Elsevier

The Lancet

Volume 377, Issue 9779, 21–27 May 2011, Pages 1778-1797
The Lancet

Series
The Brazilian health system: history, advances, and challenges

https://doi.org/10.1016/S0140-6736(11)60054-8Get rights and content

Summary

Brazil is a country of continental dimensions with widespread regional and social inequalities. In this report, we examine the historical development and components of the Brazilian health system, focusing on the reform process during the past 40 years, including the creation of the Unified Health System. A defining characteristic of the contemporary health sector reform in Brazil is that it was driven by civil society rather than by governments, political parties, or international organisations. The advent of the Unified Health System increased access to health care for a substantial proportion of the Brazilian population, at a time when the system was becoming increasingly privatised. Much is still to be done if universal health care is to be achieved. Over the past 20 years, there have been other advances, including investments in human resources, science and technology, and primary care, and a substantial decentralisation process, widespread social participation, and growing public awareness of a right to health care. If the Brazilian health system is to overcome the challenges with which it is presently faced, strengthened political support is needed so that financing can be restructured and the roles of both the public and private sector can be redefined.

Introduction

In this report, we examine the organisation, historical development, and present state of the Brazilian health system. We review published studies and original data from official sources to provide an overview of the Brazilian health system and outline future challenges.

Brazil is a federative republic that covers 8·5 million km2—or 47% of South America. With an estimated population of 190 732 694 in 2010,1 Brazil is the world's fifth most populous country. Its political system is composed of several political parties and three levels of autonomous government—federal government, 26 states and a federal district, and 5563 municipalities. Brazil is governed by means of an independent judiciary, an executive branch led by the president, and a bicameral legislature. Brazil was a colony of Portugal from the year 1500 onwards and, although it gained political independence in 1822, it did not become a republic until 1889. Slavery was abolished in 1888. The Brazilian population is multi-ethnic; in 2008, about half the population self-classified their race or skin colour as brown (43·8%) or black (6·8%), and 0·6% thought of themselves as indigenous to Brazil.2 In the 20th century, Brazil underwent rapid industrialisation during a time of political instability, military takeovers, and authoritarian governments, with brief periods of democratic rule—Brazil has had its longest period of democracy during the past 25 years.

Health sector reform in Brazil was driven by civil society rather than by government, political parties, or international organisations. The Unified Health System (Sistema Único de Saúde; SUS), instituted by the 1988 constitution, is based on the principle of health as a citizen's right and the state's duty.

Brazil has undergone major political, economic, demographic, and social changes in the past 40 years. In 1970, under the military regime, Brazil's economic growth was among the highest in the world, but improvements in quality of life disproportionately benefited the most privileged populations. Although democracy was restored in the mid-1980s, during a period of economic instability, resumption of economic growth and improvement of social protection did not happen until the 21st century.

Key messages

  • Since 1988, Brazil has developed a dynamic, complex health system (the Unified Health System; SUS), which is based on the principles of health as a citizen's right and the state's duty. The SUS aims to provide comprehensive, universal preventive and curative care through decentralised management and provision of health services, and promotes community participation at all administrative levels.

  • The Brazilian Health Sector Reform occurred at the same time as democratisation, and was spearheaded by health professionals and individuals in civil society movements and organisations.

  • Implementation of the SUS has been complicated by state support for the private sector, the concentration of health services in more developed regions, and chronic underfunding.

  • 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.

  • Future challenges for the SUS include reforming its financial structure to ensure universality, equity, and long term sustainability, renegotiating public and private roles, reshaping the model of care to cater to Brazil's rapid demographic and epidemiological changes, and assuring quality of care and the safety of patients.

  • Ultimately, the challenges facing the SUS are political because they cannot be resolved in the technical sphere but through only the concerted efforts of individuals and the society.

The country is divided into five geographical regions (north, northeast, centre-west, southeast, and south; figure 1) with differing demographic, economic, social, cultural, and health conditions, and widespread internal inequalities. For example, the southeast region covers only 11% of Brazil's territory, but accounts for 43% of the population and 56% of gross domestic product. The north region, which contains most of the Amazon rainforest, has the country's lowest population density (3·9 people per km2) and is the second poorest region, after the northeast region.

Between 1970 and 2000, Brazil underwent a demographic transition; the proportion of the population older than 60 years (10% in 2009) doubled and urbanisation increased from 55·9% to 80%.1 Fertility rates decreased (5·8 in 1970 to 1·9 in 2008), as did infant mortality (114 per 1000 livebirths in 1970 to 19·3 per 1000 livebirths in 2007). As a result, life expectancy at birth increased by nearly 40%, to 72·8 years in 2008 (table 1).

