Flawed but fair: Brazil’s health system reaches out to the poor

Until the 1970s, Brazilians used to joke that they had to die before the authorities paid any attention to them. Dr Hugo Coelho Barbosa Tomassini recalls how they used to have a full-time "death secretary" to administer funerals in the city of Niteroi, where he was once the municipal health secretary, but only one health unit to care for the living. Much has changed since then. While long queues at hospital emergency departments, beds spilling into corridors, outdated and malfunctioning equipment and a scarcity of doctors and medicine in rural areas remain common complaints, on another level, Brazil's national health system--Sistema Unico de Saude (SUS)--has been an outstanding success. The vision of a system providing "health for all" emerged towards the end of the military dictatorship that started in 1964 and during the years of political opposition that was to a large extent framed in terms of access to health care. This struggle culminated in the 1988 constitution, which enshrined health as a citizens' right and which requires the state to provide universal and equal access to health services. [ILLUSTRATION OMITTED] It was a dramatic commitment to the ideals in the 1978 Alma-Ata declaration of "health for all". Under a subsequent health reform in 1996, Brazil established a health system based on decentralized universal access, with municipalities providing comprehensive and free health care to each individual in need financed by the states and federal government. Key to this strategy was primary health care. Today, primary health care remains one of the main pillars of the public health system in this country of 190 million people. Promoting health, preventing sickness, treating the sick and injured, and tackling serious disease; these are the cornerstones of the public health system, according to nurse Maria Fatima de Sousa, who has a doctorate in health and science and is a researcher at the University of Brasilia. About 70% of Brazil's population receives care from this system, de Sousa says, while the remainder--those that can afford to avoid the queues and inconvenience of the public system--opts for private care. De Sousa says that before Brazil's "health-care revolution" a much greater proportion of the population was excluded. "It was a period when authorities did not recognize health as a right. Most of the population had little or no access to health services. Access was only for those who had a public health plan card," de Sousa says, referring to the old system. All three levels of government in Brazil--federal, state and municipal --have worked hard to encourage the poor to use and benefit from the health system through initiatives, such as the Family Health Programme and through the deployment of auxiliary health workers or agentes de saude working with the poor. Created in 1994, the Family Health Programme--Brazil's main primary health care strategy--seeks to provide a full range of quality health care to families in their homes, at clinics and in hospitals. Today, 27 000 Family Health teams are active in nearly all Brazil's 5560 municipalities, each serving up to about 2000 families or 10 000 people. Family Health teams include doctors, nurses, dentists and other health workers. De Sousa says annual resources for primary health care have increased in the past 13 years to about US$ 3.5 billion, with US$ 2 billion of that money devoted to the Family Health programme out of an overall government health budget of about US$ 23 billion. Niteroi, with a population of 475 000 in the state of Rio de Janeiro and just 13 kilometres from the city of the same name, is just one example of a city that has transformed its public health care over the past 20 years. According to Tomassini, "after the Alma-Ata conference, Niteroi devised a health plan to provide universal access on a decentralized basis--the opposite of what had existed in the past. …