As 2015 approaches, the world is contemplating the post-MDG agenda. In the area of health, there is a global movement to expand access to health care and achieve universal coverage. The World Bank is fully aligned with this movement and jointly with the World Health Organization, it has recently announced, new goals focused on the prevention and treatment of chronic diseases.
With the creation of the National Health System (Sistema Único de Saúde – SUS) 20 years ago, Brazil was one of the first and few countries outside the OECD (Organization for Economic Cooperation and Development) to integrate the goal of universal health coverage in its legislation, recognizing health as a right of citizens and a responsibility of government. Brazil is today a point of reference in the international health community, and an example to other countries that are trying to establish more equitable health systems.
Twenty years on, what is the hallmark of the SUS? The book Twenty Years of Health System Reform in Brazil: An Assessment of the Sistema Único de Saúde, recently published by the World Bank, reflects on this question. It concludes that, through the creation of the SUS, Brazil laid the foundations for a better health system and contributed to improving the quality of life of its population. The SUS triggered a fundamental restructuring of how the health system is governed; a process of decentralization and new arrangements for sharing of responsibilities across federal, state and municipal levels; and a gradual increase of public spending on health.
The increase in health spending was accompanied by an improved allocation of federal and state resources in favor of the poorest parts of the country and segments of the population. This contributed to a significant improvement in access to primary health care services, which in turn has led to a reduction in avoidable mortality and hospital admissions from primary care sensitive conditions. Overall, the number of primary care facilities increased from 2.2 per 10,000 inhabitants in 1990 to 3.6 in 2009, while the number of primary care consultations per person increased by 70 percent during the same period. In large part, this reflected the introduction and expansion of the Programa Saúde da Família [Family Health Program] (PSF), which today covers approximately 100 million Brazilians. Studies show that the PSF has been an important factor in reducing child mortality and improving other health indicators, especially in the country’s poorer North and Northeast regions. Notwithstanding the challenges that the health system still faces, improved access to health care and the political vision underpins this improvement are the true hallmarks of the SUS.
So far, no country has managed to build a perfect health system. Priorities and strategies for health system reform vary across countries. However, sustained evolution and improvement of the Brazilian health system depends on a continuous process of evaluating its performance and mapping progress and challenges.
In terms of the challenges facing the SUS, the book highlights the need to better align government health spending with public health needs and to improve management capacity in the system. It also identifies a number of areas where the health system will need to continue to develop – improving the quality and coordination of care, continuing the expansion of primary care coverage, addressing the significant barriers to accessing specialized and high-complexity care, and reducing the relatively high level of dependence on private spending to finance the health system. These challenges are expected to become more pressing in the future, as the Brazilian population ages and the burden of disease associated with cancer and cardiovascular disease continues to grow.
The transformation of a health system of the scale and complexity of the SUS is inevitably a long-term gradual process. The World Bank has supported Brazil’s development for many years and now finances projects in nearly every Brazilian state. In health, it has worked with health system managers to strengthen administrative capacity and to address the most pressing health challenges, ranging from neglected diseases to chronic conditions, such as cancer, hypertension, and diabetes. These projects are systematically prepared and implemented through partnership and close dialogue with managers at federal, state or municipal level. Through these partnerships, the World Bank has come to know and understand the many strengths of the SUS, without losing sight of the challenges the system faces.
After more than 20 years, it is important to reflect on the challenges of the SUS, but it is important to do so based on a historical perspective of the system’s evolution. From this perspective, the SUS represents an enormous achievement for Brazilian society, and in particular for the poorest and most vulnerable segments of the population. The health system has not only manage to significantly improve access to health care, but also represents a significant social and political commitment and an effort to realize rights that are an key aspect of citizenship for millions of Brazilians. The path towards a more inclusive and accessible health system is invariably full of obstacles, but Brazil has already taken an important step in the right direction.
