HEALTH CARE SYSTEM OF BRAZIL

I. People and Government

People
Nationality : Brazilian.
Population (2008 est.) : 196 million.
Annual growth rate : 1.05%.
Ethnic groups : Portuguese, Italian, German, Spanish, Japanese,
Arab, African, and indigenous people.
Religion : Roman Catholic (74%).
Language : Portuguese.
Education : Literacy--88% of adult population.
Health : Infant mortality rate--23.3/1,000.
Life expectancy--72.7 years in 2008.
Work force : 99.23 million.

2
The Federative Republic of Brazil, has a surface of 8.5 million km and shares
borders will all the countries of South America except Equador and Chile.

According to the 1996 population census, the total population was a little over 157
million.

The country is divided into five major regions:

A. The North
 The largest region which occupies 45% of the national territory but has
only 7% of the population.
 The Amazon Forest covers most of the North
 7 states and 449 widely scattered municipalities
 predominant economic activities include livestock and mining
 the demographic density is less than 1 inhabitant/km2.
 More than 50% of the country's indigenous population groups live in this
region

B. The Southeast
 Occupies 11% of the territory but occupies 43% of the population.
 Centers the country's industrial activity as well as the major finance and
service institutions
 Consist of 4 states, which have 1,668 municipalities
 greatest proportion of formal employment can be found here
 has the country's largest metropolitan areas: Sao Paulo, Rio de Janeiro,
and Belo Horizonte.

C. The South
 The smallest region, with 7% of the territory and 15% of the population.
 3 states in the South have a total of 1,188 municipalities
 the lowest illiteracy rate in the country (6.4% compared to 23.2% in the
Northeast and 11.6% in the country overall)

D. The Northeast
 Occupies 18% of the territory and a population of 29%.
 With 1,792 municipalities distributed in 9 states
  Has largest proportion of the country's poor population (55.3% of the
population subsists on half the average minimum wage of per capita
household income)
 53% of the country's rural population
 economic activities include subsistence agriculture, extensive cattle-
raising, and monocultures of sugarcane and cotton

E. The Central West

 Occupies 18% of the territory and a population of 6%.
 3 states, with 463 municipalities
 the Federal District and capital city is located here
 economy is based mostly on agrobusiness, especially soybeans and
livestock

In 2000, it has a population of 169.6 million and has an average population density
2 2
of 19.8 per km , with values ranging from 77.9 in the Southeast to 3.3 per km in the
North. Urban areas comprised 81.2% of the population in 2000.

Government
Type :Federative republic.
Independence :September 7, 1822.
Constitution :Promulgated October 5, 1988.
Branches :Executive
--president (chief of state and head of government
popularly elected to no more than two 4-year terms).
Legislative
--Senate (81 members popularly elected to 8-year
terms), Chamber of Deputies (513 members popularly
elected to 4-year terms).
Judicial
--Supreme Federal Tribunal (11 lifetime positions
appointed by the president).
Political parties : Workers' Party (PT), Brazilian Democratic Movement Party
(PMDB), Brazilian Social Democratic Party (PSDB), Democrats
(DEM), Democratic Workers Party (PDT), Brazilian Labor Party
(PTB), Party of the Republic (PR), Brazilian Socialist Party
(PSB), Communist Party of Brazil (PC do B), Progressive Party
(PP). Popular Socialist Party (PPS), Green Party (PV), Socialism
and Freedom Party (PSOL), the National Mobilization Party
(PMN), National Workers Party (PTN), Humanistic Solidarity
Party (PHS), the Brazilian Republican Party (PRB), Christian
Social Party (PSC), Christian Labor Party (PTC), and the Labor
Party of Brazil (PT do B).

The government system is democratic with a president as head of state. The

countries political-administrative organization comprises 26 states. The legislative branch,
the executive, and the judicial branch govern the country jointly. The Federal Constitution
of 1988 consolidated the return of the democratic government after two decades of military
regimes.
Its democratic rule of law has the fundamental purpose, established by the Federal
Constitution of 1988: "i) to establish a free, just, and collective society; ii) guarantee national
development; iii) eradicate poverty and marginalization and reduce social and regional
inequalities; and iv) promote the well-being of all, regardless of origin, race, sex, color, age, or
any other feature." (Article No. 3).
 Economic Context
The performance of the Brazilian economy, as seen in GDP (Gross Domestic Product)
patterns, oscillated throughout the last decade. The annual real average GDP growth rate
from 1995 to 2004 was 2.4%, and the per capita GDP was 0.9%. The growth rate in 2003
was 0.52%. There was a resurge in 2004, up to 5.2%, strongly influenced by industrial
growth (6.2%), although this rate was not sustained in the following years. In 2005 and
2006, GDP growth rates were 3.5% and 3.7%, respectively, resulting in a per capita GDP of
US$5,720. Economic growth accelerated in 2007, reaching 5.4% GDP growth rate.

Table 1 . Economic Indicators, Brazil, 1990-2005

Indicador 1990 1995 2000 2005

GDP constant prices - 1,338 1,557 1,738 1,937
R$ billion 2005**
GDP constant prices - 549.44 639.37 713.69 795.41
US$ billion 2005**
GDP per capita at 3,750 4,025 4,169 4,320
constant prices 2005
-US$**
Annual Inflation 350.35 20.41 5.83 5.55
Rate**
Total Public Sector 42.3 30.8 49.4 51.5
Debt as a % of GDP
(Dec.)**
Economically Active 50,593 54,844 63,419 69,805
Population - EAP
Urban (thousands)*
Source: * IBGE; **IPEA

Social Context
 A significant proportion of the Brazilian population still lacks adequate housing. Housing
structure is classified as rustic1 in 2.4% of the country's dwellings. The percentages are higher in
the North (6.0%) and Northeast (5.6%). In the Southeast, only 0.6% of dwellings are rustic.
 Access to treated water has risen in recent years, but almost 17% of the dwellings still are
not connected to the water supply system.
 Sewerage disposal is considered by the IBGE to be adequate when a septic tank is available
or there is connection to a sewerage system. Almost
 30% of permanent households do not yet have these conditions. Sewerage service remains
the greatest challenge: although the sewerage system is continually expanding, it is still the
service with the least coverage: it rose from 45.4% in 2001 to 49.0% in 2005. Solid waste
collection and electricity are the services with the most extensive coverage: in 2005, they served
86.8% and 97.7% of permanent households, respectively.

II. Health Status

Life Expectancy
According to the Brazilian Institute of Geography and Statistics (IBGE) and Tuesday's
Brazilian Official Gazette, the life expectancy of the Brazilian population increased from
69.66 years in 1998 to 72.86 years in 2008. Men's life expectancy was 69.11 years

1Dwellings labeled "rustic" are those with external walls made of materials classified as non-durable, since they are inappropriate for
construction (packing crate wood, mud, adobe, straw, etc.).
 and women's was 76. 71 years last year. The data indicate a significant progress compared
with 45.50 years in 1940. According to the IBGE, Brazil will need some time to catch up
with Japan, Hong Kong (China), Switzerland, Iceland, Australia, France and Italy, where the
average life expectancy is already over 81. Research has shown that Brazil would achieve
that level by 2040.

Demographic projections foresee the continuation of this process, estimating a life

expectancy in Brazil around 77.4 years in 2030. The decline in mortality at young ages and
the increase in longevity, combined with the decline of fecundity and the accentuated
increase of degenerative chronic diseases, caused a rapid process of demographic and
epidemiologic transition, imposing a new public health agenda in the face of the complexity
of the new morbidity pattern.

Mortality
The mortality information system registered almost one million deaths annually in
the country as a whole. The proportion of deaths attributed to ill-defined causes fell 25% in
the last 10 years; in 1998 it was around 15% overall. Male deaths (55% of total deaths)
were greater in virtually all age groups than female deaths. The distribution by age reveals
that the number of deaths of children under one year as a proportion of all deaths
decreased from 24% in 1980 to 8% in 1998. Diseases of the circulatory system (1/3 of all
deaths annually) continued to be the leading cause in all regions. The mortality rates per
100,000 population were 158.4 for diseases of the circulatory system, 72.2 for external
causes, 68.5 for neoplasms, and 51.9 for communicable diseases.

