Brazil’s unified health system: 35 years and future challenges

2023 marks the 35th anniversary of Brazil’s current Constitution (1988), where health was defined as a universal right and a State responsibility. Since the mid-1970s, the Health Reform Movement (Movimento da Reforma Sanitária) opposed the military dictatorship (1964–1985) and played a key role in the democratization of the country. Bringing together public health professionals, trade unions and grassroots activists, the Health Reform Movement championed the public nature of the health system and defined strategies to reform Brazil’s health sector. This led to the recognition of health as a right guaranteed by socioeconomic policies.¹

The Health Care Law (Law 8080/90) that organizes the Unified Health System (Sistema Único de Saúde or SUS), guarantees universal health care coverage and tackles health inequity was approved in 1990. The governance of SUS follows a decentralized model with each level of government (federal, state and municipal) bearing administrative responsibilities. SUS decentralized policies are managed through an innovative framework of social participation, and at both state and federal levels, intermanagerial committees and health councils monitor the implementation of health programmes.^1,2

The primary health model of SUS is the Family Health Strategy (FHS, Estratégia da Saúde da Família), which provides comprehensive health care and coordinates the coverage at the secondary and tertiary levels. FHS is also responsible for implementing intersectoral strategies for disease prevention and health promotion.² It is the largest community based PHC program in the world, providing primary care to approximately 60% of the Brazilian population (131.2 million people).²

Despite persisting disparities across geographical regions and income groups, SUS succeeded in improving health equity and providing access to comprehensive health care. From 2000 to 2014, total health expenditure rose from 7.0% to 8.3% of the GDP and population coverage with the FHS rose from 7.6% to 58.2%.¹ Health outcomes have improved dramatically, infant mortality has substantially declined by two-thirds between 1990 and 2015, life expectancy increased from 66,9 yr to 74,3 yr in the same period, and the free supply of medication expanded from 27.2% in 1998 to 46% in 2008.³ Between 1999 and 2007, avoidable hospitalizations dropped by 20%,⁴ along with the expansion of PHC coverage.⁵ Brazil has also an outstanding track record on vaccination coverage.⁵ Vaccination against tuberculosis with the BCG rose from 79% in 1990 to 99% in 2015, measles from 78% to 96%, polio from 58% to 98% and DTaP from 66% to 96% in the same period.⁵ The Brazilian AIDS program, also embedded in the SUS system, has been lauded internationally for its notable progress in granting access to affordable antiretrovirals and introducing innovative grassroots prevention programmes.⁶ SUS has also led different strategies of drug regulation and enhanced their availability.⁷

Over more recent decades, however, SUS was affected by the neoliberal reforms defended by the World Bank, which criticized the constitutional guarantee of comprehensive health care for all Brazilians and encouraged the participation of the private sector in the provision of services.^1,2 The reforms resulted in widening of geographical inequalities, insufficient funding and an inefficient private-public collaboration.⁵ Michel Temer’s (2016–2018) and particularly Jair Bolsonaro’s (2019–2022) public health governance based on political-clientelism and market-privatising interests and the adoption of long-term fiscal austerity policies, deepened privatization processes and defunding of SUS.⁸ The constitutional amendment EC 95/2016, approved in December 2016 under Temer’s term, restricts the growth of public expenditure until 2036 and resulted in a loss of R$743 billion (US$148.6 billion) for SUS over 20 years.⁸

Setbacks in primary health care were introduced involving restructuration of public administration, flexibilization of labour laws, disruption of social participation and privatizing of assistance and management.8, 9, 10 Mental health and Indigenous peoples’ health, as well as the HIV program, have suffered under Bolsonaro’s pernicious public health governance.⁶ Health indicators have worsened in the last few years. Childhood vaccination decreased from 93.1% in 2019 to 71.5% in 2021.¹⁰ Maternal mortality increased from 58 deaths for 100,000 live births in 2019 to 107 in 2021,⁹ and child malnutrition led to an increase of 11% in the number of hospitalizations.⁹ Technical staff was replaced by military personnel and scientific evidence by religious and ideological beliefs, with a direct impact on the large number of deaths during the pandemic (around 700,000) and the slow COVID-19 vaccination path.

To rebuild SUS after major setbacks is a priority and an enormous challenge for President Luiz Inácio Lula da Silva.¹⁰ The scenario encountered by the new president was chaotic, with alarming deterioration of health indicators.⁹ Main challenges for Lula’s government as recognized by various stakeholders include: (i) to define a progressive expansion of public resources allocated to SUS (from 4 to 6%–7% of the GDP) along with strategies to improve its allocation efficiency; (ii) to tackle regional inequalities in health through new governance mechanisms; (iii) to reestablish and strengthen primary health care as a comprehensive, resolutive, territorial and community-based primary care model, integrated into the regionalized SUS network; (iv) to address health market regulation to avoid expensive treatments in SUS obtained through judicialization of health; (v) to reorganize health workers’ training, allocation and provision and introduce effective policies to prevent precarious of health work, while also tackling the shortage of doctors and their deficient regional distribution; (vi) to institute a national policy of health data in SUS to enhance the system’s management and digital transformation.⁹ In addition, social participation and control which was a key feature of SUS have to be re-established and strengthened, as well as Brazil’s leadership in global health, relaunching cooperation with the global south.¹⁰

35 years after the Brazilian Constitution defined health as a universal right and a State responsibility, SUS became the main public policy for social inclusion and one of the most powerful tools for reducing inequality in the country. The defence of the right to health involves considering health expenditure as an investment and a way to advance health and equity for the Brazilian population.

Contributors

Both authors conceived and wrote the manuscript.

Declaration of interests

None to declare.