Abstract

In recent years the international debate about universality in health has been marked by a polarization between ideas based on a universal system, and notions proposing universal health coverage. The concept of universal coverage has been disseminated by international organizations and has been incorporated into health system reforms in several developing countries, including some in Latin America. This article explores the assumptions and strategies related to the proposal of universal health coverage. Firstly, a comparison is provided of the models of universal health coverage and universal health systems. This is followed by a contextualization of the international debate, including examples of different health systems. Finally, the implications of the proposal of universal coverage for the right to health in Brazil are discussed. The analysis of different concepts of universality and the experiences of different countries shows that health insurance-based models, either social or private, are not as satisfactory as public, universal health systems. Greater understanding about ongoing international projects is essential in order to identify the possibilities represented by the consolidation of the Unified Health System (SUS) in Brazil, as well as the risks of dismantling the SUS.

Universal health systems; Universal health coverage; Health reforms; Right to health; Unified Health System (SUS)

Introduction

In recent years, the international debate about different conceptions of universality in health has become polarized around proposals based on a universal health system (UHS) and ideas of universal health coverage (UHC).

The concept of universal health coverage has been disseminated by international organizations such as the World Bank (WB) and the World Health Organization (WHO)¹1. Organização Mundial da Saúde (OMS). Financiamento dos sistemas de saúde. O caminho para a cobertura universal. Relatório Mundial da Saúde 2010. Genebra: OMS; 2010.

2. Organización Mundial de la Salud (OMS). Argumentando sobre la cobertura sanitaria universal. Ginebra: OMS; 2013.-³3. World Health Organization (WHO), World Bank (WB). Tracking Universal Health Coverage: 2017 Global Monitoring Report. New York: WHO, WB; 2017._, as well as being incorporated into United Nations resolutions⁴4. Organización Naciones Unidas (ONU). Resolución aprobada por la Asamblea General el 25 de septiembre de 2015. Resolución 70/1. Transformar nuestro mundo: la Agenda 2030 para el Desarrollo Sostenible. New York: ONU; 2015..

There is uncertainty regarding the meaning of “universality” in the UHC proposals. In European countries, universality generally refers to the public coverage of national systems, under names like universal healthcare or universal health systems (UHS). In developing countries, the term universal health coverage (UHC) is used to refer to basic services coverage⁵5. Stuckler D, Feigl AB, Basu S, McKee M. The political economy of universal health coverage. Background paper for the Global symposium on health system research. 16-19 November 2010. Montreux, Switzerland., or to public or private health insurance coverage⁶6. Noronha JC. Cobertura universal de saúde: como misturar conceitos, confundir objetivos, abandonar princípios. Cad Saude Publica 2013; 29(5):847-849.

7. Laurell AC. Neoliberalism in Health Care in Mexico - the mexican popular health insurance: myths and realities. International Journal of Health Services 2015; 45(1):105-125.-⁸8. Laurell AC, Lima LD. Entrevista. Crisis y neoliberalismo: desafíos y alternativas políticas para la construcción de sistemas universales de salud en América Latina. Cad Saude Publica 2017; 33(S2):1-7., indicating an emphasis on the subsidy of demand, to the detriment of the development of universal public health systems.

In Latin America there have been disputes regarding plans to achieve universality in health; these are centered on different conceptions about the right to health and the role of the state in social protection. Brazil is the only capitalist country in the region that has adopted a universal, public system since 1988. Although the implementation of the Unified Health System (SUS) has suffered from constraints and contradictions, the recognition of health as a right of citizenship and the expansion of services has resulted in important advances. Other Latin American countries have followed different paths towards health reforms, some of which have incorporated principles that are consistent with the proposal for universal health coverage, in various forms.

This article explores the assumptions and strategies related to the idea of universal health coverage and its possible consequences for Brazil. Initially, the concept of universality is contrasted within the UHC and UHS models. This is followed by a contextualization of the international debate, including examples of different health systems. Finally, the implications of the concept of universal coverage for the right to health in Brazil are discussed. It is argued that greater understanding about different projects in the international are essential to identify the possibilities and threats for the consolidation of the SUS in Brazil.

