We had a preview of the health care system last week when we toured a municipal primary care center. Today the lesson continued with a lecture from Monike, a Brazilian nurse who went abroad to Portugal and Sweden for her Masters in Public Health. Monike had just returned from the U.S. where she had been working with the United Nations. She laid out the basics of the health care system in a straightforward way and made sure we recognized that what seemed like an elegant and simple design did not always work in practice.
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| Monike giving her lecture |
Monike began with a brief history of health care in Brazil, which originally consisted of small-scale services to attend to the Portuguese royal family and court when they arrived in Brazil in the early 19th century. With the end of slavery in 1888, Brazil saw a series of waves of European immigrants who brought diseases such as malaria, yellow fever, cholera, and smallpox. The public health system was largely in support of an agro-export economy, and its main purpose was to control such diseases coming in on seafaring vessels. From then until the 1960s, the growth of immigration, urbanization, and industrialization brought an increased demand for health care by the country's workers. For the next few decades, only the workers had access to limited services, and the care for the poor, needy, and informal workers was mostly covered by charitable and religious groups.
As Brazil shook off the yoke of its military regimes in the 1970s, greater demands for a unified system of public health resulted in the S.U.S. or Systema Unico de Saude, which was created by the new constitution of 1988. Today, 80% of Brazilians have S.U.S. as their only source of health care, and 20% have additional private health care. The system contains 6,100 hospitals, 45,000 primary care units, 30,000 Family Health Teams. It performs 2.8 billion outpatient and 9.7 million inpatient procedures and manages 11 million hospitalizations annually. The S.U.S. is financed by state, municipal, and federal taxes. Brazilian law requires that at least 12% of state taxes, and a minimum of 15% of municipal taxes, be dedicated to healthcare expenses. The percent of federal taxes varies each year with GDP. The network consists of many different kinds of healthcare centers from Basic Health Units, primary care centers that provide common health services and surveillance, to Mobile Boat Units that travel via the Amazon River to the farthest outposts of tribal villages.
As Brazil shook off the yoke of its military regimes in the 1970s, greater demands for a unified system of public health resulted in the S.U.S. or Systema Unico de Saude, which was created by the new constitution of 1988. Today, 80% of Brazilians have S.U.S. as their only source of health care, and 20% have additional private health care. The system contains 6,100 hospitals, 45,000 primary care units, 30,000 Family Health Teams. It performs 2.8 billion outpatient and 9.7 million inpatient procedures and manages 11 million hospitalizations annually. The S.U.S. is financed by state, municipal, and federal taxes. Brazilian law requires that at least 12% of state taxes, and a minimum of 15% of municipal taxes, be dedicated to healthcare expenses. The percent of federal taxes varies each year with GDP. The network consists of many different kinds of healthcare centers from Basic Health Units, primary care centers that provide common health services and surveillance, to Mobile Boat Units that travel via the Amazon River to the farthest outposts of tribal villages.
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| Mobile Boat Unit on the Amazon River |
The previously mentioned Family Health Teams are units consisting of one doctor, one nurse, one medical technician, and several community health workers that are responsible for providing primary care services to people in all sizes of cities and villages. This system was implemented in 1996 and has expanded to cover most of the regions in Brazil. Family Health Teams are always a fixed size, work a set 40 hours per week, and serve a set number of patients. They are required to come from the community they serve, in order for them to establish strong personal connections with the people whose homes they enter and whose lives they affect.
Despite having an excellent model, the S.U.S. does not always work as well as it should. The Brazilian health care system is beset with problems, many of which are common to the U.S. There are inequalities in access to care, poor service, queues and overcrowding in emergency rooms, and resource shortages and mismanagement, including human resources. There is also a shortage of expertise in some states or municipalities, outright failure of other basic ones, and variations in quality across regions and states. One of the major problems in the health care system is that doctors do not receive adequate compensation and students have no incentive to enter medical school. There is often a lack of adequate medical staffing in rural areas, although Monike said that, as in the U.S., the government gives financial incentives to professionals to work in more remote areas.
Another topic Monike discussed was the system of medical education in Brazil. Students enter medical school or nursing school directly from high school. Doctors study for 6 to 6 1/2 years and complete a 2 year residency, while nurses study for 4 1/2 to 5 years and also complete a 2 year residency. Surprisingly, there is no mandatory licensing exam after the completion of medical professional school.
As the U.S. moves towards a system of universal health care, it is important to recognize that in countries that now have such systems in place, there are still major problems with health care administration. It would do us Americans well to study what has gone wrong in these places to avoid future problems in our own country.
Despite having an excellent model, the S.U.S. does not always work as well as it should. The Brazilian health care system is beset with problems, many of which are common to the U.S. There are inequalities in access to care, poor service, queues and overcrowding in emergency rooms, and resource shortages and mismanagement, including human resources. There is also a shortage of expertise in some states or municipalities, outright failure of other basic ones, and variations in quality across regions and states. One of the major problems in the health care system is that doctors do not receive adequate compensation and students have no incentive to enter medical school. There is often a lack of adequate medical staffing in rural areas, although Monike said that, as in the U.S., the government gives financial incentives to professionals to work in more remote areas.
Another topic Monike discussed was the system of medical education in Brazil. Students enter medical school or nursing school directly from high school. Doctors study for 6 to 6 1/2 years and complete a 2 year residency, while nurses study for 4 1/2 to 5 years and also complete a 2 year residency. Surprisingly, there is no mandatory licensing exam after the completion of medical professional school.
As the U.S. moves towards a system of universal health care, it is important to recognize that in countries that now have such systems in place, there are still major problems with health care administration. It would do us Americans well to study what has gone wrong in these places to avoid future problems in our own country.
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