Twenty Years Of Health System Reform In Brazil
Public Disclosure AuthorizedPublic Disclosure Authorized78682Public Disclosure AuthorizedPublic Disclosure AuthorizedDIREC TIONS IN DE VELOPMENTHuman DevelopmentTwenty Years of Health SystemReform in BrazilAn Assessment of the SistemaÚnico de SaúdeMichele Gragnolati, Magnus Lindelow, and Bernard Couttolenc
Twenty Years of Health System Reform in Brazil
DIREC TIONS IN DE VELOPMENTHuman DevelopmentTwenty Years of Health SystemReform in BrazilAn Assessment of the Sistema Único de SaúdeMichele Gragnolati, Magnus Lindelow, and Bernard Couttolenc
2013 International Bank for Reconstruction and Development / The World Bank1818 H Street NW, Washington DC 20433Telephone: 202-473-1000; Internet: www.worldbank.orgSome rights reserved1 2 3 4 16 15 14 13This work is a product of the staff of The World Bank with external contributions. Note that The WorldBank does not necessarily own each component of the content included in the work. The World Banktherefore does not warrant that the use of the content contained in the work will not infringe on the rightsof third parties. The risk of claims resulting from such infringement rests solely with you.The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the viewsof The World Bank, its Board of Executive Directors, or the governments they represent. The World Bankdoes not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations,and other information shown on any map in this work do not imply any judgment on the part of The WorldBank concerning the legal status of any territory or the endorsement or acceptance of such boundaries.Nothing herein shall constitute or be considered to be a limitation upon or waiver of the privileges andimmunities of The World Bank, all of which are specifically reserved.Rights and PermissionsThis work is available under the Creative Commons Attribution 3.0 Unported license (CC BY 3.0) http://creativecommons.org/licenses/by/3.0. Under the Creative Commons Attribution license, you are free tocopy, distribute, transmit, and adapt this work, including for commercial purposes, under the followingconditions:Attribution—Please cite the work as follows: Michele Gragnolati, Magnus Lindelow, and BernardCouttolenc 2013. Twenty Years of Health System Reform in Brazil: An Assessment of the Sistema Únicode Saúde. Directions in Development. Washington, DC: World Bank. doi:10.1596/978-0-8213-9843-2.License: Creative Commons Attribution CC BY 3.0Translations—If you create a translation of this work, please add the following disclaimer along with theattribution: This translation was not created by The World Bank and should not be considered an officialWorld Bank translation. The World Bank shall not be liable for any content or error in this translation.All queries on rights and licenses should be addressed to the Office of the Publisher, The World Bank, 1818H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org.ISBN (paper): 978-0-8213-9843-2ISBN (electronic): 978-0-8213-9932-3DOI: 10.1596/978-0-8213-9843-2Cover photo: Mariana Kaipper Ceratti. Used with the permission of Mariana Kaipper Ceratti. Furtherpermission required for reuse.Cover design: Naylor DesignThis publication has been produced thanks to the contribution of The Government of Spain, through theSpanish Fund for Latin America and the Caribbean.Library of Congress Cataloging-in-Publication Data has been requested.Twenty Years of Health System Reform in Brazil http://dx.doi.org/10.1596/978-0-8213-9843-2
ContentsAbout the AuthorsAbbreviationsOverviewHave the SUS Reforms Transformed the BrazilianHealth System?Have the SUS Reforms Led to Better Outcomes?ConclusionsReferencesxixiii1251013Chapter 1IntroductionSUS: Origins and 20 Years of ImplementationA Framework for Assessing SUS PerformanceContribution of This ReportNotesReferences151618212222Chapter 2Have the SUS Reforms Transformed the BrazilianHealth System?Expansion and Reorganization of Service DeliveryToward Increased and More Equitable Health FinancingEnhancing Health System GovernanceNotesReferences252536465355Chapter 3Have the SUS Reforms Led to Better Outcomes?57Use of Health Services and Progress toward Universality57Are Health Care Needs Being Met?66Health System Efficiency73Has the Health System Improved Health Outcomes?80Has the SUS Contributed to Improved Health Outcomes? 83Out-of-Pocket Payments and Financial Protection88Public Perceptions of and Satisfaction withthe Health System93Notes96References100Twenty Years of Health System Reform in Brazil http://dx.doi.org/10.1596/978-0-8213-9843-2v
