Since 1988, the newly established Brazilian constitution has affirmed access to public healthcare as the right of every citizen. As the resulting healthcare system has developed over the years, it has gained global recognition as an emblem of inclusivity.
Nevertheless, longstanding inequities in the Brazilian healthcare system reflect the stark income inequality that still plagues the country today.
In the aftermath of the coup that ousted Dilma Rousseff on May 12, the future of healthcare equality in Brazil faces significant barriers at the hands of the provisionary government of Michel Temer.[1]
Overall, Brazil’s Sistema Único de Saúde (SUS) has greatly improved the state of healthcare equality in one of the world’s most historically unequal societies.
The free universal healthcare system was first implemented in the period of re-democratization in the late 1980s, and was a result of continued popular protest for the provision of public services during the era of military dictatorship.
The SUS is founded on the principles of decentralization (meaning that financing comes from federal, state, and municipal governments), equal access to healthcare, and comprehensiveness (meaning that the system covers all aspects of care, from preventative measures to hospital treatment).
Since the implementation of the SUS, Brazil has seen an increase in life expectancy from 66 years in 1990 to 74 years today.[2] In the same period, the maternal mortality rate has decreased by 50 percent and the rate of infant mortality has fallen from 27 stillbirths per 1,000 births to just 15.[3]
One of the most unique and effective elements of the SUS is its “Family Health Strategy,” which sends “healthcare teams” consisting of a physician, a nurse, a nurse’s assistant, and four to six community healthcare agents to municipalities throughout the country.
The healthcare agents are essentially lay workers with no formal medical training. Each agent is assigned to approximately 150 households and checks in with families to collect data and ensure their well being.
They do not dispense medication, but rather offer advice on exercise, nutrition, and pain management, among other helpful health tips. These agents are a critical element of the system, and help to ensure that individuals do not fall through the cracks of the massive state-run apparatus.
Despite successes, the SUS is not without flaws, and the challenge of financing a system that provides truly equal access to all has plagued the country since its inception. One of the most pressing issues in this idealistic system lies in its unique financing mechanism, which consists of a combination of tax revenue from the federal government and contributions from state and municipal budgets.
Due to the reliance on municipal budgets, municipalities in the poorer northern region have a much lower capacity to provide funding for healthcare than those in the richer south. As a result, the existing clinics in the north are rife with outdated and sparse medical tools, unsanitary conditions, and overcrowded facilities.
Since the standard of living in the north is extremely low — as is remuneration for professionals, employment opportunities for spouses, and education for children — there is little incentive for doctors to live and work in the impoverished northern region.
The stark contrast in the country’s distribution of medical professionals clearly reflects the lack of incentive to work in poor areas. Whereas the bustling Rio de Janeiro has a concentration of 3.44 doctors per 1,000 people, there are just 0.58 doctors for every 1,000 people in the rural northeast.[4]
The scarcity of doctors in poor areas is partially driven by medical school curricula that do not encourage students to pursue generalized medicine. Since most aspiring physicians are pushed to pursue the far more lucrative specialized fields, both the public and private healthcare systems suffer from an extreme lack of primary-care doctors.
As a result, Brazilians are forced to seek out several different specialized doctors to address health concerns that could otherwise be addressed by a single provider. Furthermore, the medical profession in Brazil is typically reserved for the white urban elite.
Since few medical schools exist outside the major cities, those from rural areas are unable to become doctors unless they have the means to travel elsewhere to receive training.
Since, logically speaking, those who are most likely to practice medicine in the rural northeast are people who hail from those areas, until this segment of the population has reasonable access to medical education, the distribution of care will remain a pressing issue.
Unequal access to the Brazilian legal system further contributes to inequality in the healthcare system. While about a quarter of Brazilians can afford to bypass the long lines and deteriorating clinics to pay for private healthcare, this same wealthy subset of the population also has the unique ability to use the legal system to demand that expensive drugs and costly procedures be provided for free, as per the constitution’s mandate.
Since judges almost always rule in favor of the plaintiffs, this widespread practice drains a large portion of the healthcare budget away from addressing the health issues of the larger public.[5] The country’s poor, whether they live in the favelas of Rio de Janeiro or in the rural northeast, cannot afford to sue the government to demand care.
Instead, poor Brazilians must endure long lines, and those from rural areas are forced to travel to receive relatively low quality care in crumbling, unsanitary clinics with insufficient resources.
