Download Políticas de Saúde e Federalismo no Brasil: Estrutura Política e

The Brazilian Health Reform and the
Chalenge of Decentralization
(The World Bank - February 19, 2004)
André Medici
Health Specialist
Interamerican Development Bank
How works health care before the 1988
Constitution? - 4 schemes
• 1) Social Security: Formal labor market: workers and families (60% of
the population), financed by payroll taxes;
• 2) Public Sector: informal labor market and indigents (no coverage or
under coverage) financed by general taxes;
• 3) Private Health Plans: Additional coverage for 10% of the richest
population (no mandatory, financed by firms or families);
• 4) Out of Pocket Expenditures (complementary for all groups);
Reforming the old health system
• Problems:
– Segmented coverage: inequalities and lack of coverage for the poorest
population groups;
– Poor health outcomes;
– insufficient financing and unfair distribution of the public funds.
• Political Environment:
– transition to democracy after 24 years of dictatorship;
– strong social participation and political will: the goal was to
implement a system based on the European welfare state.
• Restrictions:
– economic constraints to increase public health expenditures;
– unstable macroeconomic context
The 1988 Constitution and the Unified
Health System (Social Security + Public Sector)
• New Universal Rights on Health Care
– Universal health coverage by the public sector;
– Integral coverage for all goods and health services (absence of basic
packages and no risk management);
– Equal access for all without costs and payments by the users.
• Strategies
– Financing based on general taxation (social security budget with
specific sources tied to health);
– Decentralization of health care to local levels (federal hospitals and
ambulatory care units were transferred to States and Municipalities);
– Increasing the public role on investment and public employment.
The 1988 Constitution and the Unified
Health System (Social Security + Public Sector)
• Strategies
– Centralized management in each level of government (Federal, States,
Municipalities);
– Basic rules defined at national level (lack of administrative flexibility the PAS case in Sao Paulo);
– Lack of integration with Private Health Plans;
– Social participation (establishment of health counsels in each
government level composed by providers;employees and community
representatives);
– Strong corporatism of health related personnel.
– Hospital centered system (low incentives to primary health care).
– The system was driven by the supply side (no incentives related with
demand side as capitation).
Restrictions in the early ninities
• Restrictions
– Strong fiscal imbalances creating financial restrictions to the SUS;
– High inflation and economic instability
– Political crises and constant changes of health ministries (average less
than one year);
– Low priority of social policy and social changes;
• Consequences
– Strong corporatism and permanent strikes in health related
personnel;
– The population and communities had no confidence in the system;
– The rise of private health plans as an option for high income
employees and middle class
The Reforms under the Fernando Henrique
Cardoso Government (main achievements)
• Strengthen of financial sustainability
– Creation of the CPMF (tax related with financial transactions) to
increase the economic support for federal expenditure in health;
– Legislate that 10% of federal tax collection; and 15% of state and
municipal tax collection have to be applied in health care;
– Increase the federal sources transferred to states and municipalities;
• Increase the autonomy of States and Municipalities
– changes on the financial schemes (prospective payment to block
grants);
– decentralization of the audit system;
• Movement toward the primary health care:
– definition of a primary care basic package of services fully funded
(PAB);
– financial incentives for family doctors and community health agents;
Some outcomes
• The SUS lead to better health indicators:
– Life expectancy increase from 65 to 68 years from 1991
to 1999;
– Infant mortality rates have been reduced from 50 to 29
per thousand among 1991 and 2000;
– increase of institutional natal care;
– decrease of malnutrition rates among children under 5;
– increase immunization among children and pregnant
women;
Cuadro 1.5 – Brasil: Tasas de Mortalidad Infantil (por 1000 nacidos vivos) - 1997
Valores máximos y mínimos de los municipios de cada estado
Estado
Valores máximos y mínimos de los Municipios de Cada Estado
Alagoas
Paraíba
Rio Grande do Norte
Maranhão
Pernambuco
Ceará
Sergipe
Bahia
Pará
Acre
Piauí
São Paulo
Amazonas
Mato Grosso
Tocantins
Amapá
Roraima
Santa Catarina
Minas Gerais
Paraná
Goiás
Rondônia
Mato Grosso do Sul
Rio de Janeiro
Espirito Santo
Rio Grande do Sul
Brasil
Fuente: E, SIMÕES, C,C,S, 1998
Máximo (1)
119.33
108.61
106.15
100.73
98.07
97.00
82.19
79.08
77.90
71.29
67.52
56.01
54.05
52.00
51.30
51.04
48.23
45.74
44.52
44.31
43.33
40.41
39.74
39.58
38.12
25.24
119.33
Mínimo (2)
53.83
37.56
42.48
35.08
37.13
46.22
39.39
23.80
26.46
39.89
30.37
20.02
23.68
20.25
24.05
25.25
30.13
14.32
22.58
23.45
23.92
26.08
18.40
20.11
23.13
15.11
14.32
Relación (1)/(2)
2.22
2.89
2.50
2.87
2.64
2.10
2.09
3.32
2.94
1.79
2.22
2.80
2.28
2.57
2.13
2.02
1.63
3.20
1.97
1.89
1.81
1.55
2.16
1.97
1.65
1.67
8.33
The relationship among health expenditures
and outcomes in LAC countries
Percapita Health Expenditures and Life
expected years in good health - LAC
countries - 1997
75
Life expectancy in good health
(years)
• In 1997 Brasil performed the
8st higher health expenditure
among 27 LAC countries. (US$
428 per capita - 7,6% of GDP).
• Even son, Brazil occupied the
22st position regarding average
life years adjusted by
discapacity (59,1 life years in
good health).
• Others federative countries in
LAC, like Argentina (3th./5th.)
and México (9th./7th.)
performed better relationship
among health expenditures and
outcomes
70
65
60
Btasil
55
50
y = 3 4 .15x
R = 0 .5551
45
40
0
200
400
600
800
Per cap it a Healt h Exp end it ur e ( U S$)
10 0 0
Health Expenditure Distribution in Brazil
• Brazilian Health Expenditures 1997
Health Expenditures Distribution
Public Secttor