The concept of universal coverage in the international context

Universal health coverage (UHC) is an ambiguous term that has led to different interpretations and approaches by national health authorities, and governmental and non-governmental organizations, especially in developing countries. The implications of this ambiguity and the assumption of the principles of universal coverage for the right to health have been analyzed in the literature⁶6. Noronha JC. Cobertura universal de saúde: como misturar conceitos, confundir objetivos, abandonar princípios. Cad Saude Publica 2013; 29(5):847-849.,⁷7. Laurell AC. Neoliberalism in Health Care in Mexico - the mexican popular health insurance: myths and realities. International Journal of Health Services 2015; 45(1):105-125.,⁹9. Sengupta A. Universal Health Coverage: Beyond Rhetoric. Ottawa: Municipal Services Project. IDRC; 2013. [Occasional Paper n.20].,¹⁰10. Cueto M. Saúde Global: uma breve história. Rio de Janeiro: Editora Fiocruz; 2015..

At the international level, the concept of universal coverage was shaped in the period 2004-2010 through relationships between the WHO, the Rockefeller Foundation and the WB, bringing together a number of pro-market reform guidelines such as the reduction of state intervention and an emphasis selective and focalized health policies¹⁰10. Cueto M. Saúde Global: uma breve história. Rio de Janeiro: Editora Fiocruz; 2015._. In 2005 the WHO Assembly adopted resolution No. 58.33, “Sustainable health financing: universal coverage and social health insurance”¹¹11. Centro Brasileiro de Estudos de Saúde (Cebes). Manifesto do Centro Brasileiro de Estudos de Saúde em defesa do direito universal à saúde – saúde é direito e não negócio. Rio de Janeiro: Cebes; 2014.. However, the global debate around this issue became more prominent with the publication in 2010 of a report on financing¹1. Organização Mundial da Saúde (OMS). Financiamento dos sistemas de saúde. O caminho para a cobertura universal. Relatório Mundial da Saúde 2010. Genebra: OMS; 2010.. Based on this report, in 2011 the WHO Assembly adopted a resolution on sustainable financing and UHC¹²12. Organización Mundial de la Salud (OMS). Resolución WHA64.9. Estructuras de financiación sostenible de la salud y cobertura universal. 64ª Asamblea Mundial de la Salud. OMS 2011., which urged countries to ensure that health financing prevented direct payments from households on an out-of-pocket (OOP) basis, recommending early financial contributions as a form of risk-sharing in order to prevent “catastrophic expenditure” in health resulting in impoverishment¹²12. Organización Mundial de la Salud (OMS). Resolución WHA64.9. Estructuras de financiación sostenible de la salud y cobertura universal. 64ª Asamblea Mundial de la Salud. OMS 2011..

The issue of funding is central to the idea of UHC, which encourages increased private participation in sector financing and the expansion of the private health market, as seen in the Rockefeller Foundation’s arguments in the defense of UHC: “A large proportion of the population is willing to pay for private sector health services”, and “strong market players such as pharmaceutical manufacturers, hospital organizations, provider associations and insurance companies, are likely to increase pressure to attract public and private financing, particularly as LMICs [low and middle-income countries] adopt policies to finance health insurance as a means to Universal Health Coverage (UHC)”¹³13. .Rockefeller Foundation. Future health markets: a meeting statement from Bellagio. Belaggio: Rockefeller Foundation, 2012.. It is plausible to suppose that the economic interest behind the saturation of the private health insurance market in Europe and the USA, together with the financial crisis of 2008, have influenced the concept of UHC, in search for clientele for this market in countries with large economies such as Brazil, India and South Africa.

The ambiguities regarding the conception of universality in the UHC proposal can be perceived in the changing of concepts and approaches related to health financing in official WHO documents. The 2008 World Health Report suggested that the level of universality was related to the proportion of expenditure covered by public funds, and the path to universality would be to reduce users’ participation in expenditure by increasing public expenditure¹⁴14. Organização Mundial da Saúde (OMS). Atenção primária à saúde: mais necessária que nunca. Genebra: OMS; 2008. [Relatório Mundial da Saúde 2008].. In subsequent documents the key indicator “proportion of public expenditure on health”¹⁴14. Organização Mundial da Saúde (OMS). Atenção primária à saúde: mais necessária que nunca. Genebra: OMS; 2008. [Relatório Mundial da Saúde 2008]. was replaced by expressions such as “shared funds”, “current pooled funds”¹1. Organização Mundial da Saúde (OMS). Financiamento dos sistemas de saúde. O caminho para a cobertura universal. Relatório Mundial da Saúde 2010. Genebra: OMS; 2010., “funds raised to date”, and “coverage mechanisms”²2. Organización Mundial de la Salud (OMS). Argumentando sobre la cobertura sanitaria universal. Ginebra: OMS; 2013.. The role of public funding is reduced in importance and the strategy becomes reducing direct spending through the purchase of private health insurance or subsidized insurance for the poor¹1. Organização Mundial da Saúde (OMS). Financiamento dos sistemas de saúde. O caminho para a cobertura universal. Relatório Mundial da Saúde 2010. Genebra: OMS; 2010.,²2. Organización Mundial de la Salud (OMS). Argumentando sobre la cobertura sanitaria universal. Ginebra: OMS; 2013. (demand subsidy). In other words, the way to move towards universal coverage is no longer the extension of public funding¹⁴14. Organização Mundial da Saúde (OMS). Atenção primária à saúde: mais necessária que nunca. Genebra: OMS; 2008. [Relatório Mundial da Saúde 2008]. corresponding to a universal health system (supply subsidy).