viContentsChapter 4ConclusionsSustaining Improvements in Access to Health CareImproving Efficiency and Quality of Health Care ServicesClarifying Roles and Relationships across Levels ofGovernmentDetermining the Right Level of Health Spending andImproving EfficiencyConducting More and Better Health System Monitoringand es1.1Assessment of Health System Performance in Brazil:Approaches and Recent DevelopmentsPrimary Care and Prevention in Brazil:The Family Health StrategyPrimary Care and Prevention in Brazil: Beyond the FamilyHealth StrategyAssessing Local Capacity to Manage DecentralizedResponsibilitiesThe Social Organization Model in São Paulo StateBrazil’s Program on HIV/AIDSCesarean Sections in 12.22.32.42.52.62.72.82.92.102.11A Simple Framework for Assessing the Performance ofthe Health SystemNetwork of Health Facilities in Brazil, 1981–2009Density of the Network of Health Facilities in Brazil, 1981–2009Coverage of the ESF in Brazil, 1994–2010Coverage of the ESF in Municipalities in Brazil,by Income Quintile, 1985–2007Coverage of the ESF in Brazil, by Income Quintile, 2008Coverage of the ESF in Brazil, by State, 2008Decentralization of Public Outpatient Facilities andHospital Beds in Brazil, 1981–2009Local (State and Municipal) Management of Hospital Bedsin Brazil, 1992–2009Municipal Management of Hospital Beds in Brazil, 1992–2009Public-Private Composition of Hospitals and HospitalBeds in Brazil, 1980–2010Public-Private Composition of Outpatient Facilities in Brazil,1980–2010202627283030313233333435Twenty Years of Health System Reform in Brazil http://dx.doi.org/10.1596/978-0-8213-9843-2
y of Hospital Beds and Outpatient Facilities acrossStates in Brazil, 1988 and 2009Link between Income and Density of Facilities across Statesin Brazil, 1988 and 2009SUS and Social Security Spending on Health in Brazil,by Level of Government, 1980–2009SUS and Social Security Spending per Capita onHealth in Brazil, by Level of Government, 1980–2010SUS and Social Security Spending on Health as a Percentageof GDP in Brazil, by Level of Government, 1980–2009Annual Growth in Government Health Spending per Capitain Select Countries, 1995–2010Government Health Spending as a Percentage of GDPin Select Countries, 2010Allocation of the Ministry of Health Budget in Brazil,by Type of Care, 1995–2010Allocation of Health Spending in Brazil, by Levelof Government and Type of Care, 1984 and 2010Share of SUS Financing in Brazil, by Level of Government,1980–2009SUS Health Spending per Capita across States in Brazil,1995 and 2009SUS Spending per Capita on Health and AverageMonthly Income per Capita across States in Brazil,1995 and 2009Share of Private Health Spending in Total Health Spendingin Brazil, 1995–2009Government Financing of Health Expendituresin Select Countries, by GDP per Capita, 2010Use of Private and Public Providers of Health Carein Brazil, 2012Main Source of Care in Brazil, by Type of Service, 2008Medical Consultations, Basic Care Procedures, and HospitalAdmissions per Capita in Brazil, 1980–2009Hospital Admissions in Brazil, by Type of Provider, 1985–2009Health Services Used by Households in Brazil, 1986 and 2008Source of Care in Brazil, by Type of Facility, 1981–2008SUS Consultations per Capita and Hospitalizations per100 Persons in Brazil, by State, 1995 and 2008 (or 2009)SUS Consultations per Capita and Hospitalizations per100 Persons in Brazil, by State Income per Capita,1995 and 2008 (or 2009)Percentage of the Population Who Sought and Used Carein Brazil, by Income Decile, 1986 and 2008Twenty Years of Health System Reform in Brazil 940404142424344454546595960616262636465
303.313.32Immunization Coverage in Brazil and OtherDeveloping Countries, 1980–2009Reasons Given for Not Seeking Care in Brazil, by Income Decile,1986 and 2008Share of Persons Reporting That They Sought Care but Did NotReceive It in Brazil, by Income Decile, 1986 and 2008Patterns of Care and Possible Points of Delay in AccessingHealth Care in BrazilRates of Cesarean Section for Brazil as a Whole and forINAMPS/SUS, 1970–2009Quality of Care in the ESF and the Traditional PrimaryHealth Care System in Petropolis, Brazil, 2003Potentially Avoidable Hospital Admissions for ChronicDiseases and ESF Coverage in Brazil, 1997–2007Distribution of Health Spending in OECD Countries, 2007Density of Technology Use in Brazil and OECD Countries,1985–2009Bed Occupancy Rate in SUS Hospitals in Brazil, 1992–2010Long-Term Trends in Life Expectancy and Infant Mortalityin Brazil, 1960–2009Child Mortality and Mortality by Acute Diarrhea amongChildren Younger Than Five Years Old in Brazil, 1990–2008Maternal Mortality in Brazil and Latin America andthe Caribbean, 1990–2009Life Expectancy and Infant Mortality in Brazil, by State,1994 (or 1995) and 2007 (or 2009)Link between Health Outcomes and Average Income perCapita in Brazil, 1994 (or 1995) and 2007 (or 2009)Infant Mortality in Brazil, by Region, 1997–2007Infant Mortality in Brazil, by Income Group, 1990–2006Share of the Household Budget Spent on Health in Brazil,1987–2003Composition of Household Spending on Health in Brazil,1987–2009Household Spending on Drugs and Private Health Plansin Brazil, by Income Distribution, 1987–2003Incidence of Catastrophic Spending on Health in Select LatinAmerican Countries, Various Years, 2002–08Access to Dental Care and Medications from the SUSin Brazil, 1981–2008Drugs Paid for Out-of-Pocket in Brazil, by SUS List,Type of Prescriber, and Use, 2008Satisfaction with the Health System in Select Countries,by GDP per Capita, 96Twenty Years of Health System Reform in Brazil http://dx.doi.org/10.1596/978-0-8213-9843-2
