Brazil M F C 2011h


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MFC Background paper by Abhay shukla universal access to health care

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Brazil M F C 2011h

  1. 1. 12/4/2010 Brazil: A Country of Inequalities 100 1188 467 Among the highest 90 283 Brazil: in income 80 126 70 concentration 60A 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 <> 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 countryMinistry of Health Private SectorThe 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 paymentIn terms of medical care, the Ministry was responsible only for the creation and maintenance of chronic care facilities 1
  2. 2. 12/4/2010Pre-reform Situation Growing PrivatisationContributed 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 supplySocial 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 2
  3. 3. 12/4/2010 Mobilisation on Two FrontsMobilisation on Two FrontsMobilisation proceeded along two broad fronts. Second front consisted of the mobilization of those organized sections of society for theFirst 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 partySome 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 HealthHealth 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 3
  4. 4. 12/4/2010 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 CostsEducation In 2007, the budget of the Ministry of Health% GNP 2.9 3.5 4.6 was R$40 billion. This financed a systemPer capita 33.5 57.7 100.5 that potentially covered about 143 millionHealth 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 billionPer capita 36.3 58.5 100.5 were spent by those affiliated to the privateSocial security health care system.% GNP 6.4 6.6 8.5 It is therefore a myth that privatization reduces costsPer capita 73.3 108.8 185.6 4
  5. 5. 12/4/2010Distribution 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’sPSF 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 ConferenceAll 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 5
  6. 6. 12/4/2010 Trends in the Health Mechanisms for Transferring Movement FundsDisagreements over the manner in which public Mechanisms for transferring funds from the participation is being institutionalized and bureaucratized have led to divisions in the peoples federal to state and municipal levels – movement for health.An MOP faction has defended creation of a Peoples 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 andThe dilemma of the peoples movements in playing the role of States 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 fixedIn 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 PrivateTwo Types of TransfersWith 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, thePharmaceutical 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 - BrazilShift from Private to Public 1976 1992In 1995 the relation of public hospital beds per thousand people was 0.71 while that of private hospital beds Public Private Public Private was 2.29/1,0000In 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 6
  7. 7. 12/4/2010Organogram 7