In the Americas, the emphasis on health insurance coverage and the indistinction between coverage and access proposed by the WHO was questioned by some countries which are attempting to build universal health systems (including Brazil). The Pan American Health Organization (PAHO) consulted its member states and adopted a resolution in 2014 which broadened the conception by incorporating the guarantee of access to health services and mentioning the right to health¹⁵15. Organização Pan-Americana de Saúde (OPAS). Resolução CD53, R14, 2014. Estratégia para o acesso universal à saúde e a cobertura universal de saúde. 53º Conselho Diretor 66ª Sessão do Comitê Regional da OMS para as Américas. Brasília: OPAS; 2014., as well as disseminating “universal health” as a strategy to be implemented in the region.

With the expansion of the international debate, in 2015 universal coverage was incorporated into Agenda 2030 as one of the Sustainable Development Goals (SDGs). Target indicator 3.8 of SDG 3 “health and well-being” is to “achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all”⁴4. Organización Naciones Unidas (ONU). Resolución aprobada por la Asamblea General el 25 de septiembre de 2015. Resolución 70/1. Transformar nuestro mundo: la Agenda 2030 para el Desarrollo Sostenible. New York: ONU; 2015..

The indicators defined in 2017 by the WB and the WHO to monitor target 3.8 of SDG 3 and to monitor the evolution of coverage focus on out-of-pocket expenditure (the proportion of the population that incurs catastrophic expenditures, defined as high expenditure on health at the time of use as a percentage of domestic income) and suggest a minimum basket of services included in the proposed “essential services index” ³3. World Health Organization (WHO), World Bank (WB). Tracking Universal Health Coverage: 2017 Global Monitoring Report. New York: WHO, WB; 2017..

This choice of indicators disregards the fact that payments for private health plans can also be catastrophic, and that in a situation of poverty there is little or no available finance for health spending. Furthermore, scientific evidence shows that the greater the investment in the public health system, the lower the percentage of catastrophic private spending in sector financing.

The essential services index focuses on the maternal-child and infectious-contagious diseases group and, although it includes the prevalence of diabetes and hypertension, it does not incorporate any prognostic indicator for cancer treatment³3. World Health Organization (WHO), World Bank (WB). Tracking Universal Health Coverage: 2017 Global Monitoring Report. New York: WHO, WB; 2017.. In addition to presenting the same problems as any composite index regarding the weighting of components, in the absence of data the calculation of indicators is probably based on estimative models, with methodological limitations and results that are far from reality.

The incorporation of universal coverage among the SDGs has medium-term repercussions for all countries that are obliged to comply with these indicators by 2030. Thus, it is relevant to unveil the assumptions and strategies involved in the universal coverage proposal.

The proposals for universal health coverage (UHC) and universal health systems (UHS), which characterize projects under discussion, are characterized and contrasted here as polar (ideal) types. Nonetheless, both conceptions can be implemented in different ways¹⁶16. Atun R, Andrade LOM, Almeida G, Cotlear D, Dmytraczenko T, Frenz P, Garcia P, Gómez-Dantés O, Knaul FM, Muntaner C, de Paula JB, Rígoli F, Serrate PC, Wagstaff A. Health-system reform and universal health coverage in Latin America. Lancet 2015; 385(9974):1230-1247., which do not always correspond to all the highlighted characteristics.

The main objective of the UHC proposal is to promote financial health protection, i.e. that everyone can access health services without experiencing financial difficulties, reducing direct payments at the time of use (OOP), and avoiding catastrophic expenditure. The use of the word “coverage” refers to financial coverage due to an insurance affiliation. In other words, it means that everyone should be affiliated to some type of insurance. However, the latter does not guarantee access to and the use of healthcare whenever necessary. This concept differs from health coverage that associates health provision with access and effective use⁶6. Noronha JC. Cobertura universal de saúde: como misturar conceitos, confundir objetivos, abandonar princípios. Cad Saude Publica 2013; 29(5):847-849.. Health insurance contracts cover specific interventions, and the supply is unevenly distributed geographically, which harms disadvantaged regions and social groups¹⁷17. Heredia N, Laurell AC, Feo O, Noronha J, González-Guzmán R, Torres-Tovar M. The right to health: w hat model for Latin America? Lancet 2014; 385(9975):34-37..

