Elsevier

The Lancet

Volume 394, Issue 10195, 27 July–2 August 2019, Pages 345-356
The Lancet

Health Policy
Brazil's unified health system: the first 30 years and prospects for the future

https://doi.org/10.1016/S0140-6736(19)31243-7Get rights and content

Summary

In 1988, the Brazilian Constitution defined health as a universal right and a state responsibility. Progress towards universal health coverage in Brazil has been achieved through a unified health system (Sistema Único de Saúde [SUS]), created in 1990. With successes and setbacks in the implementation of health programmes and the organisation of its health system, Brazil has achieved nearly universal access to health-care services for the population. The trajectory of the development and expansion of the SUS offers valuable lessons on how to scale universal health coverage in a highly unequal country with relatively low resources allocated to health-care services by the government compared with that in middle-income and high-income countries. Analysis of the past 30 years since the inception of the SUS shows that innovations extend beyond the development of new models of care and highlights the importance of establishing political, legal, organisational, and management-related structures, with clearly defined roles for both the federal and local governments in the governance, planning, financing, and provision of health-care services. The expansion of the SUS has allowed Brazil to rapidly address the changing health needs of the population, with dramatic upscaling of health service coverage in just three decades. However, despite its successes, analysis of future scenarios suggests the urgent need to address lingering geographical inequalities, insufficient funding, and suboptimal private sector–public sector collaboration. Fiscal policies implemented in 2016 ushered in austerity measures that, alongside the new environmental, educational, and health policies of the Brazilian government, could reverse the hard-earned achievements of the SUS and threaten its sustainability and ability to fulfil its constitutional mandate of providing health care for all.

Introduction

2018 marked the 30th anniversary of Brazil's seventh constitution,1 the 40th anniversary of the Alma-Ata Declaration,2 and the 70th anniversary of the Universal Declaration of Human Rights.3 In Brazil, the 1988 Constitution represented an instrument of change and a social movement that established health as a right of the Brazilian population, incorporating important elements of the Declaration of Human Rights and the Alma-Ata Declaration into the social contract. The constitution mandated the state's responsibility to deliver health care to all, paving the way to the unified health system (Sistema Único de Saúde [SUS]). It also initiated the journey to universal health coverage, with the aim of improving health outcomes in a health system that was highly fragmented and characterised by wide inequities in access to health care and health outcomes.

Since its creation in 1990, the SUS has made consistent progress towards delivering universal and comprehensive health care to the Brazilian population, helping to reduce inequalities in health-care access and the achievement of better outcomes, but not without challenges.4, 5 Despite the successes, the SUS is now at a crossroads.6, 7 Austerity measures introduced in 2016 (Constitutional Amendment 95) imposed a strict limit on the growth of public expenditure until 2036 at an amount based on the value of its previous financial year adjusted for inflation,8, 9 threatening further expansion and sustainability of the SUS (appendix pp 2–5),6 with adverse consequences for equity and health outcomes.

In this Health Policy, we present an overview of the first 30 years of the SUS (appendix pp 2–5), highlighting legal and organisational trajectories, achievements, and remaining challenges, followed by an analysis of future financial scenarios and associated health outcomes until 2030 (the target year for the UN Sustainable Development Goals) to show the consequences of fiscal entrenchment for the Brazilian health system.

The fiscal, economic, environmental, education, and health policies (eg, for adolescents and primary health care [PHC]) introduced by the Bolsonaro administration in 2019 pose a number of risks to the SUS. We discuss these threats and explore policy options that need to be introduced to sustain the SUS.

Section snippets

30 years of the SUS

Following the establishment of its principles in the 1988 Constitution and its creation in 1990, the legal mechanisms for the operationalisation and expansion of the SUS were progressively developed over 30 years (appendix pp 2–5). Major health programmes were launched to tackle persistent and emerging infectious diseases, high maternal and child mortality (table 1), and new challenges driven by four important transitions: first, migration from rural to urban areas, leading to disorganised

Projected population health effects of changes in future financing of the SUS

Over the past 30 years, the SUS expanded access to health services accompanied by falling inequalities in population health indicators, but its future performance is threatened by demographic, epidemiological, economic, political, and social transitions faced by Brazil.

To assess how these transitions could affect four health indicators until 2030 (the target year for the UN Sustainable Development Goals), we considered four hypothetical scenarios of federal transfer of funds to municipalities.

Discussion: looking ahead

Our results indicate a deterioration of all four health indicators in scenario one, where funding does not increase. Most importantly, the deterioration was larger among smaller municipalities, exacerbating geographical inequalities, and thus reversing a recent trend of overall improvements.4

In 1990, the World Summit for Children adopted a target to reduce infant mortality by a third or to 70 deaths per 1000 livebirths, whichever was the greater reduction, by the year 2000.82 Brazil registered

Conclusion

The defence of health as a right, combined with creativity and the ability to overcome adversity, made the SUS an example of health system innovation for Latin America and a reference to the world. That legacy cannot (and should not) be squandered. Looking ahead, as the new context unfolds, the effect of new policies on health outcomes, disparities and the wellbeing of the society as a whole must be critically examined to assess the consequences of fiscal, economic, environmental, education,

References (98)

  • LEPF de Souza

    The right to health in Brazil: a constitutional guarantee threatened by fiscal austerity

    J Public Health Policy

    (2017)
  • Emenda Constitucional n. 95. Altera o Ato das Disposições Constitucionais Transitórias, para instituir o Novo Regime Fiscal

  • P Rossi et al.