Neoplasms and Circulatory System Diseases

Brazil has population-based cancer registries (RCBP), which make it possible to
monitor and describe the profile of incidence since the 1960s. By the 1980s, statistics began to
include information that could help assess quality of care. These broad databases, although still
growing, continue to be concentrated in the country's largest cities. The cancer registries show
that the incidence of cancer in Brazil is growing at a rate that accompanies the aging
population due to the increase in life expectancy.
One estimate indicated that there would be 472,000 new cases of cancer in Brazil in
2006, or 355,000 excluding cases of non-melanoma skin tumors, which is almost 2 new
cases per 1,000 inhabitants per year. The highest incidence of cancer, except for non-
melanoma skin cancer, are prostate, lung, and stomach cancer for men; and breast, cervix,
and intestinal cancer for women. In terms of mortality, 141,000 deaths were reported in
2004. Lung, prostate, and stomach cancer were the leading causes of death from cancer for
men; breast, lung, and intestinal cancer for females.
The incidence of malignant neoplasms has spread in all regions. In 2005, 52.9 new
cases of female breast cancer per 100,000 women were reported, and 22.1 new cases of
cervical cancer per 100,000 women. There were 51.1 new cases of prostate cancer per
100,000 men. Late diagnosis leads to the high mortality associated with these types of
cancer: there were 10.3 deaths from breast cancer per 100,000 women (in the South and
Southeast, 13 deaths per 100,000 women); 4.6 deaths from cervical cancer per 100,000
women, and 10.2 deaths from prostate cancer per 100,000 men (12.2 in the Southeast and
13.2 in the South).
The incidence of other types of cancer is also high: in 2005, 62 new cases of non-
melanoma skin cancer were reported per 100,000 men and 72 new cases per 100,000
women; 18.9 new cases of lung, trachea, and bronchia cancer were reported per 100,000
men and 9.3 new cases per 100,000 women. And 16.7 new cases of stomach cancer were
reported per 100,000 men and 8.6 per 100,000 women.
Deaths from malignant neoplasms reached 74.3 per 100,000 population for the
entire country, varying widely from region to region: in the South there were 106.1 deaths
per 100,000 population and 91.1 in the Southeast (2005).
 In 2005, the SUS recorded 423,000 hospitalizations due to malignant neoplasms,
and 1.6 million outpatient consultations in oncology. Nearly 128,000 patients per month
received chemotherapy and 98,000 received radiation treatment. In the last 5 years, the
number of cancer patients receiving medical care in the SUS special care units has steadily
increased, which could indicate an improvement in the system's capacity to expand access
to specialized treatment resources, despite the bottleneck existing in some specialties, and
the difficulties of regulation and articulation among the units in the network.
Circulatory diseases were responsible for 10.5% of hospitalizations in 2005,
according to the SUS, and for 46.5 deaths from ischemic heart diseases per 100,000
population and 49.7 deaths from cardiovascular system diseases (2005).

External causes: Violence and Accidents

In 2003, 106,814 deaths were from external causes. More specifically, 44.1%
resulted from assaults (72.2% of assaults were by firearm) and 25.5% from transportation
accidents.
Among men, 44.1% of deaths from external causes were due to assaults. Among
women, the most common cause of death from external cause was transportation
accidents (32%). The number of males who died from aggression by firearm in 2003 was 12
times higher than that observed for women. The mortality rate due to aggression by
firearms in men aged 15 to 29 practically quintupled between 1980 (17.1) and 2003, when
it reached 82.8 deaths per 100,000 men. The highest rates were found in Pernambuco
(89.8), Rio de Janeiro (84.4), and Espfrito Santo (68.8). The lowest rates were in Piauf (9.3)
and the Amazon region (10.2). Of the 33,000 deaths from ground transportation accidents
reported in 2003, 81% were men.

AIDS
It is estimated that 500,000 people in Brazil are carriers of the human
immunodeficiency virus - HIV. From 1980 to July 2005, some 325,202 cases of AIDS were
reported, 70% of which were men and 30% women (in 2000, approximately 25.6% of cases
were female). There were 17 cases of AIDS per 100,000 population in 2004. This indicator
has been increasing among women and the male/female ratio of cases dropped from 18.9/1
in 1984 to 1.5/1 in 2004, reaching 0.9/1 among adolescents in the 13-19-year-old age
bracket. The spread of the epidemic, besides rising faster among women, has also shown
two other significant trends in recent years: the penetration into the country's interior and
the impoverishment of those affected. Nearly 50% of the Brazilian municipalities have
already reported cases. The numbers of cases are increasing in the segments of society
with lower levels of schooling and poorer socioeconomic conditions, as well as in the
smaller cities (< 50,000 inhabitants).
In 2003, 11,276 deaths from AIDS were reported, 2% more than the previous year,
but the specific mortality from AIDS remained stable at 6.4 deaths per 100,000 population
in 2003 (compared to 9.7 deaths per 100,000 population in 1995). The largest drop in the
1995-2003 period occurred in the Southeast, where the greatest number of cases were
found, with a 43% reduction in rate. This extreme drop in mortality is attributed to the
introduction of antiretrovirals in the public health network with universal access through a
decentralized network of services. However, even in this region, serious inequalities persist:
death rates are higher for black women (12.29 per 100,000 population) than for white
women (5.45).

Tuberculosis
The incidence rate of tuberculosis (including all forms) has been dropping in the last
ten years, but still it remains high: 81,000 new cases were reported in 2003, or 45.2 new
cases per 100,000 population (down from 58.4 in 1995), with significant incidence in the
Southeast and Northeast (44.4% and 30.9%, respectively, of all new cases reported in the
 country). The largest gross rate of TB incidence (all forms) was observed in the North
(51.7). The incidence is greater among men (64% of all new cases reported). The
proportion of new cases of pulmonary TB and bacilliferous pulmonary TB as part of the total
remained relatively stable in recent years, at 85% and 54% of new cases, respectively. The
risk of dying from tuberculosis also varies significantly according to color: in 2003, the
crude death rate due to tuberculosis for white people was 1.9 deaths per 100,000
inhabitants (and 3.0 for men), while for brown-skinned individuals the rate was 2.7, and for
black people, 6.3. The risk of dying from tuberculosis was 2.5 times greater for the black
population than for white population.

Malaria and Dengue

Malaria persists as a significant health problem, although it varies from region to
region. Although in 2004 the Annual Parasitic Index (API) for malaria was 2.6 positive exams
per 1,000 population, exposure was highest in the North, where the largest risk is found
(30.8 positive exams per 1,000 population). In the South and Southeast, no positive case
was recorded.
The incidence rate of dengue has increased considerably since 1993 when it was 4.9
new cases per 100,000 population. The last epidemic peak of dengue occurred in 2002, due
to the introduction of DEN-3, when 794,219 thousand cases were reported (455 new cases
per 100,000 population), mostly in Rio de Janeiro. This outbreak led to implementation of
the National Dengue Control Plan, leading to a significant reduction in the following years,
although the rates remained high (65.6 new cases per 100,000 population in 2004). In the
following years, the spread of DEN-3 in other states of the country caused the emergence
of outbreaks and epidemics, without affecting the 2002 levels. In 2004, 117,500 cases of
dengue were reported, 100,000 of which were distributed evenly in the North, Northeast,
and Southeast. In 2006, 345,922 cases were reported, mostly in the Southeast (141,864
cases) and Northeast (105,017 cases). The Health Surveillance Secretariat of the Ministry of
Health (SVS/MS) recorded 438,949 cases of classic dengue between January and July 2007.
As a result of these epidemic patterns, the number of reported cases of hemorrhagic
dengue fever, a more serious form of the disease, also increased proportionally: there were
2,714 cases in 2002 and 727 in 2003. In 2004 and 2005, the rates dropped significantly,
but still 107 and 103 cases, respectively, were reported. In 2006, 682 cases and 76 deaths
were reported, and by July 2007, there were 926 reported cases of hemorrhagic dengue
fever and 98 deaths. SUS monitoring shows that 93 municipalities, with a population of
36.5 million inhabitants, had a household infestation index of greater than the 1%
parameter. Most of these localities are in the Center-West and Southeast.