The UHC proposal contains three central components: a focus on financing by pooling; affiliation by insurance modality; and the definition of a limited package of services. This proposal reduces the role of the state, restricting it to regulating the health system. It is intended that the state should promote insurance or contract out private services to offer to people who are unable to buy them in the market. The separation of functions between financing and provision implies the pricing of health services, which turns them into a commodity. For private sector actors health is a good or a product; those who are unable to pay for the merchandise or service are not entitled to receive their benefits.

The key element of UHC is the combination of public and private funding (insurance premiums, social contributions, philanthropy, general taxes) in funds managed by private or public insurers to finance the health expenditures of plan holders in accordance with their package. Eligibility is conditional upon affiliation to some form of health insurance (private or public). Individuals are eligible, or not, depending on the rules of each insurance policy, or their ability to pay.

UHS is financed by public funds from general tax revenues and social contributions, which provides greater solidarity, redistribution and equity. The degree of redistribution depends on the progressivity of the tax burden, i.e. a greater proportion of taxation on rents and property than on consumption. The UHS model aims to ensure that all people have their needs met without restrictions on access; it enshrines the guarantee of universal access as a condition of citizenship.

Thus, the different financing models have different effects in relation to solidarity. In the UHC model the effects are restricted because the coverage is segmented by insurances that are differentiated by social groups and according to income, which corresponds to different packages of services. In private insurance, risk pooling can be achieved; however, the price of premiums is calculated on the basis of risk, irrespective of an individual’s ability to pay, and therefore failing to promote equity. The public nature of the UHS model has broad effects: it absorbs and divides costs within society, promoting redistribution and ensuring to the most under privileged access under equal conditions. In this system the richest pay for the poorest, thereby reducing social inequity⁹9. Sengupta A. Universal Health Coverage: Beyond Rhetoric. Ottawa: Municipal Services Project. IDRC; 2013. [Occasional Paper n.20]..

Because the affiliation in the UHC concept is performed by an insurance contract, it presupposes the definition of an explicit and, in general, limited package of services. The basket is defined in the insurance contract and is differentiated according to purchasing power. Minimum packages for marginalized population groups generate “classes” of citizens, resulting in “poor services for poor people”. In universal systems there is no definition of a limited basket: health services should be offered according to population needs. The comprehensive nature of healthcare is one of the principles of universal systems; everyone should receive healthcare according to their needs, not based on merit or income.

In the UHC concept it is understood that the public sector is unable to meet the health demands of the population. The privatization of health insurance and health services is advocated, based on the argument that private provision is more efficient; an assertion that lacks evidence. Private providers respond to demands and not the health needs of the population; they are based in areas of greater socioeconomic development; they offer more profitable services; they provide more unnecessary services and violate standards of good medical practice more often; they are less efficient and have worse health outcomes than public services. However, they also provide more timely attention and more personalized care¹⁸18. Basu S, Andrews J, Kishore S, Panjabi R, Stuckler D. Comparative performance of private and public health care systems in low and middle-income countries: a systematic review. Plos Medicine 2012; 9(6):1-14.,¹⁹19. Berendes S, Heywood P, Oliver S, Garner P. Quality of private and public ambulatory health care in low and middle income countries: systematic review of comparative studies. Plos Medicine 2011; 8(4):1-10..

The myriad and diverse contracts between insurers and service providers in the UHC concept increase operational and administrative costs, reducing the efficiency of the system. Service provision is fragmented in UHC because it does not include design components related to the health system, such as territorial and network organization, which prevents the continuity of care and coordination both between and within services⁹9. Sengupta A. Universal Health Coverage: Beyond Rhetoric. Ottawa: Municipal Services Project. IDRC; 2013. [Occasional Paper n.20].. Furthermore, the focus of insurance protection is on individual medical attention because the contracts are individual, with premiums calculated according to the characteristics of individuals and the scope of the contracted package, regardless of population needs.