    Impacts of the new fiscal regime on health and education

    Cad Saude Publica

    (2016)
  • W Cano

    Questão regional e urbanização no desenvolvimento econômico brasileiro pós 1930

    (1988)
  • MC Castro et al.

    Malaria risk on the Amazon frontier

    Proc Natl Acad Sci USA

    (2006)
  • JAM Carvalho

    Demographic dynamics in Brazil: recent trends and perspectives

    Braz J Popul Stud

    (1997)
  • CCS Simões

    Relações entre as alterações históricas na dinâmica demográfica brasileira e os impactos decorrentes do processo de envelhecimento da população

    (2016)
  • Sustainable Development Goals. Global SDG Indicators Database

  • World Development Indicators

  • Global Health Observatory (GHO) data

  • World Development Indicators

  • GVA França et al.

    Coverage and equity in reproductive and maternal health interventions in Brazil: impressive progress following the implementation of the unified health system

    Int J Equity Health

    (2016)
  • LA Facchini et al.

    Evaluation of the effectiveness of primary health care in south and northeast Brazil: methodological contributions

    Cad Saude Publica

    (2008)
  • L Giovanella et al.

    Políticas e sistema de saúde no Brasil

    (2012)
  • ALdÁ Viana et al.

    The regionalization process in Brazil: influence on policy, structure and organization dimensions

    Rev Bras Saude Mater Infant

    (2017)
  • MV Andrade et al.

    Desigualdade socioeconômica no acesso aos serviços de saúde no Brasil: um estudo comparativo entre as regiões brasileiras em 1998 e 2008

    Econ Apl

    (2013)
  • SM Porto et al.

    Uma analise da utilização de serviços de saúde por sistema de financiamento: Brasil 1998–2008

    Cien Saude Colet

    (2011)
  • Diretoria de Desenvolvimento Setorial. Gerência-Executiva de Integração e Ressarcimento ao SUS

    (2017)
  • SF Piola et al.

    O financiamento dos serviços de saúde no Brasil

  • SF Piola et al.

    Estruturas de financiamento e gasto do sistema público de saúde

  • AC Médici

    Incentivos governamentais ao setor privado de saúde no Brasil

    Revista de Administração Pública

    (1992)
  • AC Médici

    A dinâmica do setor saúde no Brasil: transformações e tendências nas décadas de 80 e 90

    (1997)
  • MV Andrade et al.

    Transition to universal primary health care coverage in Brazil: analysis of uptake and expansion patterns of Brazil's family health strategy (1998–2012)

    PLoS One

    (2018)
  • DATASUS information technology at the service of SUS

  • MV Andrade et al.

    Brazil's family health strategy: factors associated with programme uptake and coverage expansion over 15 years (1998–2012)

    Health Policy and Plan

    (2018)
  • LF Pinto et al.

    The family health strategy: expanding access and reducing hospitalizations due to ambulatory care sensitive conditions (ACSC)

    Cien Saude Colet

    (2018)
  • Números da Saúde da Familia

    (2015)
  • Portaria no 648 de 28 de março de 2006: Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes e normas para a organização da Atenção Básica para o Programa Saúde da Família (PSF) e o Programa Agentes Comunitários de Saúde (PACS)

    (2006)
  • AF Boing et al.

    Redução das internações por condições sensíveis à atenção primária no Brasil entre 1998–2009

    Rev Saude Publica

    (2012)
  • R Aquino et al.

    Impact of the family health program on infant mortality in Brazilian municipalities

    Am J Public Health

    (2009)
  • F Guanais et al.

    Primary care and avoidable hospitalizations: evidence from Brazil

    J Ambul Care Manage

    (2009)
  • D Rasella et al.

    Impact of primary health care on mortality from heart and cerebrovascular diseases in Brazil: a nationwide analysis of longitudinal data

    BMJ

    (2014)
  • SN Girardi et al.

    Impacto do programa mais médicos na redução da escassez de médicos em atenção primária à saúde

    Cien Saude Colet

    (2016)
  • L Giovanella et al.

    A provisão emergencial de médicos pelo Programa Mais Médicos e a qualidade da estrutura das unidades básicas de saúde

    Cien Saude Colet

    (2016)
  • LMP Santos et al.

    Implementation research: towards universal health coverage with more doctors in Brazil

    Bull World Health Organ

    (2017)
  • Programa Mais Médicos no Brasil. Panorama da Produção Científica

    (2017)
  • GM La Forgia et al.

    Hospital performance in Brazil: the search for excellence

    (2008)
  • GWS Campos et al.

    A clínica ampliada e compartilhada, a gestão democrática e redes de atenção como referenciais teórico-operacionais para a reforma do hospital

    Ciencia Saude Colet

    (2007)
  • G Vecina Neto et al.

    Tendências na assistência hospitalar

    Cien Saude Colet

    (2007)
  • Cited by (0)

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