Table 2 Mortality from various causes, Brazil, 1995, 2000, and 2003-04
Indicators 1995 2000 2003/4
Total mortality 7.19 6.54 6.01
Maternal mortality 51.61 70.91 76.09
Mortality from communicable diseases 60.06 45.03 47,26
Mortality from 3.84 3.26 2.74
TB
Mortality from 9.73 6.32 6.07
AIDS
Mortality from intestinal 7.54 3.62 2.98
infection
Mortality from ischemic heart disease 44.86 46.21 46.48
Mortality from cerebro/cardiovascular 52.39 49.89 49.74
diseases
Mortality from malignant neoplasms 61.93 70.14 76.62
Mortality from external causes 73.73 69.73 70.2
Source: RIPSA, IDB 2006. Note: Total mortality: deaths per 1,000 population.
Specific mortality: deaths per 100,000 population. Maternal Mortality: maternal
deaths per 100,000 live births.
Note: Also see Pdf on next page entitled Mortality Country Fact Sheet 2006.

Morbidity
World health statistics 2008 presents the most recent health statistics for WHO's 193
Member States. The WHO Core Health Indicators database is no longer updated as of May
2008. WHO is pleased to announce the new version of the WHO Statistical Information
System (WHOSIS) available at: http://www.who.int/whosis/ and offers the latest
available data.

Table 3: Indicates Prevalence of HIV Among Adults aged > 15 years old
Indicator Value (year)
Prevalence of HIV among adults aged >=15 years (per 100 000 population) 454 (2005)

Note: Also see Pdf on next page entitled Brazil: Epidemiological Country Profile on HIV and AIDS.

Table 4: Indicates Incidence and Prevalence of Tuberculosis

Indicator Value (year)
Incidence of tuberculosis (per 100 000 population per year) 50.0 (2006)
Prevalence of tuberculosis (per 100 000 population) 55.0 (2006)
III. Health and Development Plans
The Brazilian government estimates that it can accomplish most of the MDG goals set for
2015. In some cases, the improvements of selected indicators seen in recent years is a result of
progress in improved data recording (for example, maternal mortality) or expansion of service
coverage, making it possible to increase detection capacity and service availability for citizens (for
example, breast and uterine cancer).

Table 5 Milleniun Developmental Goals

GOAL U.N. GOAL BRAZIL GOAL Indicator Previou Curren
s t
GOAL 1 • Objective 1: To 1A: Reduce to one- Percentage of 9.90% 5.70%
Eradicate halve, by 2015, the quarter, between 1990 the population
extreme proportion of the and 2015, the proportion living on less
poverty population whose of the population whose than U$1.0 PPP
and income is less than 1 income is less than 1 per day
hunger dollar PPP per day dollar PPP per day. (1990/2003)
Objective 2: To 2A: Eradicate hunger Percentage of 19.80% 7.70%
halve, by 2015, the between 1990 and 2015. children 1-2-
proportion of the years-ild with
population who suffer protein-calorie
from hunger malnutrition
(1999-2004)
GOAL 2 • Objective 3: Ensure 3A: Ensure that, by Rate of school 81.40% 93.80%
Achieve that, by 2015, 2015, the children in all attendance for
universal children everywhere, regions of the country, 7-14-year-olds in
primary boys and girls alike, regardless of color/race elementary
education finish a complete or gender, complete school
teaching cycle. elementary school. (1992-2003)
GOAL 3 • Objective 4: Objective 4: Eliminate Rate of school M= M=
Promote Eliminate the gender disparities in attendance for 15.1 F = 38.1 F =
gender disparities between elementary and middle 15 -17-years- 21.3 48.2
equality the sexes in school, if possible by olds in middle
and elementary and 2005, and at all levels of school, by
empower middle school, if teaching, by 2015 at the gender (1992-
women possible by 2005, and latest. 2003)
at all levels of
teaching, at the latest
by 2015.
GOAL 4 • Objective 5: Reduce Objective 5: Reduce by
Mortality of child 33.2 22.58
Reduce in two-thirds, from two-thirds, between 1990
under 1 year old
child 1990 to 2015, and 2015, the mortality
per 1,000 live
mortality mortality of children of children under five.
births (1996-
under five. 2004)
GOAL 5 • Objective 6: Reduce Objective 6A: Promote, Proportion of the
Improve to three-quarters, in the SUS network, by female
maternal from 1990 to 2015, 2015, universal coverage population 15-
health the maternal for sexual and 49-years-old 55.4
mortality rate. reproductive health using
activities. contraceptive
methods (1996)
Objective 6: Reduce by Rate of maternal 51.61 76.09
three-quarters, from mortality per
1990 to 2015, maternal 100,000 live
mortality rate. births (1996-
2004)
Objective 6B: By 2015, Specific breast = breast
to have stopped the mortality from 7.90 = 10.60
growth of mortality from malignant uterine= uterine
breast and cervix cancer, neoplasms -- 3.82 = 4.76
reversing the current breast cancer
trend. and cervical
cancer (1990-
2004)
GOAL 6 • Objective 7: By Objective 7: By 2015, AIDS incidence 13.25 15.05
Combat 2015, stop the spread to have stopped the rate per 100,000
HIV/AIDS, of HIV/AIDS and begin spread of HIV/AIDS and pop. (1995-
malaria to reverse the current begun to reverse the 2005)
and other trend. current trend.
diseases
Objective 8: By Objective 8A: By 2015, Tuberculosis 51.75 43.78
2015, to have to have reduced the incidence rate
stopped the incidence incidence of malaria and (19902005)
of malaria and other tuberculosis.
important diseases
and begun to reverse
the current trend.
Objective 8B: By 2010, Rate of 19.54 1.48
to have eliminated prevalence of
Hansen's disease. Hansen's
disease (cases/
10k pop)

National Health Policies and Plans:

The national health policy is based on the Federal Constitution of 1988, which sets
out the principles and directives for the delivery of health care in the country through the
Unified Health System (SUS). Under the constitution, the activities of the federal
 government are to be based on multiyear plans approved by the national congress for four-
year periods. The essential objectives for the health sector were improvement of the overall
health situation, with emphasis on reduction of child mortality, and political-institutional
reorganization of the sector, with a view to enhancing the operative capacity of the SUS.
The plan for the next period (2000-2003) reinforces the previous objectives and prioritizes
measures to ensure access at activities and services, improve care, and consolidate the
decentralization of SUS management.

MULTIYEAR PLAN 2008/2011

The continuous improvement of quality of public policies and their effectiveness in
the society is a principle which raises challenges for public management and underscores
the importance of evaluation of government action. In this sense, the results presented in
the Report of the PPA 2008-2011 should be discussed so as to allow the advance of
democracy in the interaction between state and society.

Note: Check PDF on Sectoral Assessment Booklet relating to public health efforts of the
Multi-year plan 2008/2011, office 2008.

IV. Health Agency

The Brazilian public health care system, also known as the “Unified Health System”, is
formed by the Federal, State and Municipal Services working in an integrated way but with sole
authority at each level of Government.

A. Organizational Structure
The Brazilian health care system may be divided into two subsystems:
1. The Sistema Único de Saúde (SUS or Unified Health System) , which incorporates a host
of public providers and comprises hospitals and primary health centers that belong to
federal, state, and local governments. It also includes private profit and nonprofit
providers under contract to the public system
2. The supplementary medical system includes the private plans with voluntary affiliation
as well as prepaid health plans and insurance companies.

Unified Health System

According to the Constitution of 1988, the Sistema Único de Saúde (SUS, Unified
Health System) comprises all health care and services provided by public institutions of the
three levels of government, as well as private institutions that provide services under
contract. In principle, the whole population is entitled to universal health care. SUS is
regulated by the Lei Orgânica da Saúde (LOS, Health Organization Law), which is actually
two laws - Law 8.080 and Law 8.142 - both passed in 1990.
Responsibility for SUS is shared by the three levels of government - the Ministry of
Health and the state and municipal councils, as well as their respective secretariats, which
comprise an equal representation of providers and users. Integration between the different
levels of government is carried out through an inter-management commission, composed
of authorities from each.
The Constitution of 1988 determined that SUS should be financed from the social
security budget, which is funded through salary-based compulsory contributions by
employers and employees; general taxation through federal, state, and municipal budgets;
and other sources.
Because neither the Constitution nor the social security budget specifies the amount
of resources designated for health, the Lei de Diretrizes Orçamentárias (LDO, budget
directives law) has fixed a minimum equal to 30% of the social security budget. This
minimum has not been met, however, since 1993, when the Social Security Institute
suspended the transfer of resources to the Ministry of Health. This caused a deep financial
crisis in the sector. In 1992, for instance, resources from compulsory contributions
represented 55% of the public budget for health.
 From 1993 on, SUS began to rely upon extraordinary contributions and central
government transfers to make up its budget, which amounted to 60% of its total resources
in 1995. A special tax on banking transactions was imposed in 1996 to solve the problem.
On the other hand, states and municipalities have increased the allocation of their own
resources to finance the system.