In universal systems, the guarantee of comprehensive care (individual and collective) requires coordination between services which are organized in networks, integrated and territorialized, distributed according to economies of scale, and focused on primary healthcare (PHC); there is a predominance of public administration and provision, resulting in better quality, lower costs and greater efficiency²⁰20. Wagstaff A. Social Health Insurance vs. Tax-Financed Health Systems-Evidence from the OECD. New York: The World Bank. Development Research Group; 2009.,²¹21. Schneider EC, Sarnak DO, Squires D, Shah A, Doty MM. Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care. New York: The Commonwealth Fund; 2017.. Universal systems integrate individual care, as well as collective health prevention and promotion actions. A population-based approach calls for transversal, cross-sectoral policies to address the social determinants of health⁸8. Laurell AC, Lima LD. Entrevista. Crisis y neoliberalismo: desafíos y alternativas políticas para la construcción de sistemas universales de salud en América Latina. Cad Saude Publica 2017; 33(S2):1-7..

PHC is advocated as a strategy for universal coverage¹⁴14. Organização Mundial da Saúde (OMS). Atenção primária à saúde: mais necessária que nunca. Genebra: OMS; 2008. [Relatório Mundial da Saúde 2008]._; however, it can have very different meanings. In the UHC agenda⁴4. Organización Naciones Unidas (ONU). Resolución aprobada por la Asamblea General el 25 de septiembre de 2015. Resolución 70/1. Transformar nuestro mundo: la Agenda 2030 para el Desarrollo Sostenible. New York: ONU; 2015._,PHC refers to a basic package of essential services and medicines which are defined in each country, corresponding to a selective approach designed to reach a basic universalism in developing countries. It distinguishes itself from the comprehensive approach of the universal public systems, where PHC corresponds to the basis of the system and refers patients to other levels of care whenever needed.

The two aforementioned proposals are aligned to different conceptions of citizenship: residual citizenship in UHC and full citizenship in the universal systems. Universal health coverage is aligned with a liberal vision; a government residual social intervention, that is focalized and based on selected health interventions. It is deemed that the state should intervene and assume social responsibility when individuals, their families, or community networks are unable to guarantee the satisfaction of minimum necessities in the market, in a conception of inverted citizenship, in which individuals enter into a relationship with the state when they recognize themselves to be non-citizens²²22. Fleury SM. Política social e democracia: reflexões sobre o legado da seguridade social. Cad Saude Publica 1985; 1(4):400-417.. The state should subsidize insurance and guarantee a restricted package of benefits for poor groups that have “failed” to secure their basic needs in the market.

Chart 1 summarizes and contrasts the main characteristics of the conceptions of universal health coverage and of the universal health system.

The universalization of social protection in health in advanced industrialized countries

A striking feature in European countries is the universal guarantee of access to health services through publicly-funded national health systems that are one of the pillars of welfare regimes. The classic European models for universal healthcare are Bismarckian-type social insurance, which is funded on the basis of mandatory social contributions from employees and employers, and membership depending on participation in the labor market; and the Beveridgian model of a national health service, with universal access based on citizenship and financed by fiscal resources with a predominance of public providers.

The process of universalizing European health systems in most Western and Nordic countries was completed in the 1960s and 1970s with the expansion of social insurance for all workers and their dependents, in full employment, or via the creation of national health services such as in the United Kingdom (1948), Portugal (1974), Italy (1978) and Spain (1986).

The pioneering National Health Service (NHS) in the UK is an international reference for the universal access system; it is fiscally financed, with a centralized structure and regionalized coverage. It guarantees comprehensive care at all levels through robust PHC, with mandatory registration of citizens at a general practitioner’s office; this is a pathway and filter for access to specialists who are situated at a second level in hospital outpatient clinics, most of which are public (Chart 2)²³23. Boyle S. United Kingdom (England). Health system review. Health systems in transition 2011; 13(1):1-483..

The Bismarckian model of social insurance, which began in 1883 in Germany, had an important international impact after it was implemented during the first decades of the twentieth century in many countries, including some in Latin America, where, due to the high informality of the labor market, it reached restricted sections of the population. However, in European countries there was a progressive inclusion of population groups, with a broadening and standardization of benefits and universal coverage.

Social insurance differs from private insurance because it is compulsory and because it comprises contributions regardless of the risks of becoming ill. By combining contributions proportional to income and access according to necessity, it is based on principles of solidarity and promotes redistribution between those who are insured from higher to lower incomes, from young people to the elderly, from the healthy to the sick.

In general, national health services are more efficient and have similar or better health outcomes than social insurance models. Both systems have more positive results than market-centered modalities, such as in the United States of America (Table 1)²⁰20. Wagstaff A. Social Health Insurance vs. Tax-Financed Health Systems-Evidence from the OECD. New York: The World Bank. Development Research Group; 2009.,²¹21. Schneider EC, Sarnak DO, Squires D, Shah A, Doty MM. Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care. New York: The Commonwealth Fund; 2017..

