The Unified Health System—SUS—of Brazil Vinod Vyasulu

1. The Unified Health System—SUS—of BrazilVinod Vyasulu

2. Objective To understand the way the Brazilian Health System has been organised; how it is managed and financed; and draw out lessons for India

3. Important Background Facts - 1 The 2013 UNDP Human Development Report for Brazil has shown that, in 20 years, the proportion of cities with low human development indices fell from over 80% to less than 0.5%, for all 5,565 Brasilian cities.

4. Important Background Facts - 2 The infant mortality rate (the deaths of children less than one year old) fell from 29.4 per one thousand infants born in 2001 to 17.3 in 2010. This represents a reduction of almost 50% over the last decade. Life expectancy at birth improved to 73 years in 2010 from 70 years in 2000. Before 1988, only 30 million Brazilians had access to health services, according to the Ministry of Health. The coverage expanded to 140 million, roughly three-quarters of the population, by 2008.

5. This presentation • A description of the Brazilian Health System • Key lessons from the SUS, as the Unified Health System is known • My analysis of the challenges before the SUS. • Challenges for India

6. Brazilian Approach After the 1988 Constitution made health a fundamental right, Brazil chose a gradual approach to health reform, building on what existed, trying to blend stakeholders interests and avoid social conflict in the process of providing from the supply side a universal access, decentralised system of health in a highly unequal society.

7. Great Inequality...This

8. And Across the Road, this

9. And serving both...

10. The Health System of Brazil -1 • A long history of struggles for health care such as movement of Brazilian sanitary engineers, resulting in the right to health becoming an integral part of the 1988 Constitution • Built upon what existed earlier—mainly government hospitals, with some charity and private institutions in the big cities. • The private sector, consisting of hospitals and insurance companies providing health plans, coexist with the SUS. These had existed earlier, and were the result of union struggles for better conditions.

11. The Health System of Brazil - 2 • Health is seen not the absence of disease, but a sense of positive wellbeing. • The focus is on the family and community, not the individual per se, and adopts an educational, lifestyle approach. • Social Councils have an important role to play in health policy at municipal, provincial and federal levels.

12. Principles on which SUS is built • Universal and free health care for all Brazilians • One unified system, designed in a decentralised way within the federal structure of Brazil • Two branches—the Family Health System and the Hospital System • The Family Health System is almost completely under the state, with no private participation

13. The Family Health System -1 • Family Health Centres, catering to around 10000 people, set up in each municipal jurisdiction • This consists of 5 doctors specialising in family health, one gynaecologist/obstetrician, a dentist, a general physician, a pharmacist, and at least 5 nurses and para medical staff, who are employed by the municipality. • There are about 20 community health workers in each PSF centre • No OT or rooms for overnight stay. Open during the day.

14. Catchment Area of PSF Betania, Belo Horizonte

15. A Poor Neighbourhood PSF

16. The Family Health System - 2 • The Centre updates information after each visit or consultation. This is a centralised datadase accessible everywhere—cadastro unico. • Facilities for counselling—rooms—and teaching children to brush their teeth. • A fully equipped pharmacy, with free distribution of medicines, closely monitored.

17. The Family Health System - 3 • Medicines only given on prescription to patients; control on overuse of antibiotics • Visits to schools to check child health, ensure complete immunisation etc. • Deal with 85% of the health problems that arise. • Refer emergency, accident cases to the next tier—the UPA—a referral unit with OT, casualty and related facilities, open 24/7.

18. The Family Health System - 4 • Health Campaigns as needed • Headed by a person with a health background—doctor, nurse etc • Based on experience, UFMG has begun a new undergraduate course of Health Managers for the SUS system, so that health professionals can focus on health and not administration.

19. Health Conference in PSF Belo Horizonte

20. Health Workers Meeting, BH

21. Focus on Family Health and Outreach • All families in the catchment area are visited, and an up-to-date database is kept. • Education and counselling are essential ingredients of its work. • Each week a support group of hypertensives, diabetics etc meets with the family doctor • Community workers and doctors have weekly meetings to discuss issues.

22. Neighbourhood Vaccination Campaign

23. Beware of Seasonal Flu

24. The Hospital System • On reference from the PSF or private doctors • Consists of both government-local, provincial and private institutions • Both non profit and for profit hospitals function • Second level is the UPA, then speciality hospitals at tertiary level

25. The UPA • Second referral level, with a casualty and surgical facilities. Ambulances available. • Except for accident cases, treatment only on a reference from the PSF centre doctors. • Cases referred up to hospitals if UPA cannot handle the case. • Admission to hospitals only on a reference—no walk in patients in tertiary hospitals.

26. Hospital das Clinicas -1 • Well equipped tertiary institutions, all specialities • Set up in all cities • Admission on reference from UPA/PSF doctors. • All serious cases only here—bone marrow transplants, dialysis, HIV/AIDs etc • Facilities to transport patients—buses etc.

