Health System in Brazil: Reforms, Transformation and Challenges

Abstract

This paper analyses the Brazilian health system in the backdrop of the country’s health system reform, Sistema Único de Saúde (SUS), implemented in the 1990s. The objective of this analysis is to draw lessons for health system strengthening aimed at access and equity in health services, financial protection and improved health outcomes for lower and upper middle income countries aspiring to achieve universal health coverage (UHC). The paper traces the trajectory of health system reform in Brazil, from 1990 to 2019, and analyses the contextual factors that drove the reform process.

Prior to SUS, the Brazilian health system experienced challenges ranging from centralization in financing and administration, a fragmented health delivery system with predominance of private sector, with low public spending in health causing inequities in the distribution of health resources. These led to high out of pocket expenditure on health, regional disparity in access and health outcome.  To address the gaps, SUS took several measures including the decentralization of the health system, strengthening  primary care services, constitution of health as a legal right, and leveraging private sector by applying contracting mechanism with effective regulation through the  establishment of  autonomous agencies.

These  interventions contributed to reducing regional disparity in health care access, outcome, and financing.  The inequity in maternal and child health outcomes witnessed considerable improvement, along with an increase in the coverage of preventive services. Through the Family Health program, th reform led to an increase in primary health care coverage  from 6.7 percent in 1998 to 75 percent in 2019. Out of pocket expenditure (as percentage of total health expenditure) reduced from 39 percent in 1995 to 28 percent in 2020. Despite these achievements, gaps remain in terms of the greater utilization of SUS linked hospitals instead of PHC, persistent utilization of private facilities (covering 25 percent of the population), rising disease burden due to non communicable disease, and relatively high out of pocket expenditure. This paper attempts to understand the key policy instruments that contributed to these positive shifts and the context within which they were successful.