The US health system exemplifies the restrictive consequences for the right to health of a model based on different types of insurance, with a strong emphasis on the private sector. In a survey of the systems in eleven developed countries, it was evaluated as the worst due to higher health spending, reduced administrative efficiency, and worse results in terms of equity, access, quality, life expectancy and infant mortality²¹21. Schneider EC, Sarnak DO, Squires D, Shah A, Doty MM. Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care. New York: The Commonwealth Fund; 2017..

The USA differs from other advanced, industrialized countries because of the residual nature and predominance of the private market in health insurance and healthcare, with a significant portion of the population uncovered (Table 1). The system is segmented and fragmented in its organization (insurance companies are the main purchasers of services), supply (the importance of private, for-profit hospitals), financing, eligibility rules and basket of covered services²⁴24. Birn AE, Hellander I. Market-driven health care mess: the United States. Cad Saude Publica 2016; 32(3):1-4..

In 2010, intense discussions culminated in the passing of The Affordable Care Act (so-called “Obamacare”), which expanded coverage through subsidies for private insurance and inclusion in publicly segmented schemes, but without achieving universality.

The interests of US healthcare companies are in favor of universal coverage through insurance. Financial capital holds sway as the administrator of health insurance and of service provider companies; those interests are linked to those of the pharmaceutical and medical equipment industries through increased share of the global insurance and health services market²⁵25. US Census Bureau. Current Population Survey, 2014 to 2017 Annual Social and Economic Supplements). Washington: US Census Bureau; 2017..

Reform models for UHC in Latin America

In Latin America, two countries (Colombia and Mexico) implemented health reforms consistent with the proposal for universal coverage, at different times and in different ways.

In Colombia, the radical reform of 1993 adopted the model of structured pluralism²⁸28. Cárdenas WIL, Pereira AMM, Machado CV. Trajetória das relações público-privadas no sistema de saúde da Colômbia de 1991 a 2015. Cad Saude Publica 2017; 33(Supl. 2):1-16., which is characterized by the separation of the functions of financing, assurance and the provision of services, under the respective responsibility of the state, financial intermediation organizations (insurers) and a variety of providers. Different schemes were created such as a Contributory Regime which was compulsory for formal workers and those with a contributory capacity, and a Subsidized Regime which focused on the poor, with inequalities in its benefit plans and per capita values²⁸28. Cárdenas WIL, Pereira AMM, Machado CV. Trajetória das relações público-privadas no sistema de saúde da Colômbia de 1991 a 2015. Cad Saude Publica 2017; 33(Supl. 2):1-16..

Some of the results of the reform were an increase in public spending and health coverage (Charts 3 and 4), although there was still inequality between the regimes. There was an expansion of health insurance and service delivery in the private sector, which accentuated segmentation and led to problems such as refusal of services, high administrative expenses, and a focus on profit generation and corruption²⁸28. Cárdenas WIL, Pereira AMM, Machado CV. Trajetória das relações público-privadas no sistema de saúde da Colômbia de 1991 a 2015. Cad Saude Publica 2017; 33(Supl. 2):1-16.

29. Echeverry-López ME, Borrero-Ramírez YE. Protestas sociales por la salud en Colombia: la lucha por el derecho fundamental a la salud, 1994-2010. Cad Saude Publica 2015; 31(2):354-364.-³⁰30. Colombia. Ministerio de Salud y Protección Social (MSPS). Informe al Congreso de la República 2016- 2017. Sector administrativo de salud y protección social. Bogotá: MSPS; 2017.. The incremental changes from 2004-2015, which were the result of social mobilization and the work of the judiciary, were not sufficient to overcome the failures inherent to the model. In the face of the power of private agents, market dynamics remained, with persistent distortions and inequalities³¹31. Uribe-Gómez M. Nuevos cambios, viejos esquemas: las políticas de salud en México y Colombia en los años 2000. Cad Saude Publica 2017; 33(S2):1-12..

In Mexico, social health insurance reforms began in the 1990s in the context of neoliberal adjustment policies. These reforms met with resistance but were not dismantled; however, they were financially constrained by reduced employer contributions⁷7. Laurell AC. Neoliberalism in Health Care in Mexico - the mexican popular health insurance: myths and realities. International Journal of Health Services 2015; 45(1):105-125.,³²32. HomedesN, Ugalde A. Twenty-Five Years of Convoluted Health Reforms in Mexico. Plos Medicine 2009; 6(8):1-8..

