Brazil’s National Health Care System at Risk for Losing Its Universal Character

Brazil, the largest medium-high–income country in Latin America, inscribed in its 1988 constitution health as a universal right. This led to the creation of a publicly funded national health system with universal access: the Unified Health System (SUS, the abbreviation of the Portuguese name). Since then, despite all the difficulties arising from being underfunded, pressure from the private health care sector, and fiscal adjustments, the SUS has allowed the extension of access to health care for the entire population.¹ At the same time—especially during the center-left presidencies (2003–2014)—the expansion of access to SUS services, coupled with important advances in social cash transfer programs such as Bolsa Familia, rural retirement, and rising minimum wages, has contributed to the improvement of the health status of the population and the reduction of social inequalities.²

Among the advances in SUS, the implementation of the Family Health Strategy (ESF, the abbreviation of the Portuguese name) is a community-oriented primary health care (PHC) model based on the performance of multiprofessional teams delivering clinical and health-promotion activities.³ Stimulated by federal funds, the ESF was progressively enlarged with the adaptation of institutional rules to the geographic and population diversity of the country in a manner consistent with the SUS principles of universality of access, comprehensive care, and equity. Access to health care was increased; the ESF enabled extending community-based primary care as a cost-effective way of covering underserved populations.⁴

In 2019 there were more than 43 000 Family Health teams deployed, which consist of physicians, nurses, and community health workers; operate throughout the national territory; and cover a great diversity of municipalities and population groups. This model was implemented progressively after intensive discussions that included academic institutions and the civil society; it has had undeniable positive effects on the population’s health. Now, however, these developments are under threat.^3,5 Although Brazil has made a major effort to improve its population’s health, as evidenced by a substantial increase in governmental health expenditure per capita from 2003 to 2014, the SUS remained underfunded. Funding was never sufficient to accomplish the goal of a universal system that would reduce the social and regional inequities that still persist in Brazil.^3,5

Massuda et al.⁵ show that the SUS’s structural problems and disparities will worsen with the austerity measures introduced by the current federal administration and risk reversing its achievements in improving population health outcomes. A constitutional amendment (EC95) approved by the Brazilian congress in December 2016 limited federal expenditure on health over the following 20 years, with projected accumulated losses in the federal health budget (currently approximately US $29 billion per year) of approximately US $93 billion by 2036, according to projections by the Institute for Applied Economic Research.

The deterioration of the overall funding of the SUS and the ESF will be intensified by the new measures. The ultraneoliberal policy of the Bolsonaro government has imposed successive direct attacks on the SUS that not only change the form of funding, causing serious economic risks for states and municipalities, but also disregard the model of care that was being built up until recently.

The transfer of federal resources for PHC to the municipalities, which was previously calculated according to the number of inhabitants of each municipality and specific incentives for the ESF multiprofessional teams under the current government measure, will be calculated according to the number of people enrolled in any kind of primary care team’s patient lists—abolishing the incentives for multiprofessional teams as well. This shift in the resource allocation, from a population-based to an enrolled persons–based model, will have dire consequences for municipal funding. Unless all residents in a given area are enrolled in the ESF teams, there will be a reduction in the reference number for budgeting. Achieving high levels of enrollment is even less likely in large cities, where most of the population lives. Furthermore, with no specific funding, multiprofessional health care teams, another key feature of the ESF, are unlikely to persist.

This is a stark departure from the principle of health as a universal right, making it impossible to apportion public resources according to the health needs of the population and thus nullifying the ESF care model. It is supported by World Bank proposals, driven by the idea of focused social policy, which is inherently inimical to universal access principles. Moreover, it does not include the necessary investments to reduce inequalities and inequities in health service delivery and does not add new funding. The new funding modalities mean significant losses for many overburdened municipalities. So far, no studies have been presented to support the new funding proposal. There is a risk of defunding PHC services in the urban peripheries of large cities. Estimates of the Councils of Municipal Health Secretariats of Rio de Janeiro⁶ and São Paulo⁷ point to considerable losses. The 12 municipalities of the Baixada Fluminense, a very poor region in the larger Rio de Janeiro metropolitan area, for example, would require enrolling more than 2 million people by May 2020, which is highly unlikely to say the least. More probably this will lead to a monthly loss of about US $1.5 million, more than 40% of the total federal funding for this area in 2019, which will undoubtedly result in a lack of care to the population.⁶ On the other hand, the Councils of Municipal Health Secretariats of São Paulo estimates a loss of 47% of federal resources for PHC in the São Paulo state municipalities in 2021.⁷

The historic underfunding of the SUS is being aggravated by a draconian fiscal adjustment that has burdened municipalities to an extent that they will not endure any additional financial constraints. The Brazilian federation pact requires joint action between the three government levels to fulfill the state’s responsibilities to the population’s health. The transfer of municipal population-based federal resources according to the current system is fundamental and nonnegotiable, and its removal may lead to very serious damage to the organization of the universal system.

The new PHC-funding model and other government initiatives completely change the community-oriented ESF care model, which reduced child mortality rates and hospitalizations for conditions sensitive to PHC and hospital expenses and increased prenatal coverage.^3,4 The proposed model eliminates the incentive to have ESF multiprofessional teams and weakens the community territorial approach. It induces a fragmented care model, centered on physician-delivered care, at the risk of making basic health units into minor emergency units. It limits the scope of ESF activities to focused and selective primary care, without integration into the wider health care network, with a consequent regression in the principle of comprehensive care and the advances resulting from the PHC community-oriented model of the ESF adopted in Brazil. Care will be restricted to the enrolled public, compromising collective health-promotion actions. Considering only the enrolled population, in practice, means doing away with the universal access and equity of the SUS.

It is important to draw attention to the damaging effects of this new funding modality and the PHC model being proposed by the federal government in Brazil. We have to shore up the democratic debate among health professionals, managers, academia, and civil society to ensure that the principles of universality of access, comprehensive care, and equity of the Brazilian health system are guaranteed and continue to serve as an example for other countries.