Regardless of the deficiencies in the current system, it is worth noting that without access to free treatment through the SUS, millions of middle and lower class Brazilians would otherwise be unable to receive any kind of at-cost medical assistance.
Workers’ Party and the SUS
While the legacy of the SUS predates the arrival of the Partido dos Trabalhadores (Workers’ Party, PT) to the political stage, both the administrations of Luis Inácio Lula da Silva and Dilma Rousseff have made substantial improvements to the universal healthcare system — improvements that now face dissolution at the hands of the provisional Temer government.
Notably, both Lula and Rousseff prioritized the issue of access to essential medicines and led a fight against international pharmaceutical companies to implement intellectual property laws that have facilitated the production of low-cost generic drugs.[6]
Through the Popular Pharmacy program, established during Lula’s presidency in 2004, the government increased subsidies for medicines and constructed public pharmacies throughout the country that dispense free drugs for chronic diseases such as diabetes, hypertension, and asthma.
In addition to growing the number of participating pharmacies and eligible drugs, the Ministry of Health under Rousseff expanded upon Lula’s free emergency ambulatory care program (SAMU) by building more emergency clinics. Throughout their terms, both leaders maintained their commitment to providing critical care for the poor.
Rousseff’s most notable contribution was the launch of the 2013 Mais Médicos program, implemented in response to protests over mounting healthcare inequalities. This program, which has strived from the outset to recruit Brazilian doctors, sends physicians into the most remote areas of the country to fill gaping holes in the public healthcare system.
Since the program began, Mais Médicos has deployed approximately 18,000 medical professionals to over 4,000 municipalities and has benefited 63 million people. Due to a high demand for doctors and a strikingly low number of Brazilian doctors willing to work in remote areas despite offered incentives, the Rousseff government signed an agreement with Cuban authorities to contract Cuban doctors to fill these slots.
To date, Cuban medical professionals, who receive three-year contracts to work in Brazil, constitute approximately two-thirds of the program’s personnel, and of those working in indigenous communities, 99 percent are Cuban.[7]
Aside from drawing in more doctors, the Rousseff government vowed to invest US$ 1.8 billion in healthcare infrastructure and aimed to build 11,500 new healthcare centers by 2017.[8]
The Mais Médicos project, which has received technical support from the Pan American Health Organization (PAHO), has also sought to reform curricula in Brazilian medical schools so that students are encouraged to study more generalized medicine.[9]
Whereas prior to the launch of Mais Médicos, 700 municipalities in Brazil did not have a primary care physician, two years after the launch of the program, every single municipality in Brazil housed at least one primary care physician.[10] The largely poor and rural beneficiaries of the project have reacted favorably.
Independent evaluations report a 95 percent rate of satisfaction with the quality of care and a 33 percent increase in the average number of monthly consultations. They also found that 86 percent of users believe that the quality of care has improved since the launch of the program.[11]
The program’s reliance on foreign doctors has been met with significant controversy from Brazilian doctors and conservatives who argue that it takes jobs away from Brazilians. In reality, these jobs were offered to Brazilians, but they refused to accept the posts because they were unwilling to work in the remote northeast region.
By both refusing to accept the posts, and protesting the arrival of the Cubans, Brazilian doctors are choosing to reserve the healthcare market for themselves rather than to do something about the country’s dire need for doctors. Despite the domestic criticism, the Mais Médicos program has been highly regarded by the international community.
In May, the United Nations Office on South-South Cooperation recognized Mais Médicos in its “Good Practices Report,” stating that “the temporary migration of foreign doctors to offer immediate assistance to underserved communities has allowed the Government of Brazil to rapidly expand its universal healthcare access…and … to initiate profound transformations in medical education.”[12]
The report further exclaimed that the project “is replicable and would potentially be beneficial in any country that decides to adopt it.”[13]
Healthcare Down the Drain
On May 12, President Rousseff was suspended from office after the Senate voted 55-22 to initiate an impeachment process over accusations of manipulating public finances. In what has been widely recognized and condemned as a coup, Vice President Michel Temer assumed office as the interim president, and his right-wing administration is now threatening to roll back nearly fifteen years of progressive policy reforms put in place by the PT coalition.[14]
Temer has already shut down or combined several important ministries, effectively diminishing the government’s focus on social justice issues. Most notably, Temer has combined the three distinct Ministries of Women, Racial Equality, and Human Rights into just one Ministry of Justice.[15]
In May, the Temer government announced major cuts to the country’s multi-billion dollar social housing program, which has provided homes to several million Brazilians.[16]
One of the most severe blows to equality in Brazil is taking place in the realm of healthcare. Encouraged by positive outcomes, Rousseff had officially announced the extension of the Mais Médicos program for another three years in early May. After assuming power, however, the interim Temer government, backed by associations of private healthcare providers, initiated discussion of immediately withdrawing all foreign doctors from the program.