ixContentsTables2.1B2.3.13.1Coverage of the ESF and the PACS in Brazil,by Size of Municipality, 1998–201031Performance Scores for Essential Public Health Functionsof Five State Secretariats in Brazil, 200650Change in Health Outcomes in Brazil and Comparable Countries,1985–200982Twenty Years of Health System Reform in Brazil http://dx.doi.org/10.1596/978-0-8213-9843-2
About the AuthorsMichele Gragnolati is the Human Development Sector Leader forArgentina, Paraguay, and Uruguay at the World Bank, based in Buenos Aires.Previously, he served as Human Development Sector Leader for Brazil, basedin Brasilia; human development country sector coordinator for the WesternBalkans, based in Sarajevo; and human development economist, based inWashington, DC. He holds a bachelor’s degree in economics from BocconiUniversity in Milan, a master of science degree in demography from theLondon School of Economics, and a doctorate in statistical demography fromPrinceton University.Magnus Lindelow is the Human Development Sector Leader (Health, Education,and Social Protection) at the World Bank in Brazil. He holds a doctorate in economics from Oxford University. At the World Bank, he has worked on healthsystem reform, service delivery, public expenditure management, and povertyand social protection issues. Over the last few years, he has been involved inprojects and research in Cambodia, China, the Lao People’s DemocraticRepublic, Malaysia, Mongolia, the Republic of the Union of Myanmar, Thailand,Timor-Leste, and, most recently, Brazil. He has published books and researcharticles on impact evaluation of health sector programs, distributional issues inthe health sector, public finance, service delivery, poverty, and other topics. Priorto joining the World Bank, he worked as an economist in the Ministry of Planningand Finance in Mozambique and later as a consultant on public finance andhealth sector issues.Bernard Couttolenc is Chief Executive Officer of the Performa Institute, a newpolicy research center in São Paulo, Brazil. He has a master’s degree in businessmanagement and a doctorate in health economics from Johns HopkinsUniversity. He has worked for many years in executive positions in public andprivate hospitals in Brazil as well as in planning and financing of the publichealth system. He has nearly 20 years of experience consulting with international organizations such as the Asian Development Bank, Inter-AmericanDevelopment Bank, World Bank, and World Health Organization, among others.He has participated in projects in 15 developing countries in Africa, Asia, andLatin America on health sector reform; health financing and paymentTwenty Years of Health System Reform in Brazil http://dx.doi.org/10.1596/978-0-8213-9843-2xi
xiiAbout the Authorsmechanisms; hospital management, efficiency and reform; health care financing;health systems planning and e valuation; and public-private partnerships. Formore than 10 years, he held a teaching position at the University of São Paulo,where he conducted research in health economics, financing, and economicevaluation.Twenty Years of Health System Reform in Brazil http://dx.doi.org/10.1596/978-0-8213-9843-2
AbbreviationsAIHautorização de internação hospitalar, the inpatient care informationand billing system of the SUSAMSAssistência Médico-Sanitária, a survey by the IBGEANSAgência Nacional de Saúde Suplementar, National RegulatoryAgency for Private Health Insurance and PlansBRICSfive upper-middle-income emerging countries: Brazil, Russia, India,China, and (recently) South AfricaCNIConfederação Nacional da Indústria, National Confederation ofIndustryCONASS Conselho Nacional de Secretários de Saúde, National Council ofState Secretaries of HealthCPMFContribuição Provisória sobre Movimentações Financeiras,a contribution of financial transactions passed to finance the public health systemCTcomputerized tomographyDATASUS data-processing arm of the Ministry of HealthESFFamily Health StrategyGAPAGrupo de Apoio à Prevenção à AIDSGDPgross domestic productHIV/AIDS human immunodeficiency virus/acquired immunodeficiencysyndromeIBGEInstituto Brasileiro de Geografia e Estatística, Brazilian Institute ofGeography and StatisticsIDSUSÍndice de Desempenho do SUS, SUS Performance IndicatorINAMPS Instituto Nacional de Assistência Médica da Previdência Social,National Institute for Social Medical Assistance, in charge of curative care under the Social Security system that preceded SUSIPEAInstituto de Pesquisa Econômica Aplicada, Institute of AppliedEconomic ResearchMACmédia e alta complexidade, a grouping of medium- and high- complexity services in SUS classification of health care levelsTwenty Years of Health System Reform in Brazil http://dx.doi.org/10.1596/978-0-8213-9843-2xiii
