health.3 These disparities will likely worsen due to Brasilia, Brazil Conceived in the late 1980s by the civil the current economic and political crises 11 Correspondence to society as part of the ‘Sanitary Reform Move- and the new long-term austerity measures, 12 Dr Rifat Atun; ment’ (Movimento da Reforma Sanitária) which are testing health system’s resilience, ratun@ hsph. harvard. edu against the military dictatorship, SUS has jeopardising the sustainability of SUS13 and Massuda A, et al. BMJ Glob Health 2018;3:e000829. doi:10.1136/bmjgh-2018-000829 1 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2018-000829 on 3 July 2018. Downloaded from reversing the hard-achieved improvements in equity, SUS, underpinned by the principles of equity, solidary UHC and health outcomes. and social participation, aimed to develop a universal, We analyse the context that enabled of the expansion comprehensive and decentralised health system, free of SUS from 2000, the economic and political crises that of charge at the point of service provision.5 However, began in 2014, the austerity policies which followed and initial expansion of SUS was limited by weak technical the impact of these external and internal shocks on SUS. capacity of the federal government and lower levels of External shocks, such as economic and political crises, administration, inadequate financing stemming from can trigger cascades of events that adversely affect health economic instability and postmilitary right-wing govern- systems by increasing unemployment and poverty, ments opposed to social sector investments.9 Limited reducing funds for health services and increasing investment in SUS and the transfer of the responsibility demand for social protection programmes (figure 1; for health service provision to municipal governments blue arrows).2 This cascade of events can affect health with variable financial and administrative capacity have outcomes and health inequalities through changes in led to large disparities in health service coverage and health needs, behaviours and healthcare service use. access to healthcare.7 However, despite these limitations, Political crises, which can be triggered by economic crises, influence social protection and policies for UHC Brazil achieved major health system changes, with the development of inclusive decision-making at all levels of (figure 1; red lines), and could lead to worsening health 5 outcomes through poverty, and reduced coverage of government. healthcare services. In times of economic crisis, politi- In 2002, the right-wing government ceded power with cians could choose to maintain socially protective policies the election of President Luís Inácio ‘Lula’ da Silva and and protect health and social well-being of populations. his left-wing Workers’ Party (Partido dos Trabalhadores), However, although evidence from high-income countries which committed to improving health, reducing social shows protective effect of social welfare expenditures and disparities and alleviating poverty. During Lula’s presi- adverse effects of austerity measures,14 15 few studies have dency, economic stability and growth (figure 2) enabled explored the short and long-term effects of economic the government to introduce redistributive social assis- recessions in middle-income countries, and the protec- tance policies, which were associated with rising incomes tive effect afforded by UHC and social policies.16–18 and reductions in unemployment and inequalities.19 We undertook a literature review and analysed poli- The favourable political and economic climate allowed cies and secondary data from governmental sources to greater public funding for SUS. For each level of govern- examine changes in health financing, health service ment, minimum expenditure levels on health were estab- coverage and resources for health and the effect of the lished in 2000 and set in law in 2012.9 economic and political crises on SUS and population Between 2002 and 2013, with expansion of SUS, health in Brazil. there was near universal access to essential health http://gh.bmj.com/ services, such as immunisations and antenatal care, with EXPANSION OF THE UNIFIED HEALTH SYSTEM IN BRAZIL improved population health outcomes, and declines in 6 Following the end of the military dictatorship, the 1988 regional health inequalities. However, despite prog- Constitution established ‘health as a fundamental right ress, health inequalities remained a feature of Brazil, and a responsibility of the State’, with provisions to mirroring the wealth and income inequalities in the create a unified national health system. At its inception, country. on September 25, 2021 by guest. Protected copyright. Figure 1 The political and economic crisis cascade