Supplementary Medical System

This system includes various models of private prepaid health plans and health
insurance companies. It enrolls people voluntarily or employees through contracts with
their firms. Although legally all the health services rendered in the country come under the
framework of the Sistema Único de Saúde (SUS, Unified Health System), the supplementary
medical system is still not integrated with SUS. Also, regulation of this system has only
very recently come under the responsibility of the public health authorities.

There are four main types of supplementary medical coverage:

a) Group medical companies - Offer prepaid plans in which the services differ
according to the contract made. The services may be provided through a network of
facilities and professionals belonging to the company; free choice of provider
followed by reimbursement; or through various combinations of the two. Premiums
are paid monthly and prorated by age. In 1996, there were 700 companies, with
17.3 million people enrolled. Their revenues were approximately US $3.7 billion.
b) Medical cooperatives are organized by professionals to render services based
on prepaid arrangements. They work in a way similar to the group medical
companies, although they restrict the use of services to their own professionals. On
the other hand, they usually offer a larger number of providers. In 1996, there were
320 enterprises, with 10 million people enrolled. Their revenues were approximately
US $3.5 billion.
c) Health insurance companies function rather differently in Brazil than in some
other countries, because they incorporate both the functions of reimbursement and
service delivery. Although they are based on a free-choice system, most of them
offer a network of services and professionals, which makes similar to the previous
systems. Their growth in recent years is due to the enrollment of large enterprises,
which in the past bought services from the previous two models. Even more
recently, traditional financial institutions have assumed part of this market through
association with firms providing smaller insurance plans. In 1996, there were 40
such companies, with 6 million people enrolled. Their revenues were about US $3
billion.
d) Self-managed plans allow employers to offer employees and their families
access to health services through differentiated assistance plans. They use two
models: * either they enroll providers, creating their own network of services, or *
they contract the services from another firm, which acts as a intermediary
responsible for the management of services. This method is increasing and has
stimulated the growth of the so-called "representation" companies, acting as
intermediaries between payers and providers.

The Ministry of Health (MS)

 The MS has the responsibility of steering the health system by assigning
responsibilities among five specific Secretariats and the Executive Secretariat (SE), which is
responsible for supervising and coordinating activities related to the planning and
budgeting federal systems, administrative organization and modernization, accounting,
financial administration, administration of information and informatics resources, human
resources, and general services, within the scope of the Ministry. The SE is also responsible
for monitoring public health expenditure through the Public Health Budget Information
System (SIOPS).
Furthermore, the SE is responsible for supervising and coordinating the activities of
the internal management systems and the information systems for current SUS activities,
as well activities of the National Health Fund (FNS), Datasus, and the SUS card. It is also in
charge of strengthening relations with states and municipalities in defining and
implementing programs. It exercises the role of sectoral leader of the Federal
Administration Civil Personnel System (SIPEC), Administration Organization And
Modernization System (SOMAD), Information and Informatics Resource Management
System (SISP), General Services (SISG), Federal Planning and Budget System, Federal
Financial Administration System, and Federal Accounting System, under the Subsecretariat
of Administrative Matters and the Subsecretariat of Planning and Budget.
The Health Care Secretariat is made up of the departments of Specialized Care;
Regulation, Evaluation, and Control; Basic Care; and Strategic Programming Activities,
which are responsible for formulating and implementing policies on basic and specialized
care. It is also responsible for designing the policy on assistance regulation, monitoring and
evaluating care delivery, defining criteria for the systematization and standardization of
techniques and procedures in the areas of control and evaluation, as well as keeping the
National Health Facilities Census (CNES) up to date.
The Secretariat of Science, Technology, and Strategic Inputs is responsible for
formulating and implementing national policy on science, technology, and innovation in
health; and on pharmaceutical assistance and drugs, which includes blood derivatives,
vaccines, immunobiologicals, and other related inputs. These policies are articulated and
cross-cutting in order to help promote industrial development through activities that foment
innovation and research of interest to the SUS and development of the industrial complex
in health.
The Secretariat of Work and Education Management in Health (SEGETES) is
 responsible for actions designed to regulate and promote technical training, both graduate
and postgraduate, in connection with the Ministry of Education (MEC) and the process of
continuing education for SUS health workers, based on the population's health needs.
The Strategic and Participatory Management Secretariat, through its two
departments (the Participatory Management Support Department and the Monitoring and
Evaluation Department of the SUS), has, among its responsibilities, formulating and
implementing policy on democratic and participatory management of the SUS and
strengthening social participation; articulating the Ministry of Health's activities in terms of
strategic and participatory management with the various governmental and
nongovernmental sectors related to health determinants; formulating and coordinating the
Ombudsman Policy for the SUS; conducting audits and controls in the SUS and coordinating
the implementation of the SUS national auditing system.
The Health Surveillance Secretariat (SVS) is responsible for epidemiological and
environmental surveillance activities. Among its responsibilities, it coordinates the
communicable disease prevention and control actions, including the national programs to
combat dengue, malaria, and other vector-borne diseases, the national immunization
program, and surveillance of emerging diseases. In addition, the SVS includes important
national programs to combat diseases such as tuberculosis, Hansen's disease, viral
hepatitis, STDs, and AIDS. The SVS is also responsible for coordinating SUS activities on
environmental surveillance and risk factor surveillance of noncommunicable diseases.

B. Vision, Mission and Policies

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.
The national health policy is based on the Federal Constitution of 1988, which
sets out the principles and directives for the delivery of health care in the country
through the Unified Health System (SUS). Under the constitution, the activities of the
federal government are to be based on multiyear plans approved by the national
congress for four-year periods. The essential objectives for the health sector are the
following:
• Improvement of the overall health situation, with emphasis on reduction of child
mortality.
• Political-institutional reorganization of the sector, with a view to enhancing the
operative capacity of the SUS.

C. Resources
c. 1. In Terms of Work Force and Financial Funding:
At present, According to the Bulletin of the World Health Organization, April
2008, 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. 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 programe
out of an overall government health budget of about US$ 23 billion.
World health statistics 2008 presents the most recent health statistics for
WHO's 193 Member States. The WHO Core Health Indicators database is no longer
updated as of May 2008. WHO is pleased to announce the new version of the WHO
Statistical Information System (WHOSIS) available at:
http://www.who.int/whosis/ and offers the latest available data.

Table 6: Indicates the Funding of Brazilian Health Care

Value
Indicator
(year)
External resources for health as percentage of total expenditure on health. 0.0 (2005)
General government expenditure on health as percentage of total expenditure on
44.1 (2005)
health.
General government expenditure on health as percentage of total government
6.7 (2005)
expenditure.
Out-of-pocket expenditure as percentage of private expenditure on health. 54.60 (2005)
Per capita government expenditure on health at average exchange rate (US$). 164.0 (2005)
Per capita government expenditure on health(PPP int. $). 333.0 (2005)
Per capita total expenditure on health (PPP int. $). 755.0 (2005)
Per capita total expenditure on health at average exchange rate (US$). 371.0 (2005)
Private expenditure on health as percentage of total expenditure on health. 55.9 (2005)
Private prepaid plans as percentage of private expenditure on health. 30.2 (2005)
Social security expenditure on health as percentage of general government
0.0 (2005)
expenditure on health.
Total expenditure on health as percentage of gross domestic product. 7.9 (2005)

Table 7: Professional personnel employed in health facilities, by region, Brazil, 2005

Region Total Populati Professional Personnel in Health
s Number of on Facilities
Facilities
Total Doctors Nurses Nurse :
Doctor

Brazil 77,004 181,341,4 870,36 527,625 116,126 0.22

99 1
North 5,528 14,342,71 39,147 21,412 6,840 0.32
0
Northea 22,834 50,376,46 184,27 105,279 31,488 0.30
st 3 5
Southea 28,371 77,271,77 447,31 282,771 54,022 0.19
st 0 2
South 13,113 26,603,92 136,27 81,022 16,790 0.21
9 4
Center- 7,158 12,746,62 63,353 37,141 6,986 0.19
West 7
Source: IBGE, WHA 2005.

