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.
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
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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.
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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.
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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.
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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.
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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.
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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