If enacted, this move would mean the loss of over 11,000 doctors from the program and would affect roughly 38 million Brazilians.[17] After a series of protests shook the streets of several Brazilian cities, interim Health Minister Ricardo Barros reluctantly declared that non-Brazilians would be able to remain a part of Mais Médicos.
They would be allowed to stay only until the October 2016 municipal elections so as to ensure a sufficient healthcare presence through the duration of the Olympic Games.
Beyond threatening the end of the Mais Médicos project, the new health minister has stated his intent to cap the federal healthcare spending for the next 20 years, despite substantial projected population growth.[18]
Barros expressed that, “it should be the responsibility of the municipalities to contract doctors and offer basic healthcare, not that of the federal government.”[19]
He has claimed that he intends to incentivize Brazilian doctors to fill the posts in rural municipalities that will be emptied if the Cubans leave in November, but he has not yet proposed a concrete plan by which to do so.[20]
Such recent statements by interim cabinet members suggesting that conditions will inevitably worsen for healthcare providers have prompted a reaction from the Cuban government. A note from the Cuban Ministry of Health earlier this month reported that the first two groups of Cuban doctors (of 400 and 2,000, respectively) that arrived in August 2013 must return to Havana by November, eliminating any possibility of renewing their contracts.[21]
The Ministry did not explicitly state the motive, but vaguely referenced “political reasons” as the justification for the removal of doctors. Days later, however, the Cuban Embassy in Brazil released a statement saying that the Brazilian doctors would be able to stay, but only on the condition that the Brazilian government re-negotiate the terms of the doctors’ contracts for higher pay.
Since the interim Temer administration has made no indication that it will either increase remuneration or allow Cubans to renew their contracts, the future of the Mais Médicos program, and thus the health of marginalized Brazilians, remains in limbo.
Already, Brazil spends relatively little on healthcare in comparison to other countries with similar systems. For example, Brazil spends just 13 percent of what Canada spends on a single patient. While the United States spends 18 percent of its GDP on healthcare in an albeit non-universal system, Brazil spends just 9 percent of its GDP on healthcare.
The healthcare system has suffered from a lack of funding since the beginning. Since the government lost a vote in Parliament in 2007 to continue imposing a financial transaction tax that had been providing the SUS with about a quarter of its revenue, implementation has become increasingly difficult.[22]
Given the already unequal access to care in the SUS, the healthcare system in Brazil arguably requires more federal funding — not less — to address the health needs of Brazil’s growing population.
Instead of recognizing this, Temer and his entirely white male cabinet are choosing neither to acknowledge the strengths nor to address the structural issues of the SUS to improve upon the system already in place. Rather, they claim that it is no longer feasible to honor the universal right to healthcare.[23]
The government has thus geared toward privatizing emergency care services and health insurance in an apparent effort to emulate the U.S. system — a move that will likely serve to deepen inequality by reserving access to care for the elite.
The interim government has also proposed to completely remove the current obligation of federal and municipal governments to dedicate a specified amount of funding for healthcare, meaning that it will be up to the discretion of government officials as to how much funding will be allocated.[24]
Furthermore, recent investigations have revealed that Barros, a former engineer with no formal healthcare experience, has received significant contributions from private pharmaceutical and insurance companies for his campaign.[25] Such donations serve as a major incentive for the interim government to turn away from a universal system, and more towards one that is privatized.
In an interview with the World Health Organization, Francisco Eduardo de Campos, a professor in the department of preventative medicine at the Federal University of Minas Gerais, lamented the move towards the privatization of a public good in the face of a lack of funding.
