It has been more than 20 years since the 1988 Constitution formally established the Brazilian Unified Health System (Sistema Único de Saúde, SUS). The impetus for the SUS came in part from rising costs and a crisis in the Social Security system that preceded the reforms, but also from a broad-based political movement calling for democratization and improved social rights. Building on reforms that started in the 1980s, the SUS was based on three overarching principles: (a) universal access to health services, with health defined as a citizen’s right and an obligation of the state; (b) equality of access to health care; and (c) integrality (comprehensiveness) and continuity of care. Other guiding ideas included decentralization, increased participation, and evidence-based prioritization (Couttolenc 2011a).
The SUS reforms established health as a fundamental right and duty of the state and started a process of fundamentally transforming Brazil’s health system to achieve this goal. This report focuses on two questions: What has been achieved since the SUS was established? And what challenges remain in achieving the goals that were established in 1988? The report assesses whether the SUS reforms have transformed the health system as envisaged more than 20 years ago and whether the reforms have led to improved outcomes with regard to access to services, financial protection, and health status.
Any effort to assess performance confronts a host of challenges concerning the definition of boundaries of the “health system,” the outcomes that the assessment should focus on, the sources and quality of data, and the role of policies and reforms in explaining how the performance of the health system has changed over time. Building on an extensive literature on health system assessment, this report is based on a simple framework that specifies a set of “building blocks” that affect intermediate outcomes such as access, quality, and efficiency, which, in turn, contribute to final outcomes, including health status, financial protection, and satisfaction. Based on this framework, the report starts by looking at how key building blocks of Brazil’s health system have changed over time and then reviews performance with regard to intermediate and final outcomes. The report is, however, selective, and some important building blocks, such as human resources and pharmaceuticals, are not discussed systematically.