Table 8: Indicates Workforce of the Brazilian Health Care System

Indicator Value (year)
Births attended by skilled health personnel (%) 97.0 (2004)
Dentistry personnel density (per 10,000 population) 11.00 (2000)
Number of Dentistry personnel 190,448 (2000)
Number nursing and midwifery personnel 659,111 (2000)
Number of health service providers 191, 518 (2000)
Number of pharmaceutical personnel 51, 317 (2000)
Nursing and midwifery personnel density (per 10,000 population) 38.00 (2000)
Other health service providers density (per 10,000 population) 11.00 (2000)
Pharmaceutical personnel density (per 10,000 population) 3.00 (2000)

c.2. In Terms of Health Supplies:

 Brazil is among the greatest consumers markets for drugs, accounting for
3.5% share of the world market. To expand the access of the population to drugs,
incentives have been offered for marketing generic products, which cost an average
of 40% less than brand-name products.
In 1998, the National Drug Policy was approved, whose purpose is to ensure
safety, efficacy, and quality of drugs, as well as the promotion of rational use and
access for the population to essential products. The responsibility for national
production of immunobiologicals is entrusted to public laboratories; which have a
long-standing tradition of producing vaccines and sera for use in official programs.
The Ministry of Public Health invested some US$ 120 million in the development of
the capacity of these laboratories. In 1999, quality control of the transfused blood
consisted of 26 coordinating centers and by 44 regional centers. In 2000, there
were 14 industries authorized to produce generic drugs and about 200 registered
generic drugs were being produced in 601 different forms. The supply of products
was sufficient to meet the need for heterologous sera, such as those used in the
vaccines against tuberculosis, measles, diphtheria, tetanus, whooping cough, yellow
fever, and rabies.

Table 9: Number of health facilities by region, Brazil, 1985-2005

Region Health facilities

1985 1992 1999 2002 2005

Entire country 28,972 49,676 56,133 65,34 77,00

3 4

North 1,722 3,513 4,645 5,137 5,528

Northeast 9,174 13,106 16,265 18,91 22,83

2 4

Southeast 10,977 19,717 21,483 24,41 28,37

2 1

South 5,221 10,012 9,819 11,75 13,11

7 3

Center-West 1,878 3,328 3,921 5,125 7,158

Source: IBGE, Directorate of Surveys, Department of Population and Social Indicators.

Medical and Health Care Survey, 1999, 2002, and 2005.

Table 10: Public and private hospital beds in health facilities, Brazil, 1976-2005
Year Total Entity

Public % Private %

1976 443,888 119,062 27 324,826 73

1986 512,346 114,548 22 397,798 78

1992 544,357 135,080 25 409,277 75

2002 471,171 146,319 31 324,852 69

2005 443,210 148,966 34 294,244 66

 Source: IBGE, Directorate of Surveys, Department of Population and Social
Indicators Medical and Health Care Surveys,1999, 2002, and 2005

D. Strategies
Primary Health Care remains one of the main pillars of the public health system in
Brazil 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 Fátima de Sousa, who has a doctorate in health and
science and is a researcher at the University of Brasília.

d.1. Family Health Programme (PSF) – Brazil’s main primary health care strategy
created in 1994 by the municipal health secretariats in collaboration with the states and the
Ministry of Public Health. The federal government supplies technical support and transfers
funding through Piso de Atenção Básica that seeks to provide a full range of quality health
care to families in their homes, at clinics and in hospitals.
The PSF offers health care to a given population in a given geographical area,
through assignment of this population to a multidisciplinary team, composed of at least one
doctor, one nurse, nursing auxiliaries, and community health workers (in the ratio of one
agent for a maximum of 150 families or 750 people). Each family health team is responsible
for monitoring nearly 1,000 families. Formal training of professionals is carried out by
capacity building and educational centers in all regions of the country, and emphasizes the
promotion of intersectoral activities.
By 2005, the program, created in 1993, was already being implemented in 4,986
municipalities, with 24,600 teams offering coverage to 44% of the country's population (78
million people).
Dr Maria das Graças Vieira Esteves, who has been the director of the clinic for the
past 11 years, says Niterói’s 23 Family Health teams are an essential part of Brazil’s health
system. “Initially, I did not believe the Family Health programme could be effective, but
gradually I saw they were doing marvelous work and getting results,” she says. “In Itaipu,
pregnant women attend 10 prenatal appointments. This approach has contributed to the
fall in infant mortality rates.”

E. Health Services/Programs/Reforms
The current legal provisions governing the operation of the health system, instituted
in 1996, seek to shift responsibility for administration of the SUS to municipal governments,
with technical and financial cooperation from the federal government and states. Another
regionalization initiative is the creation of health consortia, which pools the resources of
several neighboring municipalities. An important instrument of support for regionalization is
the Project to Strengthening and Reorganization the SUS. Hence, public health care is
provided to all Brazilian permanent residents and is free at the point of need (being paid for
from general taxation).

Citizen - Actions and Programs

The Ministry of Health carries out various actions programs in order to bring care closer to
the citizen, and give the professional expertise to which he can carry his work with more quality.

E.1. Maternal and Child Care Services/Programs

• “Right to be Born Right” Program
- Introduced in 1995 by the Department of Health of Rio de Janeiro City. This
regularly monitors maternal and perinatal deaths.
• High Risk Newborn Surveillance System
- Provides special care to high risk pregnancies
• National Program for Control and Cervical Cancer and Mama
-Live Woman released in 1997, this program aims to reduce the number of deaths
caused by cancer of the cervix and breast, allowing women access to faster and
 easy to early diagnosis and adequate treatment for the tumor. Through joint action
of the Ministry of Health with the 26 Brazilian states plus the Federal District are
offered preventive services and early detection in the early stages of the disease, as
well as treatment and rehabilitation throughout the country.
• Human Milk Banks
- The Brazilian Network of Human Milk Banks, created in 1998 by the Ministry of
Health and the Oswaldo Cruz Foundation (Fiocruz), aims to promote the quantitative
and qualitative expansion of human milk banks in brazil, through integration and
building partnerships among federal agencies, private enterprise and society.
• Program of Community Health Workers
− Sponsored by MOH and conducted by local government and communities in the
poorest parts of the country particularly on the Northeastern states. This
prioritizes maternal and child care.

E.2. Emergency Care Services/Programs

• Emergency Services
- Brazilian emergency medical service is called "Serviço de Atendimento Móvel de
Urgência (Mobile Emergency Attendance Service)." Emergency Medicine (EM) is not
a new field in Brazil. In 2002, the Ministry of Health outlined a document, the
"Portaria 2048," which called upon the entire health care system to improve
emergency care in order to address the increasing number of victims of road traffic
accidents and violence, as well as the overcrowding of Emergency Departments
(EDs) resulting from an overwhelmed primary care infrastructure. The document
delineates standards of care for staffing, equipment, medications and services
appropriate for both pre-hospital and in-hospital. It further explicitly describes the
areas of knowledge that an emergency provider should master in order to
adequately provide care. However, these recommendations have no enforcement
mechanism and, as a result, emergency services in Brazil still lack a consistent
standard of care.

* Pre-hospital emergency medical services use a combination of basic

ambulances staffed by technicians and advanced units with physicians on-board. No
universal phone number exists for emergency calls, and the dispatch center
physician determines whether the call merits an emergency transport or not. Pre-
hospital physicians have variable training in emergency care, with training
backgrounds ranging from internal medicine to obstetrics to surgery.
Similar to the early years of EM in the United States, emergency department
physicians in Brazil come from different specialty backgrounds, many of them
having taken the job as a form of supplementary income or as a result of
unsuccessful private clinical practice. Since 50% of medical school graduates in
Brazil do not get residency positions, these new physicians with minimal clinical
training look for work in emergency departments. In larger tertiary hospitals, the ED
is divided into the main specialty areas, internal medicine, surgery, psychiatry,
pediatrics, and staffed by the corresponding physicians. Still, significant delays in
care can occur when patients are inappropriately triaged or when communication
between the areas is inadequate. In the non-tertiary care centers, which make up
the majority of hospitals in the country, emergency department physicians are
largely under-trained, underpaid and overstressed by their working conditions. This
has compromised patient care and created an incredible need for improvement in
the emergency care system.

• SAMU 192
− Provide relief to people in emergencies is the purpose of the Office of Mobile
Emergency Care and Emergency, the Ministry of Health conducts SAMU care
anywhere: homes, workplaces or public roads. The bailout is done after call to the
phone 192. The call is free and can be done anywhere in the country.
E.3. Community Health Care Services/Programs
• Individual Health Care Service
Ambulatory care is provided mostly by public and teaching services, the institutional
composition varying according to the type of care being offered.

