The pandemic has exposed the importance of Unified Health System (SUS) for all Brazilians – even those with a private plan. THE public network was able to vaccinate 900,000 people a day despite failing federal coordination. In addition to chronic underfunding, a study by economists from the world Bank shows that 30% of the Union budget for the SUS is misused. For specialists, avoiding wasting resources involves improving the distribution of doctors, establishing public-private partnerships (PPPs), among other measures.
“Vaccination against covid has shown that the SUS is consolidated in Brazil. An example for countries with similar income levels,” says Edson Araujo, a senior economist at the World Bank in Washington. The challenges of offering a universal system for 200 million inhabitants, however, will become even greater in the coming years, with the aging of the population.
“We live in a perfect storm: the economy has suffered a big contraction and, at the same time, there have been additional health expenses caused by the pandemic”, he says. “If health expenditures continue to grow more than the production of wealth in Brazil, at some point the country may enter an economic collapse because health increasingly absorbs the productivity generated by other sectors”, he explains. “The Brazilian scenario is not conducive to an increase in health spending in the short term, which makes the discussion about efficiency even more important.”
Two main challenges remain: improving the quality of services (varies widely across states and regions) and ensuring access to them. According to the authors’ analysis, in 2017 alone, SUS inefficiencies totaled BRL 35.8 billion.
Health has one of the most significant budgets of the Brazilian government (R$304 billion for the three levels of government in 2019, R$128 billion for the federal government alone in 2019). “If current patterns of nominal growth in spending are maintained, the SUS account will reach more than R$700 billion by 2030”, they write. And suggest how to reduce the problem.
Funding needs for the proper maintenance of the system are not lacking. One of the recurring complaints from service providers, managers and parliamentarians is the lack of updating the SUS table, the instrument that regulates transfers from the federal government to states and municipalities. With values without readjustment for years, the list establishes low remuneration for most of the more than 5 thousand procedures performed by SUS.
According to experts, this lag encourages distortions. “We can say that the SUS table is for enemies”, says researcher Maria Angélica Borges dos Santos, from the Fiocruz National School of Public Health. Technical coordinator of the book Health Accounts in the Perspective of International Accounting, Maria Angélica says that few private providers are paid according to the SUS table. “She sets the value of R$400 for a delivery, but there are providers who receive R$10,000 for the same service”, she says.
According to the doctor, the current SUS table works, in practice, as a floor. “This list causes an inequality in the remuneration of providers because they come to depend on complements from municipalities and states to receive a little more”, she says. Maria Angélica’s group is working on creating a table that considers municipal and state contributions to create a more reliable rule. “It is not possible to think of a health system without having a table closer to what Brazil can pay.”
The Institute for Health Metrics and Evaluation reports that global spending on health ($8 trillion a year) is expected to double by 2050. The growth in financing needs is expected to accelerate, particularly in low- and middle-income countries, where the population is aging. and health systems still face difficulties in coverage and quality.
According to a study published by Rudi Rocha, research director at the Institute for Studies on Health Policies (Ieps), and colleagues in the journal Health Economics, Brazil has one of the highest national health expenditures in relation to GDP, compared to other nations. From Latin America. However, it remains close to three percentage points below the average compared to high-income countries. The difference is that, in Brazil, public spending on health is lower than in rich nations.
“The body of evidence shows that, despite spending little in the public sector, advances in health in Brazil have been very important”, says Rocha. “In a macro view, the country does not spend badly on health, but we could spend better in some specific circumstances”, says Rocha. “We could, for example, reduce duplication of effort and unnecessary examinations.”
With the adoption of the spending ceiling, the capacity for federal investments in health is greatly reduced. This forces states and municipalities to assume most of the SUS funding. “There is a tension arising there, because they are already spending a lot on health and will reach a limit”, says Rocha. “If we put a general ceiling on public spending in the three spheres, in 40 years Brazil will come to assume only 20% of total health expenditure (the rest will be private expenditure)”, he says. “This average is comparable to that of the poorest sub-Saharan countries.”
According to the authors, by 2040, health financing needs will reach 11.7% of GDP. In a scenario of a federal spending freeze, public health spending is expected to decrease by seven percentage points by 2060, while the importance of local governments in sustaining the public system is expected to increase substantially. “SUS is one of the most important policies to reduce inequality in Brazil, a country that is very good at generating it”, says Rocha. “To finance future health needs, society will have to mobilize additional resources and reflect on what should be a priority in public spending.”
The SUS hospital network operates on a low scale. In other words, most establishments in small municipalities have few beds, high vacancy rate and low volume of procedures. To reduce this problem, it is necessary to invest in regionalization. Instead of maintaining small hospitals in most municipalities, it is smarter to transform establishments with less than 30 beds into health posts or polyclinics and maintain general hospitals with more structure (between 200 and 300 beds) in larger municipalities to serve the entire population. the region.
There are difficulties in distributing health workers (especially doctors) across the territory. Possible solutions would be to guarantee more resources to primary health care (PHC) in remote areas and improve its integration with regional hospitals; in addition to expanding the scope of nurses’ practice in PHC, in order to reduce dependence on physicians.
Ideally, each Brazilian should know the name of their family doctor, be accompanied by him and the entire PHC team, and have his health and socioeconomic information correctly recorded. In this way, it would be possible to make each team responsible for the health of citizens and offer extra remuneration and other incentives to teams that managed to improve certain indicators. Instead of remunerating health units and their professionals only for the number of visits and procedures, the SUS would also adopt some remuneration for the results achieved.
Management and investing in PPP
More public-private partnerships (PPPs) need to be adopted. The bureaucratic process of selecting and hiring personnel by competition is one of the major obstacles to increasing teams in direct administration services. According to World Bank scholars, a private entity would have more agility in managing people and more ability to offer good working conditions and incentives. There is strong evidence that autonomously managed hospitals, such as Social Health Organizations (OSS), outperform.