The most radical reform occurred in 2003 with the creation of Popular Health Insurance (SPS). The SPS was intended to provide universal health coverage by 2010, covering the poorest sectors of society and providing them financial protection by offering a restricted package of actions (90 in 2004, and 287 in 2016) (Chart 3). Adherence to SPS is voluntary and it receives tripartite funding from the federal government, the states and families, with exemption by quota for lower income groups⁷7. Laurell AC. Neoliberalism in Health Care in Mexico - the mexican popular health insurance: myths and realities. International Journal of Health Services 2015; 45(1):105-125.,³³33. López-Arellano O, Jarrillo-Soto EC. La reforma neoliberal de un sistema de salud: evidencia del caso mexicano. Cad Saude Publica 2017; 33(S2):1-13..

Despite the expansion of coverage to the poor, the main criticisms of the SPS are as follows: failure to achieve universal coverage (there are still 21 million people without insurance); the restricted nature of the service package and inequalities of access; the inadequacy of the care model; and the persistence of high out-of-pocket expenses, including those who are affiliated to the SPS. The reforms did not result in improvements in the health of the population, a significant reduction in inequalities, greater efficiency or quality. On the contrary, segmentation was accentuated and funding limits persisted⁷7. Laurell AC. Neoliberalism in Health Care in Mexico - the mexican popular health insurance: myths and realities. International Journal of Health Services 2015; 45(1):105-125.,⁸8. Laurell AC, Lima LD. Entrevista. Crisis y neoliberalismo: desafíos y alternativas políticas para la construcción de sistemas universales de salud en América Latina. Cad Saude Publica 2017; 33(S2):1-7.,³²32. HomedesN, Ugalde A. Twenty-Five Years of Convoluted Health Reforms in Mexico. Plos Medicine 2009; 6(8):1-8.,³³33. López-Arellano O, Jarrillo-Soto EC. La reforma neoliberal de un sistema de salud: evidencia del caso mexicano. Cad Saude Publica 2017; 33(S2):1-13..

Universality in the Brazilian Unified Health System (SUS): advances and challenges

In Brazil, an eventual implementation of the UHC proposal would generate many deleterious effects. On the one hand, the universal right to health was constitutionally established in Brazil in 1988 and since then the SUS has expanded access to the entire population, favoring the improvement of health conditions and even the country’s economy. The system is based on a comprehensive notion of universality, which provides coverage and comprehensive healthcare for the entire population: UHC would break with that right.

On the other hand, the Brazilian health sector has characteristics that make the SUS more vulnerable to the private interests that underpin the UHC proposal. It is worth emphasizing the legacy of the Brazilian health system, which, since the 1970s, has had a strong private supply of healthcare services, of which the SUS is the main buyer. Since then, Brazilian governments have favored the private sector through various incentives and subsidies¹¹11. Centro Brasileiro de Estudos de Saúde (Cebes). Manifesto do Centro Brasileiro de Estudos de Saúde em defesa do direito universal à saúde – saúde é direito e não negócio. Rio de Janeiro: Cebes; 2014.. Recently, there has been a progressive reduction of the state’s managerial capacity resulting from contracts with private organizations to manage and provide services in public health units. Whilst the private sector is privileged, the SUS is insufficiently funded, at levels below that provided for by the Brazilian Constitution, with resources less than 4% of GDP (Table 1), which is insufficient to guarantee the universal right to comprehensive healthcare.

Since the passing of the Brazilian Constitution (1988), the SUS and the private sector have grown significantly. Currently, 24.5% of the population have double health coverage (private and public coverage) and these are mainly workers in the formal market, which in practice reflects a segmented health system.

Nonetheless, the SUS organizes healthcare in more than 5,500 municipalities for 200 million Brazilians. The SUS broke with the previous model by establishing new institutional, managerial and care bases. It is a universal health system with a territorial design and foreseeing a hierarchical network at comprehensive levels of care. In keeping with the guidelines for decentralization and the participation of society, the SUS’s institutional and decision-making framework incorporated instruments for democratization and the sharing of health system management between different government entities and civil society. Guided by the importance of a comprehensive approach, the system’s design considers integration between public health actions and individual care, with guarantee of care at all levels of complexity, according to necessity, and without defining a restricted basket of services.

The expansion of PHC services in Brazil, including remote and disadvantaged areas, has increased access to collective and individual care, producing positive impacts on the health of the population. The strategy for PHC within UHC refers to a basic package of services and medicines, corresponding to a selective approach, which would represent a step backwards from the comprehensive concept of PHC within the SUS. The characteristics of the private sector (a fragmented nature, a procedural approach to healthcare, and payment for services) are incompatible with comprehensive PHC. When the private sector incorporates family doctors it seeks to reduce costs and barriers to access to comprehensive care.