• Family Health
The goal of Family Health is to act in the promotion and maintenance of human
health and disease prevention, thus altering the model centered health in hospitals.
Launched in 1993, the program now serves 103 million individuals. Besides visiting
the homes of Brazilians, health professionals do educational work in schools, and
attend the Basic Health Units Each team of professionals is responsible for
monitoring a set number of families, located in a specific geographic area.

• Anti Tuberculosis Service (TB DOTS)

- Government commitment to promoting social services has increased the visibility
of TB as a public health problem, and funding for TB control has increased
substantially in recent years. DOTS expansion has progressed and TB control
activities have prioritized 315 of a total of 5565 municipalities accounting for 70% of
the country’s TB cases. TB services are integrated into the primary health-care
system. The process of decentralizing TB control management to state and
municipality levels is continuing. Collaborative TB/HIV activities have been
implemented and scaled up. About 14% of the 72% of TB patients tested for HIV
infection are found to be HIV-positive. Special initiatives to control TB in vulnerable
groups such as indigenous populations and prisoners have been implemented in
collaboration with relevant governmental organizations and NGOs. Despite the
progress made in controlling TB, rates of case detection and treatment success are
still below the global targets. For further information, see next pages for Pdf entitled
Brazil: Tuberculosis.

• Global Malarial Control Services

- In 2002, Brazil reported approximately 40% of the total number of the malaria cases in
the Americas. Almost 99% of cases occur in the Legal Amazon Region, where no more
than 12% of the country’s population resides. An increase in the number of cases
began in the 1980s. In 1992, 572 000 cases were reported and a peak of 610 878 cases
was reported in 2000. By 2002, the number of cases was reduced to 349 873 among
2.12 million slides examined, giving a 16.5% smear positivity rate. A slight rebound in
2003 of 379 500 cases was reportedly associated with population movement to the
periphery of large cities as well as to the Legal Amazon Region.
This program includes:
 Insecticide Treated Nets – Provided to target populations of children under
5 years of age (U5) and pregnant women

 Service Delivery and Malaria related Commodities - Services delivered

for malaria control include numbers of nets and insecticides delivered or sold,
numbers of nets (re-)treated with insecticide and numbers of households
(HHs)/units sprayed during IRS campaigns.

 Monitoring Anti Malarial Drug Efficacy - Important for understanding the

impact of antimalarial treatment being delivered and the need for drug policy
change, essential for ensuring prompt access to effective treatment

 Annual Funding for Malarial Control

• The National Vaccine Competitiveness Program (Inovacina)

-Which aims at breaking the dependency and reducing the deficit in the trade
 balance through investment in production, development, and technological
innovation for immunobiological production. Six vaccines considered priority -
pentavalent, rabies in cellular culture, meningitis B and C, hepatitis A, and canine
leishmaniasis - are in the final phase of development and should be in use within
three years at most. The pentavalent, which will be produced in conjunction with
Biomanguinhos and the Butantan Institute (SP), is going to unite the triple bacterial
vaccine (against diphtheria, tetanus and whooping cough) with the Hepatitis B
vaccines and Haemofilus Influenzae (bacterium that causes meningitis). It is
estimated that within five years, eight more inputs will be produced in
national labs: combined vaccine against meningitis B and C, rabies in tissue
culture (for canine use), inactive yellow fever, Streptococcus pneumoniae, PV
(virus associated with cervical cancer), inactive poliomyelitis, DTPa (acellular vaccine
against whooping cough, with fewer adverse reactions) and MMR (triple viral vaccine
against mumps, measles and rubella). Six more vaccines are in the predevelopment
stage and should be ready in the next ten years. The vaccine against leishmaniasis
is predicted to be ready in 15 years.

• National Program to Fight Dengue

− Dengue is a major public health problems worldwide, especially in tropical countries like
Brazil, where environmental conditions, combined with urban characteristics, promote
the development and spread of the mosquito. Every year, the Ministry of Health
conducts a national campaign to combat the disease. The success of this action
depends on you: how, in 90% of cases, the outbreak of the mosquito is in the home,
some precautions should be adopted by all.

E.4. Pharmaceutical Services/Programs

• Popular Pharmacy of Brazil
− The People's Pharmacy of Brazil is the program of the Ministry of Health designed to
broaden the population access to essential medicines. It is structured in two lines of
action. The first works through the ministry partnership with states and municipalities
for the physical construction of its own network of outlets, which are sold all
medications that are part of the cast of the program. The other line of work, known as
People's Pharmacy Here It is held by the ministry partnerships with the private
pharmacies and drugstores. In this case, the cast of drugs is limited, focused on
products against diabetes, hypertension and contraceptives.

• Drug fractionated
- Medicines are medicines made from fractionated special packaging and sold as
accurate as recommended by the doctor. If the patient has to take four pills, is not
necessary to but a box of six. To acquire fractionated product, simply submit the
prescription at a drugstore enabled. The drug will be split under the supervision and
responsibility of the pharmacist.

E.5. Dental Program

• Smiling Brazil
− The Smiling Brazil program is one that is present in several actions by the Ministry of
Health and seeks to improve the oral health of Brazilians of all ages. In 90 years, Brazil
has advanced a lot in preventing and controlling caries in children, however, the
situation of adolescents, adults and seniors ranked among the worst in the world.
Launched in 2004, the Smiling Brazil have promoted actions to reverse this scenario.

E.6. Nutrition Program

• National Food and Nutrition
- Policy National Food and Nutrition of the Ministry of Health aims to ensure the quality
of the food available for consumption in the country, as well as promote healthy eating
practices and prevent and control nutritional disorders.
E.7. Cancer Control Program
• Expands Project
- Launched in 2001 by the National Cancer Institute (Inca) and the Ministry of Health,
Project Expands has the main objective of structuring the Integration of Cancer Care in
Brazil in order to obtain a high quality standard in the coverage of the population.

• Programme for Tobacco Control and Other Risk Factors of Cancer

- The National Cancer Institute (INCA) is the national Ministry of Health responsible for
coordinating and implementing the Tobacco Control program in Brazil. The goal is to
prevent illness and reduce the incidence of cancer and other diseases related to
tobacco, through actions that encourage the adoption of behaviors and lifestyles. In the
institute's website, you can get various information about the program, it would also be
available information on passive smoking, guidelines on how to stop smoking and
frequently asked questions about tobacco use, among others.

E.8 Other Services and Programs

• National Health Card
- The National Health Card is a tool that enables the binding of the procedures
implemented under the National Health System (SUS) to the user, the professional who
performed them and also to the health facility where they were performed. Therefore, it
is necessary to build entries of users, health professionals and health facilities. From
these countries, users of the public and health professionals receive a national
identification number.

• Organ Donation
− The Ministry of Health has invested in raising awareness of organ donation to be
transplanted into sick people who need a noble attitude for living donation. Their
tissues, bone marrow, blood and organs can save lives. In Brazil, the donation takes
place only with the consent of relatives.
− The national transplants system (SNT) is present in 22 states of the federation, with
540 health facilities and 1,338 medical teams authorized by the SNT to perform
transplants. The public network is responsible for most procedures of this kind
performed in the country. Besides the state centers, eight regional centers exist, located
in the states of Parana and Minas Gerais. In the state of Sao Paulo, the task of locating
organ donors was delegated to 10 public teaching hospitals, called organ procurement
organizations (OPO). In 2005, the SUS paid for 11,000 organ and tissue transplants. The
cost of the procedures carried out through the SNT was more than R$450 million reais,
or 1.3% of the total MS expenditure on health activities and services.

• HumanizaSUS
- Established by the Ministry of Health in 2003, the National Humanization Policy (NHP),
the HumanizaSUS proposes a new relationship between the user of the unified Health
System (SUS) and the professional who will serve. The police encourages the
establishment of humane practices and trading contributions from managers, health
professionals and users. The HumanizaSUS also offers courses, conducts workshops,
and certify the experiences of the successful humanization. The idea is to work in
partnership for the SUS is more welcoming, responsive and local service delivery more
comfortable.

• Look at Brazil
- The project will look at Brazil, created in partnership by the Ministries of Education and
Health, in 2007, is the primary goal of identifying visual problems enrolled in public
elementary schools and in people over 60 years of age. The project provides direct
assistance to 44 million people, over a period of three years.