27. Hospital das Clinicas - 2 • For non emergency cases, long waits, eg. • May need to wait months for chemotherapy, ---Patients have passed away before treatment began • Insurance cover taken for this • Shortages at this level evidence, in my view, of underfunding by the State

28. Innovations - Telemedicine • In Minas Gerais, the UFMG Hospital das Clinicas has pioneered a system of telemedicine • A sophisticated two way communication system of computers, with scanners etc set up • Control centre in the hospital, with remote terminals in PSF centres in remote municipalities • Experts available 24/7 in the Telemedicine centre for giving expert opinion and advice on treatment

29. Innovations - 2 • In the municipal PSF centre the doctor can take an ECG etc and transmit it by internet to the expert; based on this, treatment is suggested. • If needed the patient can be taken to the nearest hospital that has the required facilities • Training in using the system given to all concerned, from doctors and nurses to other staff regularly • Teleconferences held as continuing education

30. In the Amazon • Well equipped hospital ships ply along the river providing tertiary services • Originally operated by the Brazilian Navy, now handed over to the SUS • Density of population less than 10 per sq kilometre • Patients in remote areas brought in by helicopter • Traditional medicines extensively used, based on herbs and plants locally available in abundance.

31. Unified System of Health • Health is part of social protection and development • Link to education, nutrition, sanitation etc ensured at municipal level • Federal Government makes cash transfers to families from a single database that integrates health, education, etc • Open system—acupuncture, traditional knowledge etc all respected

32. Complementary Policies • Social protection and assistance are an integrated set of programmes: the Zero Hunger Strategy. • Integrated schools where parents can leave young children when they go to work. • Schools are supplied with food grains purchased locally from farmers at market price • Food not sold by evening in the markets donated to orphanages etc • Community workers use the counselling approach to deal with problems faced by families • De-addiction and rehabilitation centres for young people with mental issues available

33. Integrated School, BH

34. Play Area, Integrated School

35. Playroom

36. The Private System of Health - 1 • Focus on tertiary care • Both charity and profit making institutions exist • Privately managed, charge fees; considered expensive • No catastrophic services—eg dialysis • Doctors from SUS can also consult in private institutions

37. The Private System of Health - 2 • Financed via regulated health plans • People working in government or the organised sector can opt for these health plans, part paid by employer • Tax incentives for health plans • Choice of health plans to chose from • Premiums increasing over time for a given level of coverage

38. The Private System of Health - 3 • Existed before the 1988 constitution and continue to function • Open to all government and organised sector employees, who are also entitled to SUS services • Regulated by a Federal Commission • Insurance does not pay SUS for patients with health plans treated in SUS institutions.

39. Citizen Feedback • PSF appreciated; needs to cover the whole country. At present only 50% coverage • Waiting times in UPA too long • SUS hospitals excellent, but overcrowded and entail long waits • Less of waiting, and choice of doctor/hospital possible in private sector • ‘If you have a good lawyer, you can get excellent care’

40. Financing of Health - 1 • Free and universal access and decentralised delivery a constitutional obligation of the Brazilian state after 1988 • Health fund at the federal level, with subventions as per law at each level • States both fund and run hospitals

41. Financing of Health - 2 • Municipalities deliver integrated services • About 8% of GDP, with government share coming down from 4 to 3.5% in recent years. • Some years ago a [Tobin] tax on financial transactions was levied and used to fund social protection. This has been voted out by Congress; consequent strain on the fisc; a possible reason for underfunding today

42. Cost of a PSF centre • Around USD 200,000 per month per centre • Is this an expenditure or investment? • Opportunity cost—money saved via health education and preventive health practices • Need to cover the whole country • President Dilma Rouseff has promised to extend the SUS. Today SUS is underfunded.

43. Challenges before the SUS • The co-existence of the private sector, based on privately provided health plans is a threat to the SUS • Expensive treatments are provided to those who have such plans by the SUS, but the insurance companies do not pay SUS for these services. • Many of those who have health plans do not seem to be aware of what the SUS is now offering—an amazing blind spot...

44. The cost of medicines • Medicines are provided free at PSF centres • Medicines are expensive, using India as a benchmark. • Brfazil does not have a patent law like India; • It pays MNCs for the drugs it buys • These include large royalties

45. A Possible Answer • Can Brazil learn from Indian experience with patents and compulsory licencing? • If yes, then resources will be freed which can used to expand SUS without a need for increased allocations. • A research question waiting to be studied.

46. Health Plans Create Distortion • Health Plans have put limits on consultation fees etc. If you depend on them, you still have to wait. Otherwise, full payment is to be made • SUS consultation free, with a wait; health plan consultation, limited to say BRL 30 per visit; requires a wait • Immediate consultation on payment is around BRL 200 per visit. Huge difference

47. If I were Brazilian Policymaker... • Would include health plan data in the SUS card; insist on payment for services rendered by SUS from the insurance company. Former Health Minister Jose Serra failed in his attempt to do this. • Remove the income tax incentive for health insurance. • Increase SUS funding to ensure complete coverage after debate on level of UPA and hospital services desired.

48. A Reality Check • In June 2013, when the Confederation Football championships were on, millions of Brazilians across the country staged peaceful protests against the lack of investments in health, education, public transport etc. • The very success of Brazil’s policies led to a demand for better services to those newly out of poverty. • The President has acknowledged these are legitimate demands; this is democracy at work.

49. A Few Thoughts • Clarity in converting Objectives into goals and programmes • Working the federal system so that each sphere of government played its part • Mechanisms of discussion across government levels and with Social Councils • Taking time to prepare the ground for the implementation of a strategy, building on the past.

50. Lessons for India? • A single database like the cadastro unico; federally designed and maintained, locally updated and used for all social protection schemes • Federal functioning—each sphere of government plays its role in an integrated way while delivery of service is by the municipal government • Neither of these conditions apply in India.