xivAbbreviationsand a block grant covering most inpatient care and specializedcareMRImagnetic resonance imagingOECDOrganisation for Economic Co-operation and DevelopmentPACSPrograma de Agentes Comunitários de Saúde, Community HealthAgents Program that preceded the ESFPMAQPrograma Nacional de Melhoria do Acesso e da Qualidade daAtenção Básica, National Program for Improvement of Access andQuality in Primary CarePesquisa Nacional por Amostra de Domicílios, IBGE’s yearlyPNADhousehold surveyPesquisa dos Orçamentos Familiares, a household surveyPOFPROCON Bureau of Consumer ProtectionSAMUSistema de Assistência Médica de Urgência, Mobile EmergencyServiceSistema de Informação sobre Orçamentos Públicos em Saúde,SIOPSPublic Health Budget Information System of the Ministry ofHealth, which records and monitors budgetary expenditures onhealth from all levels of governmentUnified and Decentralized Health SystemSUDSSUSSistema Único de Saúde, Unified Health SystemTribunal de Contas da UniãoTCUWHOWorld Health OrganizationTwenty Years of Health System Reform in Brazil http://dx.doi.org/10.1596/978-0-8213-9843-2
OverviewIt has been more than 20 years since the 1988 Constitution formally establishedthe Brazilian Unified Health System (Sistema Único de Saúde, SUS). The impetusfor the SUS came in part from rising costs and a crisis in the Social Security system that preceded the reforms, but also from a broad-based political movementcalling for democratization and improved social rights. Building on reforms thatstarted in the 1980s, the SUS was based on three overarching principles: (a) universalaccess to health services, with health defined as a citizen’s right and an obligationof the state; (b) equality of access to health care; and (c) integrality (comprehensiveness) and continuity of care. Other guiding ideas included decentralization,increased participation, and evidence-based prioritization (Couttolenc 2011a).The SUS reforms established health as a fundamental right and duty of thestate and started a process of fundamentally transforming Brazil’s health systemto achieve this goal. This report focuses on two questions: What has beenachieved since the SUS was established? And what challenges remain in achieving the goals that were established in 1988? The report assesses whether the SUSreforms have transformed the health system as envisaged more than 20 years agoand whether the reforms have led to improved outcomes with regard to accessto services, financial protection, and health status.Any effort to assess performance confronts a host of challenges concerning thedefinition of boundaries of the “health system,” the outcomes that the assessmentshould focus on, the sources and quality of data, and the role of policies andreforms in explaining how the performance of the health system has changedover time. Building on an extensive literature on health system assessment, thisreport is based on a simple framework that specifies a set of “building blocks”that affect intermediate outcomes such as access, quality, and efficiency, which,in turn, contribute to final outcomes, including health status, financial protection,and satisfaction. Based on this framework, the report starts by looking at how keybuilding blocks of Brazil’s health system have changed over time and thenreviews performance with regard to intermediate and final outcomes. The reportis, however, selective, and some important building blocks, such as humanresources and pharmaceuticals, are not discussed systematically.Twenty Years of Health System Reform in Brazil http://dx.doi.org/10.1596/978-0-8213-9843-21
2OverviewHave the SUS Reforms Transformed the Brazilian Health System?The SUS reforms envisaged profound changes in the organization and financingof health services as well as the governance and accountability arrangements ofthe system. Specifically, they targeted several perceived weaknesses of the preSUS system, including the limited availability of services in some parts of thecountry, the weak primary care system, and excessive centralization. The futurerole of the private sector was debated intensively in the lead-up to the newConstitution; in the end, the Constitution and founding legislation of the SUSdefined the role of the private sector as “complementary.”Expansion and Reorganization of Service DeliverySince the establishment of the SUS, there have been many changes in theorganization of service delivery. Most notably
2.14 SUS and Social Security Spending on Health in Brazil, by Level of Government, 1980–2009 39 2.15 SUS and Social Security Spending per Capita on Health in Brazil, by Level of Government, 1980–2010 39 2.16 SUS and Social Security Spending on Health as a Percenta
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