• Program Back Home

 - The Program Back Home, ministry of Health, proposes the social reintegration of
people affected by mental disorders and who were in longer hospitalizations, according
to criteria defined in Law no, 10,708 of July 31, 2003, which also providing for the
payment of aid psychosocial rehabilitation.

• QualiSUS
- QualiSUS The program is the Ministry of Health that seeks the qualifications of the
Unified Health System (SUS). It contains a number of changes to provide greater
comfort for the user, care according to the degree of risk reduction and patient length of
stay in hospitals in the public health. As a result, the QualiSUS helps to save a greater
number of lives by reducing health hazards, as well as ensure satisfaction among the
population with treatment received at health facilities. The performance of the program
envisages the deployment of new equipment and renovation of facilities of the
hospitals, among other actions.

• Technical Cooperation Projects

− Carried out with different countries, as well as with the World Bank and UNESCO
among many others. International foundations also provide direct financing for projects
or individuals. Brazil is also engaged in an intense exchange with the Mercosul
countries, aimed at establishing common health regulations.

F. Issues and Problems

Issues:
F.1. Continuous Quality Improvement – A possible quality approach to issues of
improving quality health care in Brazil. Information dissemination and improvement in
educational activities should be developed based on the concept that a systematic
approach to this issue is possible. There are regulatory processes related to the quality of
health care in Brazil:
• Norms for licensure in health facilities set by the MOH
• Hospital accreditation under the federal reimbursement system
• Private payer systems for accrediting services
• Norms for infection control set by the MOH
• Licensing of schools for health professionals
• Licensing for professional practice (medicine, nursing, pharmacy, etc)
• Norms and standards of practice set by medical societies and councils

F.2. In Brazil, there is poor quality improvement issues.

This is the reason why the Brazilian Programme of Quality and Productivity was
created in 1990. In 1996, greater amplitude was given to the program enlarging the
concept and scope of quality initiatives. Quality prizes like National Quality Prize are also
rewarded that are now attracting health care professionals. But there are two more
important prizes in the state of Rio Grande do Sul and Rio de Janeiro.
The WHO World Health Survey (2004) reported that there is high user dissatisfaction
(57.8%) with the health system in the country, both public and private, although the
evaluations differ between private and public users. Nearly 72% of the private plan users
expressed dissatisfaction, compared to 53.3% dissatisfaction among SUS users.
Another survey, conducted by the Ministry of Health together with the national
council of health secretariats (Conass) in 2003, showed that more than 90% of the Brazilian
population uses some SUS services. According to the survey, the waiting lines in hospital
emergency rooms, the long waiting period for exams and surgeries, and the health units'
inability to take patients are frequent complaints among SUS users.

Problems:

SPECIFIC HEALTH PROBLEMS

Analysis by population group
Children: In 1999, infant mortality was 33 per 1,000 live births - 30% below the 1990 rate
of 48 per 1,000. Substantial inequalities exist in infant mortality among regions and states.
The Northeast registered high rates throughout the period, while the opposite occurred in
the South. Among children aged 1-4 years, the leading causes of death in 1998 were
communicable diseases (43.0%), external causes (22.5%), diseases of the respiratory
system (8.2%), acute diarrheal diseases and acute respiratory infections (7% each).

Schoolchildren: Fewer than 0.6% of all deaths occurred in this age group, where 46% of
the deaths were caused by accidents and violence, followed by communicable diseases
(18%) and malignant neoplasms (13%).

Adolescents: In 1998, 47% of deaths in those aged 10-14 years and 68% of those aged 15
to 19 years were due to external causes, mainly by homicide. In 1998, adolescents 10-19
years of age comprised 24% of all deliveries and 0.9% of all live births were in the age
group 10-14 years of age.

Adults: The male mortality rate 471 per 100,000 males was double that of females, 209
per 100,000 females. The leading causes of death were: external causes (32%), diseases of
the circulatory system (23%), and malignant neoplasms (14%). The average maternal
mortality is estimated around 127 deaths per 100,000 live births. In 1999, excluding
hospitalization related to pregnancy, childbirth and puerperium, (41%), principal reasons for
hospitalization were diseases of the digestive system (13.9%), genitourinary system
(13.7%) and circulatory system (11.0%) were.

Elderly: In 1998, diseases of the circulatory system (46%), malignant neoplasms (17%)
and respiratory diseases (11%) were the leading defined causes of death. A high
percentage of deaths were attributed to ill-defined causes (18%), and this percentage
tended to rise in the oldest subgroups of the elderly population. Older adults represented
18% of hospitalizations in the public health system in 2000, where leading causes were
diseases of the circulatory systems (28%), respiratory system (20%) and digestive system
(10%).

Disabled: According to data from 1991, the prevalence rate of disabled persons is 1.1% of
the total population.

Indigenous and other special groups: The indigenous population 350,000 constituted
only 0.2% of the total population. Their health situation is characterized by a high incidence
and mortality from malaria, tuberculosis and other respiratory diseases, and vaccine-
preventable diseases. Since 1999, indigenous health care is under the direct responsibility
of the Ministry of Health.

Analysis by type of health problem

Vector-borne diseases: In 1999, 632,600 new cases of malaria were recorded, the
greatest number since the seventies. Between 1986 and 1998 malaria mortality was
reduced from 0.7 to 0.1 deaths per 100,000 population. A dengue epidemic hit its peak in
1998, with nearly 570,000 reported cases. In 1999 and 2000 there were nearly 4,000 cases
each year of visceral leishmaniasis and in 2000 there were 34,513 cases of cutaneous
leishmaniosis reported.

Vaccine-preventable diseases: In 1997, a measles epidemic occurred with 53,664 cases

and 61 deaths especially affecting young adults, who were not part of the immunization
target group. Between 1999-2000 the number of confirmed cases of measles declined 95%
from 890 to 36. The number of rubella cases reported in 1999 and 2000 remained at about
14,000 annually. The incidence among adults aged 20-29 increased from 5.7 per 100,000 in
1999 to 11.9 in 2000. In 1989, the last cases of poliomyelitis were recorded. In 1994, the
interruption of the transmission of poliomyelitis was certified. In 1999, 66 cases of neonatal
tetanus were reported and 41 in 2000. Diphtheria manifested little variation from 56 to 54
 cases in 1999 and 2000. In 2000 there were 4,263 reported cases of hepatitis B.

Chronic communicable diseases: In 1999 there were reported 78,870 cases of

tuberculosis of all forms, with a incidence rate of 48.1 cases per 100,000 population.

Leprosy: Leprosy remains an important problem, with a prevalence rate of 4.9 cases per
10,000 population in 1998 with 78,000 patients recorded.

Acute Respiratory Infections (ARIs): ARIs are among the leading causes of morbidity
and mortality of children under five years of age.

HIV/AIDS: In 1997, 23,172 new cases and 7,545 deaths were confirmed. The male:female
ratio of new cases was 2:1 in 1999.

Sexually transmitted infections: A total of 166 deaths from syphilis in 1999 were
reported. In 1998, the average rate of congenital syphilis was 1.2 cases per 10,000 live
births.

Intestinal infectious diseases: In 1999, 4,620 cases of cholera were reported. In 2000,
only 753 cases were reported, the lowest number since 1991. Mortality from acute
gastroenteritis declined from 9,391 deaths in 1996 to 7,214 in 1999.

Zoonoses: Cases of rabies were 26 human cases and 1,227 canines reported in 1999;
There were also 26 human cases reported in 2000. During 1986-2000, 83 cases of human
rabies were transmitted by bats (6.3% of the total). During 1995-2000, 22,651 cases and
1,951 deaths of leptospirosis were registered.

Accidents and violence: Nearly 15% of deaths from defined causes are due to external
causes, which accounted for the highest rate in 1996 (76 per 100,000). While the overall
rates are declining, significant inequalities exist in their distribution by cause, age, and sex.

Malignant neoplasms: In 1999, cancer mortality was 75.5 deaths per 100,000 males and
62.5 deaths per 100,000 females. Among men, the lung was the leading site for cancer
mortality (12 per 100,000) followed by stomach and prostate. Among women, breast
cancer remained the leading site for cancer mortality, followed by lung and the cervix.

Diseases of the circulatory system: The leading causes of mortality were due to
ischemic heart diseases (25% of total deaths) and cerebrosvascular diseases (34%). This
group of diseases was the third leading cause of hospitalization in the public health care
system (10% of hospitalizations).