Unemployment in 2007 was low at 8·2%, but many (43·8%) workers were employed in the informal sector—56% of those employed had social security coverage. By 2020, the old-age dependency ratio is expected to be 68 people older than 60 years to every 100 children and adolescents,9 and the proportion of the population of age to enter the labour market is expected to be larger than ever before.10 School attendance has increased since 1990, and illiteracy rates have decreased from 33·7% in 1970 to 10·0% in 2008 (table 1).

Between 1991 and 2008, Brazil's gross domestic product doubled and its Gini coefficient, although among the highest in the world, decreased by 15% from 0·637 to 0·547.5 The poverty index decreased from 68% in 1970 to 31% in 2008—this improvement can be attributed to a combination of social policies, including the social security system, the Bolsa Família conditional cash transfer programme (which, in 2008, distributed R$13 billion [about US$7·2 billion] among 10·5 million families),11 and increases in the legal minimum wage.

Living conditions have also changed substantially. In 1970, only 33% of households had indoor water, 17% had access to sewerage, and less than half had electricity (table 2). By 2007, 93% of households had indoor water, 60% had access to sewerage, and most had access to electricity. Ownership of consumer goods has also increased; in 2008, more than 90% of households had a refrigerator and television, 75% had mobile phones, 32% had a personal computer, and 80% of Brazilians who were 15 years or older reported use of broadband internet.1

Such changes in living conditions have had an effect on Brazilians' health and health behaviour. The prevalence of overweight and obesity is increasing; 47·3% of men in state capitals report being overweight.13, 14 About a third of families report that they do not have enough food to eat.15 Although only 19% of adults in state capitals eat enough fruit and vegetables (ie, at least five portions of fruit or fruit juices and vegetables per day, five or more days per week), the quality of peoples' diet seems to be improving with time.16 Physical activity is low in state capitals,2 but tobacco use has decreased as a result of the National Tobacco Control Programme—in 2008, 17·2% of the population smoked, compared with 34·5% in 1989, when the programme began. Alcohol misuse is another challenge; 17·6% of people aged 15 years or older report binge drinking.9

Changes in mortality and morbidity rates are related to these demographic, epidemiological, and nutritional transitions. Diseases of the circulatory system are the leading cause of death, followed by cancer and external causes (largely homicides and traffic accidents).17 Chronic diseases are the biggest contributor to the burden of disease, and communicable diseases, although decreasing with time, still affect a substantial proportion of the population. An estimated 40–50% of Brazilians older than 40 years are hypertensive and 6 million are diabetic,9 representing an enormous challenge to a health system organised to provide predominantly acute care (table 3).22

Geographical and social inequalities in morbidity and mortality rates exist. In 2006, the northeast region had an infant mortality rate 2·24 times higher than that of the south region, although this disparity has decreased.4 In Brazil, people who identify their race or skin colour as brown or black tend to be from lower income and educational groups, and inequalities in some health outcomes (such as the prevalence of hypertension) exist between people of different race or skin colour. However, for other indicators, such as self-assessed health, outcomes are much the same after adjustment for socioeconomic status.23, 24, 25 Although race and social class are also related in other countries, the means by which racial relations in Brazil affect health are distinct.26

Section snippets

Background to the Brazilian health system

The Brazilian health system consists of a variety of public and private organisations that were set up in different historical periods (figure 2). In the early 1900s, public health campaigns, undertaken in an almost military fashion, were used to implement public health activities. The authoritarian nature of these campaigns brought about opposition from parts of the population and some politicians and military leaders. Such opposition led to the vaccine revolt in 1904, a period of unrest in

Health system components

The SUS is tasked with undertaking health promotion, health surveillance, vector control, and health education, and with ensuring continuity of care to all Brazilians at the primary, specialist outpatient, and hospital levels.

Conclusions

The 1988 Brazilian constitution recognised health as a citizen's right and a duty of the state, and established the basis for the creation of the SUS, which was based on the principles of universality, integrality, and social participation. Such constitutional recognition of health care was made possible after lengthy political struggles and the actions of the Brazilian Health Reform Movement. The implementation of a universal health system in Brazil began in an unfavourable political and

References (115)

  • J Macinko et al.

    Going to scale with community-based primary care: an analysis of the family health program and infant mortality in Brazil, 1999–2004

    Soc Sci Méd

    (2007)
  • Séries estatísticas & séries históricas. Rio de Janeiro: O Instituto

  • Microdados PNAD

    (1981)
  • Rede Interagencial de Informações para a Saúde–RIPSA. Indicadores e Dados Básicos – Brasil, 2008 - IDB

  • CG Victora et al.