“What we need is a review of the management model,” claimed de Campos, “giving it more flexibility, and an adjustment of its funding. These are the key factors for improving the quality of the care and services provided by the SUS.”[26]
The proposed cuts to Brazil’s universal healthcare system are sure to have catastrophic effects both for the 19.2 million Brazilians living under US$ 3.10 (2011 PPPs) per day, and also for the rapidly expanding middle class who similarly rely on the public system for healthcare.[27]
The Zika virus, a mosquito borne illness known to cause microcephaly in infants, has ripped through the warm and wet climate of Brazil’s poor northeast region, and intensifies the immediate need for an expanded healthcare presence in those areas.
With the loss of thousands of foreign doctors from the Mais Médicos program, marginalized groups will once again be neglected by a system that claims to provide for everyone. Of all those affected, indigenous Brazilians living in remote parts of the Amazon, who are cared for almost exclusively by foreign doctors, face the gravest threat.
While the middle class is not as likely to be affected by the end of Mais Médicos, the overall privatization of healthcare would greatly limit the general public’s ability to access the system and could threaten to derail individuals’ ascendance to the middle class.
Leticia Penna Braga and Luiza Pinheiro are doctoral students at the University of Rio de Janeiro. “This is a broad problem,” they stressed in an interview, “and we are very worried in general about losing our rights. Young people like us will also be left out of the system.”
Despite their concerns, Braga and Pinheiro also expressed confidence that the Brazilian people will continue to fight for their right to healthcare regardless of who is in power.
“There’s always going to be problems with the SUS, because its very idealistic,” Braga stated, “but ultimately, the SUS is the result of political activism by the people, and we will keep fighting to ensure that it still exists.”
The final vote in the Brazilian Senate to determine whether Rousseff will be able to return to office is set for late August. Regardless of the outcome, however, marginalized groups in Brazil have been dealt a serious blow to their fight for equality, especially in the healthcare arena, and activists and progressive leaders will have to re-double efforts to make possible a future of equitable, sustainable healthcare in Brazil.
In the long term, the SUS is in need of major re-structuring to ensure that Brazilians from every social stratum have the opportunity and the incentive to study medicine so that Brazilian doctors can fill posts in poor rural areas. In the short term, however, the answer is not to take away desperately needed medical care for individuals who cannot afford to pay for it.
The system as it stands is imperfect, but it is not hopeless and it can be improved. The next administration must not give up on the vision of universal healthcare, regardless of party affiliation.
In the face of the raging Zika epidemic, on top of countless other diseases that disproportionately affect the poor, that administration must recognize the immediate need to preserve the rights of the many over the profits of the few.
NOTES:
[1] Greenwald, Glenn, David Miranda, Andrew Fishman. “New Political Earthquake in Brazil: Is it now Time for Media Outlets to Call this a Coup?” 23 May 2016. The Intercept. Accessed 12 August 2016: https://theintercept.com/2016/05/23/new-political-earthquake-in-brazil-is-it-now-time-for-media-outlets-to-call-this-a-coup/
[2] World Health Organization, “Global Health Observatory Data Repository,” Accessed August 10, 2016. http://apps.who.int/gho/data/view.main.SDG2016LEXREGv?lang=en
[3] Ibid.
[4] Kazhan, Olga. “What the U.S. Can Learn from Brazil’s Healthcare Mess,” The Atlantic, May 8, 2014, accessed August 9, 2016, http://www.theatlantic.com/health/archive/2014/05/the-struggle-for-universal-healthcare/361854/
[5] Victora, Cesar G., Mauricio L. Barreto, Maria do Carmo Leal, Carlos A. Monteiro, Maria Ines Schmidt, Jairnilson Paim, Francisco I. Bastos et al. “Health conditions and health-policy innovations in Brazil: the way forward.” The Lancet 377, no. 9782 (2011): 2042-2053.
[6] “The List of Medications Increases Every Two Years.” Instituto Lula, accessed 10 August 2016: http://www.brasildamudanca.com.br/en/saude/list-medications-increases-every-two-years
[7] “Good Practices in South-South and Triangular Cooperation for Sustainable Development.” May 2016. United Nations Office for South-South Cooperation. Accessed 10 August 2016: https://undg.org/wp-content/uploads/2016/06/Good-Practices-in-South-South-and-Triangular-Cooperation-for-Sustainable-Development-May-2016.pdf
[8] Ibid.
