Health PolicyBrazil's unified health system: the first 30 years and prospects for the future
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)
- et al.
Successes and failures in the control of infectious diseases in Brazil: social and environmental context, policies, interventions, and research needs
Lancet
(2011) - et al.
Chronic non-communicable diseases in Brazil: burden and current challenges
Lancet
(2011) - et al.
The Brazilian health system: history, advances, and challenges
Lancet
(2011) - et al.
Explaining trends in inequities: evidence from Brazilian child health studies
Lancet
(2000) Constitution of the Federative Republic of Brazil of 1988
Declaration of Alma-Ata. International Conference on Primary Health Care
Universal Declaration of Human Rights
- et al.
Horizontal equity in health care utilization in Brazil, 1998–2008
Int J Equity Health
(2012) - et al.
The impact of primary healthcare on population health in low- and middle-income countries
J Ambul Care Manage
(2009) - et al.
The Brazilian health system at crossroads: progress, crisis and resilience
BMJ Global Health
(2018)