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Print version ISSN 0042-9686
Bull World Health Organ vol.86 n.4 Genebra Apr. 2008
Flawed but fair: Brazil's health system reaches out to the poor
Despite its many problems, Brazil's revamped public health system has brought quality health care to millions of poorer inhabitants who were previously denied even basic care. Claudia Jurberg reports on how primary health care is playing an essential role.
Until the 1970s, Brazilians used to joke that they had to die before the authorities paid any attention to them. Dr Hugo Coelho Barbosa Tomassini recalls how they used to have a full-time "death secretary" to administer funerals in the city of Niterói, where he was once the municipal health secretary, but only one health unit to care for the living.
Much has changed since then. While long queues at hospital emergency departments, beds spilling into corridors, outdated and malfunctioning equipment and a scarcity of doctors and medicine in rural areas remain common complaints, on another level, Brazil's national health system Sistema Único de Saúde (SUS) has been an outstanding success.
The vision of a system providing "health for all" emerged towards the end of the military dictatorship that started in 1964 and during the years of political opposition that was to a large extent framed in terms of access to health care. This struggle culminated in the 1988 constitution, which enshrined health as a citizens' right and which requires the state to provide universal and equal access to health services.
It was a dramatic commitment to the ideals in the 1978 Alma-Ata declaration of "health for all".
Under a subsequent health reform in 1996, Brazil established a health system based on decentralized universal access, with municipalities providing comprehensive and free health care to each individual in need financed by the states and federal government.
Key to this strategy was primary health care. Today, primary health care remains one of the main pillars of the public health system in this country of 190 million people.
Promoting health, preventing sickness, treating the sick and injured, and tackling serious disease; these are the cornerstones of the public health system, according to nurse Maria Fátima de Sousa, who has a doctorate in health and science and is a researcher at the University of Brasília.
About 70% of Brazil's population receives care from this system, de Sousa says, while the remainder those that can afford to avoid the queues and inconvenience of the public system opts for private care. De Sousa says that before Brazil's "health-care revolution" a much greater proportion of the population was excluded.
"It was a period when authorities did not recognize health as a right. Most of the population had little or no access to health services. Access was only for those who had a public health plan card," de Sousa says, referring to the old system.
All three levels of government in Brazil federal, state and municipal have worked hard to encourage the poor to use and benefit from the health system through initiatives, such as the Family Health Programme and through the deployment of auxiliary health workers or agentes de saúde working with the poor.
Created in 1994, the Family Health Programme Brazil's main primary health care strategy seeks to provide a full range of quality health care to families in their homes, at clinics and in hospitals.
Today, 27 000 Family Health teams are active in nearly all Brazil's 5560 municipalities, each serving up to about 2000 families or 10 000 people. Family Health teams include doctors, nurses, dentists and other health workers. De Sousa says annual resources for primary health care have increased in the past 13 years to about US$ 3.5 billion, with US$ 2 billion of that money devoted to the Family Health programme out of an overall government health budget of about US$ 23 billion.
Niterói, with a population of 475 000 in the state of Rio de Janeiro and just 13 kilometres from the city of the same name, is just one example of a city that has transformed its public health care over the past 20 years. According to Tomassini, "after the Alma-Ata conference, Niterói devised a health plan to provide universal access on a decentralized basis the opposite of what had existed in the past." A handful of other Brazilian municipalities also started to establish primary health care services at the time.
In Niterói, health-care units were set up in areas that previously had no health services. Today, the health clinic in Itaipu, a neighbourhood of Niterói, is a good example of how Brazil's primary health care system works. More than 62 000 people from Itaipu and 11 surrounding neighbourhoods are treated there for common complaints, such as parasitic diseases, diabetes and hypertension.
Dr Maria das Graças Vieira Esteves, who has been the director of the clinic for the past 11 years, says Niterói's 23 Family Health teams are an essential part of Brazil's health system. "Initially, I did not believe the Family Health programme could be effective, but gradually I saw they were doing marvellous work and getting results," she says. "In Itaipu, pregnant women attend 10 prenatal appointments. This approach has contributed to the fall in infant mortality rates."
Community participation is crucial to the programme's success. "Since 2004, on the last Tuesday of each month, there are meetings at the clinic attended by members of the community, including representatives from the church, NGOs [nongovernmental organizations] and schools," says Vieira Esteves. "We always listen to the community and their needs." This input is passed to Niterói's municipal health council, which is then responsible for implementing measures to cater for the health needs of all its constituents. Vieira Esteves says the major challenges are to convince people that the system can work to their benefit and to persuade the authorities to devote more money to primary health care.
After two decades in operation, Brazil's national health system still faces significant problems not least a double burden of infectious diseases and increased risk of noncommunicable diseases often associated with ageing populations of affluent countries. "Brazil is going through an epidemiological transition," Tomassini says.
"Although we are a developing country, our people are at risk from [noncommunicable conditions such as] cancer and trauma resulting from violence and accidents, as well as from infectious diseases such as dengue, Chagas, schistosomiasis."
In Brazil, primary health care remains the most effective way to provide greater access to health services. Although, Brazil did not achieve the Alma-Ata goal of "health for all" by the year 2000, it has made significant progress, albeit along a tortuous road. "Today," says Tomassini, "the SUS [national health system] works, but it is not operating to its full capacity because there are many obstacles, such as conservatism and politics. The lack of political will to help people in rural areas causes problems for the health system."
In the cities, Tomassini says, there is a climate which favours the provision of complex, specialized treatment. "There is a duel between the hospital network and primary health care," he says, referring to a legacy of the old health system that remains today. One of the biggest challenges, Tomassini says, is to gain people's confidence. Sometimes people travel to urban areas to receive treatment that they could have received from primary health units in their rural areas.
"We have learned many lessons in the past 13 years from the implementation of the Family Health programme," says de Sousa. "We have learned that it is possible to build a new model for primary health with the principles of fairness and solidarity as long as there is the political will to do this."
"Primary health care services are key to the success of the SUS [national health system]," concludes Tomassini. "It is through primary care that we can end the queues in public hospitals and stop the wait for medical appointments."