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.
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