Although the SUS is one of the largest universal health systems in the world, since its inception it has suffered from private sector competition and constraints which affect the capacity of the state to guarantee the universal right to health. One of these constraints is the Divestment of Union Revenue (DRU), which has reduced the federal budget by 20% since 1994 (a percentage recently increased to reach 30% by 2023), in addition to the creation of a mechanism for divesting state and municipal budgets.

Most recently, Constitutional Amendment 95/2016 froze government expenditure for the next twenty years and nullified the constitutional foundations of social security. The long period of time provided by this amendment is indisputably sufficient to change the basis of the SUS and other social policies, confirming that the Brazilian state will no longer guarantee social rights.

Other threats to the precept of the universal right to health in Brazil are contained in Law No. 13,097/2015, which allows direct or indirect participation and the control of foreign capital in the health field, and PEC 451, which is being drafted in Congress and which aims to oblige employers to offer workers a private health plan.

The economic crisis in Brazil has affected the private health sector, especially the insurance market, which is mainly supported by clientele linked to employment. Due to unemployment, insurers have lost two million customers since 2014. In 2016 the Minister of Health proposed an accessibility plan to “review the size of the SUS” because it was considered that it would not be possible to “sustain the level of rights determined by the Constitution”³⁶36. Santos IS. A solução para o SUS não é um Brazilcare. RECIIS 2016; 10(3).. Affordable plans would have coverage that was exclusively limited to outpatient care and a low monthly cost, with the expectation of expanding the private market. This proposal coincides with the UHC idea of promoting the provision of health coverage through private insurance.

The UHC proposal would meet the demands of Brazilian insurers and, possibly, those of financial capital and international insurers by increasing participation in the “health market”¹³13. .Rockefeller Foundation. Future health markets: a meeting statement from Bellagio. Belaggio: Rockefeller Foundation, 2012.. The further strengthening of the private sector represents the greatest threat to the SUS and to the universal right to health.

Conclusion

The universal health coverage (UHC) proposal is unclear in terms of its assumptions and strategies. The use of concepts and terms similar to those used for universal health systems makes it difficult to understand the changes in progress. The analyzed characteristics demonstrate the contradictory and deleterious aspects of insurance-based models of expansion of coverage; this results in the segmentation, selectivity, focalizationand crystallization of inequalities, which violates the universal right to health.

As Noronha⁶6. Noronha JC. Cobertura universal de saúde: como misturar conceitos, confundir objetivos, abandonar princípios. Cad Saude Publica 2013; 29(5):847-849. has observed, there has been a semiotic shift from the right to health and from universal and equal access to healthcare, to the concept of “universal coverage”, specified as “the protection of financial risk” and the search for alternative mechanisms of sector financing.

In advanced industrialized countries, universalization was achieved by the 1970s through the introduction of Bismarckian social insurance or Beveridgiannational health services, resulting in greater efficiency and equity in national universal access services based on full citizenship. On the contrary, the case of the USA, where health coverage has been provided by the market, has been marked by inefficiencies due to high expenses, low effectiveness, poor health outcomes and a high proportion of the population without health coverage.

In Latin America, classical European models have influenced health policies, but have not been fully implemented. The two paradigmatic experiences of reforms in the Latin American region disseminated as models for UHC show the failure to achieve universal access through insurance. The goals of universal coverage were not met, service baskets remained unequal, and the segmentation and fragmentation characteristic of Latin American health systems were intensified.

In summary, the promises of the models based on UHC have not materialized and there is no evidence that they have produced more effective results than the universal systems (Chart 4).

In Brazil, the SUS was established as a response to a conception of full citizenship, providing access to healthcare for the vast majority of Brazilians as a human right. Organizational changes have made it possible to reorient the system towards integrality and equity, with a reduction in inequalities in access to services, although it is still far from its egalitarian ideology³⁷37. Paim J, Travassos C, Almeida C, Bahia L, Macinko J. The Brazilian health system: history, advances, and challenges. Lancet 2011; 377(9779):1778-1797..

The experiences of the analyzed countries demonstrate that any insurance arrangements - social, private or subsidized - do not outweigh the strengths of the design of the national public health system adopted in Brazil, even though the results achieved by SUS have not yet reached their full potential. It is crucial to resist the current conjuncture of attacks on the SUS and the risks of that it may be dismantled by fiscal adjustment policies. The challenge is to overcome the storm while maintaining the central objective image: health is not a commodity. It is the right of all and the duty of the state.

Acknowledgments

L Giovanella and CV Machado are CNPq Research Productivity Fellows; MC Rosa CNPq fellowship of the Master’s degree in Public Health.

References

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