Diabetes mellitus: In 1999, diabetes caused 31,000 deaths or 3.4% of total mortality.

Malnutrition and Obesity: In 1996, the average prevalence of malnutrition among

children under 5 was 5.7%. The average prevalence of acute malnutrition among children
under 5 was 2.3%. The prevalence of stunting (height for age) was around 10.5%. The
prevalence of obesity has increased among children and adults of both sexes in all regions
and income levels. The most important nutritional deficiency is iron deficiency, which is
found in all regions. The prevalence in preschool children ranges from 48% to 51%.

G. Future Directions and Care Systems Alternatives

Although Brazilians like to think of themselves as "the country of the future," and although
they have made significant gains in combating infectious diseases and establishing a unified
healthcare system, many challenges remain. Brazil is still a country of enormous social disparities.
Over 50 million Brazilians live in poverty, 32 million have no access to clean water, and many live
in shantytowns (favelas), earning the minimum wage of $77 per month (BBC, 2000).
 A recent study conducted by the Sao Paulo Center for Health Economics at the Federal
University of Sao Paulo warned that without substantial economic growth and more equitable
distribution of income, the Brazilian health care system will be in chaos by 2025; there will be
too few care givers and too few resources to provide care for everyone (Medical News
Today, May, 2006). The study warns that merely to maintain current service levels, the country
will have to devote 12% of its GDP to healthcare, which is a major increase over the current level
of 7-8% of GDP. The study notes that, without changes to current income distribution trends, an
increasing percentage of the population will not be able to afford private health care.

Brazil has 102 medical schools for a country of about 188 million people (Institute for
International Medical Education, 2007). All but one of these schools is recognized by the
Panamerican Federation of Associations of Medical Schools. These schools generally teach the
western biomedical model. Nevertheless, medical students enrolled in at least one major medical
school expressed an interest in learning more about homeopathic remedies and acupuncture. A
survey of students at the Faculdade de Medicina da Universidade de Sao Paulo indicated:

Over 85% of the students considered that homeopathy and acupuncture should be included
in curricula, as options (72%) or compulsorily (19%); 56% showed great interest in learning about
them. Although 76% had little or no knowledge, 67% believed that these therapies had some
effectiveness, and that chronic diseases (37%) or even chronic and acute diseases (29%) would be
the main indicators for their use. Around 35% were receptive towards offering public primary care
using both therapies, while 34% thought these treatments should also be available in hospitals
and 60% believed they could be integrated with conventional medical practices (Texeira, Lin, &
Martins, 2005). Because of the generally high quality of medical education in Brazil, as well as the
availability of good jobs within the country, Brazil has not experienced the brain drain of qualified
medical personnel that has plagued many developing countries (Saravia and
Miranda, 2004).

Medical training can be influenced by cultural attitudes. Organ donation, for example,
might not be seen as positively in some countries as it is in the United States. But a survey of
medical students at a Catholic medical school in Sao Paulo suggests that organ donation is
approved by nearly all students. Of 580 students surveyed only five were opposed to donation.
About 90% would authorize organ retrieval from their own relatives (Texeira, Lin, & Martins, 2005).

As in other countries, there are shortages in certain medical specialties. By 2025 the elderly
population in Brazil is expected to grow to 32 million, but there are less than 500 doctors in Brazil
who specialize in geriatrics, and even this small number is not
distributed evenly, so providing services in rural areas is especially problematic (Garcez-Leme,
Leme, & Espino, 2005).

Although the program for training doctors resembles training programs in many developed
countries, nursing training had lagged behind within the last couple of decades. Brazil had 200,
000 uncertified and untrained "auxiliary nurses" who had simply worked their way up from low-
level positions with little or no training. About six years ago Brazil's Director of Work and Education
in Health and the Inter-American Development Bank (IDB) jointly started a program called the
National Program for Training Auxiliary Nurses (PROFAE). As a result of this program, 200, 000
auxiliary nurses were trained and certified, and an additional 123, 000 were trained and are now
practicing in every state in the country, as funded by the IDB. The program provided about 1, 200
hours of instruction for each nurse. It cost over $300 million per year and was funded by the
central Brazilian government supplemented with a loan from the IDB. The program was so
successful that the government approached IDB to extend the program beyond nursing to include
radiology, dental technical skills, home health care, laboratory skills, and health surveillance (IDB,
2006).

Development of the health workforce

 Both public and private institutions are responsible for training professional personnel in the
health sector. As a result of policies on improving higher education adopted in the country
throughout the 1990s that promoted expansion of the private network, there has been growing
participation of private institutions, either for-profit or charitable, in the formal preparation of
health professionals. By the end of the decade, in 1999, of the 97 courses in medicine, 54% were
in the public sector, as well as 38% of the 130 courses in dentistry, and nearly half of the 153
courses in nursing and obstetrics. According to statistics from the National Institute of Educational
Studies and Research Anfsio Teixeira (INEP/MEC), between 1991 and 2006, 78 new courses in
medicine were created (an increase of 98%), 451 new courses in nursing (increase of 425%), and
102 new courses in dentistry (increase of 123%). The 2006 census on higher education showed a
total of 557 courses in nursing, 158 courses in medicine, and 185 courses in dentistry in the
country.
In the area of public health (post-graduate level), also known as collective health, human
resources training and education and scientific and technological output correspond,
predominantly, to public institutions. The MS maintains the National School of Public Health Sergio
Arouca (ENSP), one of the technical and scientific units of the Oswaldo Cruz Foundation (Fiocruz),
which provide technical cooperation to all states and municipalities. It offers postdoctoral, doctoral
and master's degrees in public health, in eight areas of concentration: health systems and services
planning and management; epidemiology; endemic diseases; environment and society; health and
society; environmental health; occupational health; occupational/environmental toxicology; and
public policies and health. In addition to the ENSP, other schools include the School of Public
Health (University of Sao Paulo-USP), the State University of Rio de Janeiro (course in social
medicine), and some public health schools under the state health secretariats. All provide
technical cooperation with states and municipalities.
The MS, through the Work and Health Management Secretariat (SGTES),2 is working closely
with MEC, establishing technical cooperation for the training and development of health
professionals, at the graduate and post-graduate level. Several joint strategies have been
developed, aiming at integrating education/work in health, including: (1) incentive and support for
changes in the graduate health courses and implementation of the national curriculum guidelines,
such as the national program for restructuring professional training in health (Pro-Saude); (2)
incentives and strengthening of technical professional education activities in health; (3)
strengthening of postgraduate programs, especially specializations in family health and
multidisciplinary residences in health and in family and community medicine; and (4) Telehealth,
which seeks, through the use of modern information and communication technologies, certification
of family health teams, improving SUS basic care services.
However, serious problems persist in the geographic distribution of professionals (see
Section 2.3.4), who are concentrated in major urban centers, as well as inequalities in salaries and
work contracts, in addition to work processes inadequate to the goals of the system. To address
these issues, the MS coordinates the preparation of proposals to improve working conditions in
health and of a SUS career plan with a defined path.

Refer to Ministry of Health Multiyear Plan 2008-2011 pdf

References
Flawed but Fair: Brazil's Health System Reaches Out to the Poor. Bulletin of the World Health Organization.

April, 2008.

World Health Organization: Brazil. (http://www.who.int/whosis/)

Ministry of Health Multiyear Plan 2008-2011 (http://portal.saude.gov.br)

2See www.saude.gov.br/sgtes for more information on SGTES.

 Brazil HEALTH SITUATION ANALYSIS AND TRENDS SUMMARY: Specific Health Problems. Pan American
Health Organization, (http://www.paho.org/English/DD/AIS/cp_076.htm#problemas)

Jose Carvalho de Nohoronha and Maria Luisa Garcia Rosa. Quality of Health Care: Growing Awareness in
Brazil. International Journal for Quality in Health care, 1999, Volume II, Number 5. Pp. 437 – 441.

SAINT LOUIS UNIVERSITY

College of Nursing

A REPORT ON:
THE BRAZILIAN HEALTH CARE SYSTEM
 In Partial Fulfillment
of the requirements for the Course
Comparative Health care System

Submitted by:

ROBERT PATIO, RN
GENEVIVE CLAIRE ANTONIO,RN
MSN I

Submitted to:
Professor Thea Batan, RN, MSN

Date Submitted:

May 08, 2010