    Maternal and child health in Brazil: progress and challenges

    Lancet

    (2011)
  • Statistical Information System Whosis. Geneva: World Heatlh Organization

  • Sistema de Informações Orçamentos de Saúde

    (2008)
  • Diretoria de Pesquisas. Coordenação de Contas Nacionais. Contas Nacionais, número 29. Conta Satélite de Saúde. Brasil 2005–2007

    (2007)
  • Sistema de Planejamento do SUS: uma construção coletiva

    (2010)
  • M Pochmann

    Pobreza e crise econômica: o que há de novo no Brasil metropolitano. Nota Técnica

    (2009)
  • As causas sociais das iniquidades em saúde no Brasil

    (2008)
  • AP Pereira

    Consumo residencial de energia e desenvolvimento: um estudo da realidade brasileira [dissertação]

    (2008)
  • MI Schmidt et al.

    Chronic non-communicable diseases in Brazil: burden and current challenges

    Lancet

    (2011)
  • Datasus. Vigitel - Vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico - state capitals only, 2006 and 2008

  • Pesquisa de Orçamentos Familiares 2008/2009

    (2010)
  • Divulgados resultados do Vigitel 2008

    (2009)
  • ME Reichenheim et al.

    Violence and injuries in Brazil: the effect, progress made, and challenges ahead

    Lancet

    (2011)
  • Brasil. Ministério da Previdência Social. AEPS infologo

  • Anuário Estatístico do Brasil, 1983

    (1983)
  • Informações de Saúde. Assistência à Saúde

  • Cadastro Nacional de Estabelecimentos de Saúde (CNES) - May 2010. Brasília-DF: O Ministério

  • E Mendes

    As redes de atenção à saúde

    (2009)
  • JNW Dachs

    Determinantes das desigualdades na auto-avaliação do estado de saúde no Brasil: análise dos dados da PNAD/1998

    Ciênc Saúde Coletiva

    (2002)
  • P Singer et al.

    Prevenir e curar: o controle social através dos serviços de saúde

    (1978)
  • R Machado et al.

    Danação da norma: medicina social e constituição da psiquiatria no Brasil

    (1978)
  • JC Braga et al.

    Saúde e previdência: estudos de política social

    (1981)
  • S Escorel

    Reviravolta na saúde: origem e articulação do Movimento Sanitário

    (1998)
  • MH Almeida

    Federalismo e políticas sociais

  • SM Draibe et al.

    Desenvolvimento de políticas de saúde nos anos 80: o caso brasileiro

    (1990)
  • CM Almeida

    A assistência médica ao trabalhador rural: FUNRURAL, a história de uma política social [dissertação]

    (1981)
  • L Bahia

    Padrçes e mudanças das relações público-privado: os planos e seguros saúde no Brasil [tese]

    (1999)
  • RA Pego et al.

    Teoria y práctica de las reformas de los sistemas de salud: los casos de Brasil y Mexico

    Cad Saúde Pública

    (2002)
  • CM Almeida

    As reformas sanitárias nos anos 80: crise ou transição? [tese]

    (1995)
  • MT Luz

    Notas sobre as políticas de saúde no Brasil de “transição democrática” - anos 80

    Physis Rev Saúde Coletiva

    (1991)
  • J Birman

    A Physis da Saúde Coletiva

    Physis Rev Saúde Coletiva

    (1991)
  • SMF Teixeira

    O dilema reformista na reforma sanitária brasileira

    Rev Adm Pública

    (1987)
  • AC Médici

    Financiamento e contenção de custos nas políticas de saúde: tendências atuais e perspectivas futuras

    Planej Polít Públicas

    (1990)
  • B Lamounier et al.

    A era FHC, um balanço

    (2002)
  • Secretaria Executiva. Departamento de Apoio à Descentralização. Diretrizes operacionais dos Pactos pela Vida, em Defesa do SUS e de Gestão

    (2006)
  • MC Maio et al.

    Fórum. O desafio SUS: 20 anos do Sistema Único de Saúde. Introdução

    Cad Saúde Pública

    (2009)
  • C Almeida

    La implementación de la reforma en Brasil: la dinámica del Sistema Único de Salud y algunos resultados

  • SV Côrtes

    Fórum. Sistema Único de Saúde: espaços decisórios e a arena política de saúde

    Cad Saúde Coletiva

    (2009)
  • MR Moreira et al.

    Conselhos Municipais de Saúde

    Ciênc Saúde Coletiva

    (2009)
  • S Escorel et al.

    Participação social

  • AS Miranda

    Intergovernmental health policy decisions in Brazil: cooperation strategies for political mediation

    Health Policy Plan

    (2007)
  • JS Müller Neto et al.

    Conferências de saúde e formulação de políticas em 16 municípios de Mato Grosso, 2003–2005

    Saúde Debate

    (2006)
  • L Tatagiba

    Os conselhos gestores e a democratização das políticas públicas no Brasil

  • AI Carvalho
  • Cited by (0)

    View full text