[9] “Ministro de Temer anuncia redução de 10 mil médicos no programa Mais Médicos.” 17 May 2016. Plantão Brasil. Accessed 10 August 2016: http://www.plantaobrasil.net/news.asp?nID=94379
[10] “Good Practices in South-South and Triangular Cooperation for Sustainable Development.” May 2016. United Nations Office for South-South Cooperation. Accessed 10 August 2016: https://undg.org/wp-content/uploads/2016/06/Good-Practices-in-South-South-and-Triangular-Cooperation-for-Sustainable-Development-May-2016.pdf
[11] Ibid.
[12] Ibid.
[13] Ibid.
[14] Greenwald, Glenn, David Miranda, Andrew Fishman. “New Political Earthquake in Brazil: Is it now Time for Media Outlets to Call this a Coup?” 23 May 2016. The Intercept. Accessed 12 August 2016: https://theintercept.com/2016/05/23/new-political-earthquake-in-brazil-is-it-now-time-for-media-outlets-to-call-this-a-coup/
[15] “Para buscar eficiência, novo governo corta ministérios.” 12 May 2016. Portal Brasil. Accessed 10 August 2016: [15] http://www.brasil.gov.br/governo/2016/05/para-buscar-eficiencia-novo-governo-corta-ministerios
[16] “Fears for Poor as Brazil cuts Social Housing Plan.” 24 June 2016. Telesur. Accessed 10 August 2016: http://www.telesurtv.net/english/news/Fears-for-Poor-as-Brazil-Cuts-Social-Housing-Plan-20160624-0010.html
[17] Spinillo, Luana. “Mais Médicos complete 3 anos sob ataque de gestão golpista de Temer.” 08 July 2016. Partido dos Trabalhadores. Accessed 10 August 2016: http://www.pt.org.br/mais-medicos-completa-3-anos-sob-ataque-da-gestao-golpista-de-temer/
[18] Ibid.
[19] Ibid.
[20] Cancian, Natália, “Programa Mais Médicos é provisório, diz Ricardo Barros, ministro da Saúde. 22 July 2016. Folha de Sao Paolo. Accessed 10 August 2016: http://www1.folha.uol.com.br/cotidiano/2016/07/1794201-programa-mais-medicos-e-provisorio-diz-ricardo-barros-ministro-da-saude.shtml
[21]Menezes, Cynara. “Governo de Raul Castro convoca médicos do programa Mais Médicos de volta a Cuba.” July 2016. Socialista Morena. Accessed 10 August 2016: http://www.socialistamorena.com.br/governo-cubano-convoca-medicos-de-volta/
[22] “Funding, flexible management needed for Brazil’s health worker gaps.” Bulletin of the World Health Organization 2013; 91:806-807. Accessed 10 August 2016: http://apps.who.int/bulletin/volumes/91/11/13-031113/en/index.html
[23] “Ministro de Saúde à Folha: SUS pode acabar e saúde não deveria direito universal.” 17 May 2016. Plantão Brasil. Accessed 10 August 2016: http://www.plantaobrasil.net/news.asp?nID=94362
[24]Brito, Adriano. “Sucateamento do SUS? A ameaça de corte no gasto obrigatório com saúde.” 17 May 2016. BBC Brasil. Accessed 10 August 2016: http://www.bbc.com/portuguese/brasil/2016/05/160517_desvinculacao_saude_ab
[25]Ramos, Murilo. “Maior doador de campanha do ministro do Saúde é sócio de gigante de planos de saúde.” 17 May 2016. Época. Accessed 10 August 2016: http://epoca.globo.com/tempo/expresso/noticia/2016/05/maior-doador-de-campanha-do-ministro-da-saude-e-socio-de-gigante-de-planos-de-saude.html
[26] “Funding, flexible management needed for Brazil’s health worker gaps.” Bulletin of the World Health Organization 2013; 91:806-807. Accessed 10 August 2016: http://apps.who.int/bulletin/volumes/91/11/13-031113/en/index.html
[27] Roser, Max. “World Poverty.” 2016. OurWorldinData.org. Accessed 10 August 2016: https://ourworldindata.org/world-poverty/
Jessica Farber is a research associate at the Council on Hemispheric Affairs (COHA) – www.coha.org. The organization is a think tank established in 1975 to discuss and promote inter-American relationship. Email: coha@coha.org.