Brazil's Sistema Único da Saúde (SUS): Caught in the Cross Fire

In late May, a small team from the CSIS Global Health Policy Center traveled to Brazil to research Brazilian approaches to protecting health in emergency situations. With the 5th greatest landmass, the 5th largest population, and the 9th largest economy in the world, what happens in Brazil matters regionally and globally, and Brazilian experts play an influential role in international discussions about public health. My colleague and I were particularly interested to learn how public health experts in Brazil understand the term "health security."
A number of our conversations centered on the role of Brazil's unique health system in determining the country's capacity to prepare for, and respond to, emerging outbreaks. Several experts noted that in October, 2014, it was a local health clinic in the southern state of Paraná that identified a potential case of Ebola in a man who had recently arrived from the West African country of Guinea, where the Ebola outbreak was then raging: Brazilian health authorities quickly isolated the patient and transferred him via military aircraft to a hospital in Rio de Janeiro for assessment, eventually concluding that the patient did not, in fact, suffer from Ebola.  In 2015, it was a research team working in the northeastern state of Pernambuco that discovered that pregnant women infected with Zika virus were at risk of delivering children with microcephaly and other neurological problems.
A policy report on Brazil's approaches to health security, as well as the role of U.S.-Brazil collaboration on health in shaping Brazil's approaches to managing public health emergencies, will be forthcoming. However, given the importance of Brazil's health system, it's relevant to outline some of the system's key features in advance of the full analysis.
Brazil's Sistema Único da Saúde, or SUS, is one of the largest public health systems in the world. More than three-fourths of Brazil's roughly 210 million people rely exclusively on the SUS for health services.
The SUS was launched in the late 1980s, during Brazil's transition to democracy following two decades of military dictatorship, from 1964 to 1985. Through the influence of the sanitarista movement and the participation of public health specialists in drafting Brazil's 1988 Constitution, health is a right in Brazil, with the state responsible for providing health care to the population free of charge.
Offering access to health services through a mix of public and private care providers, the SUS is financed through public funds, and by employer/employee contributions. A constitutional amendment in 2000 created a tripartite system that requires federal, state and municipal contributions to, and management of, SUS programs.
Back in 2010, I traveled to Brazil to learn about the government's vision of "health in all policies" and its endorsement of the 2007 Oslo Declaration through the Global Health and Foreign Policy Initiative. At the time, Brazil's economy was booming, and the country was expanding its overseas health engagement. The officials with whom I spoke emphasized Brazil's responsibility to share with other countries the lessons it had learned in developing and sustaining the SUS.
So it was disappointing, to discover on my recent visit that the collapse of global commodity prices and economic recession in Brazil, along with a series of political scandals and corruption within the health sector, have created serious challenges for the SUS and raised questions about the future of the health program.
Even before the recession, equitable access to quality health services was a challenge for SUS subscribers, with residents of Brazil's poorer areas having to travel greater distances for a lower quality of care than Brazilians living in better-resourced states and urban centers.
These inequities in access to quality services were made painfully clear during the 2015-2016 Zika virus outbreak, which was centered in Brazil's historically underdeveloped Northeast. In cities such as Recife and Salvador, and in smaller municipalities in such states as Pernambuco or Ceará, the number of confirmed cases of babies born with congenital Zika syndrome rose alarmingly over late 2015 and 2016. In remote settings, where residents report that health clinics are closed more often than they are open, finding the kind of long-term therapy required to assist children born with Zika congenital syndrome will almost certainly be a struggle.
The latest challenge to the SUS is a constitutional amendment that limits increases in public spending to inflation for the next 20 years. Funding for some health programs is supposed to be protected from the spending limits, and an effort has been made to project costs associated with long-term care of the children born with Zika congenital syndrome. Restricting increases to inflation may not allow adequate resources for future emergencies or take into account changes in demand for care as chronic diseases take a greater toll.
On the day last month that my colleague and I were in Brasilia, several thousand protesters had gathered in front of Brazil's Congress to decry the latest round of corruption scandals engulfing the Brazilian political class and to demand the resignation of President Michel Temer, who assumed power last August, following the impeachment of former President Dilma Rousseff. As protesters and the police faced off, fireworks popped in the distance, and from a conference room on the 2nd floor of the Pan American Health Organization (PAHO) country office, we could see black smoke curling up from the Agriculture Ministry, which had been set ablaze. Later that day, Temer authorized the Brazilian military to maintain order in the capital, prompting opposition party officials to denounce the move as an insult to all who had lived through the difficult years of dictatorship, warning that Brazil's democracy was in danger.
As Brazil digs out of economic recession and confronts political challenges new and old, it is important that its health system, and the millions of people who depend on it, not get caught in the cross fire. In mid-May the government declared that the Zika emergency is over. However, the ongoing outbreak of Yellow fever in the south, and the arrival of refugees from Venezuela seeking medical care in Brazil's economically weak state of Roraima, in the north, fuel a steady supply of health crises, which a further weakened SUS may be ill-equipped to extinguish.
Katherine E. Bliss
Senior Fellow and Director, Immunizations and Health Systems Resilience, Global Health Policy Center