Central Government
States
 Municipalities
Health Maintenance Organizations

US$ millons
9%
22,867.4
12,162.5
Out of
pocket
4,285.5
6,419.4
Public
14,800.0
Familias
9,594.4
 Emterprises
Out of pocket expenditurews
5,205.6
23,466.9
Internacional Funds
TOTAL
265.0
61,399.3
37%
54%
HMOs
Evolution of Health Public
Expenditure
•
•
•
In 1980, the public expenditure in
health was distributed as following:
Federal Government (74%), States
(18%) and Municipalities (8%);
In 1996 the public expenditure in
health changed as following:
Federal Government (53%); States
(19%) and Municipalities (28%);
There is no data for all the 5,6
thousands of brazilian
municipalities, but some evidence
shows that municipalities is
increasing their participation in the
health expenditure in recent years
given the recent brazilian
government regulation
Brasil - Evolution of Public Health Expenditure
1980-1996 (US$ mil milions)
30
25
20
federal
15
state
10
municipal
total
5
0
0
-5198
82
9
1
84
9
1
86
9
1
88
9
1
90
9
1
92
9
1
94
9
1
96
9
1
Federal Transfers for States and Municipalities
•
•
•
•
Federal transfers to states and
municipalities represents almost 20% of
the Pub lic Health Expenditure
In the early eighties, federal
government drove sent most of the
transfers sources to states. In the
ninities, this trend was reverted. Most
of federal sources now are transferred
to municipalities;
In 1999 the transfers to States and
Municipalites represented almost 36%
of federal expenditures in health
In other hand, federal transfers
represented 11% of state expenditure
on health and 25% of the health
municipal expenditure.
50
40
30
20
10
0
Tr ansf er s t o S t at es
Tr ansf er s t o Municipalit ies
Brazilian Public Health Expenditure
by Sources and Uses
Uses of Public Expenditure
by Level of Government
Sources of Public Expenditure
by Level of Government
28%
35%
F ed er al
F ed er al
45%
St at e
St at e
53%
M unicip al
19%
M unicip al
20%
Public Health Expenditure and GDP
percapita by State
•
•
•
•
Per Capita Health Expenditure x GDP per capita
This graphic shows the total
1996 (US$)
percapita health expenditures by
states (including federal
expenditure)
Health expenditures are in
someway directly co-related with
the state percapita GDP
Even then, some poor states
presented higher health percapita
expenditures than other rich states.
In some way, the federal level
expends too much in some rich
states, as Federal District and some
poor states of the North Region.
Does the federal government own
a redistributive role on health expenditure?
Federal Health Expenditure per capita x
GDP per capita in the States: 1996 (US$)
Federal Health Expenditure
Per Capita
• Federal Health Expenditure
don’t have a clear redistributive
behavior
• The graphic shows that there is
no trend
• It was expected that federal
health expenditure need to be
bigger in poorest states then in
richest states, but it is not
happing
72
67
62
57
52
47
42
10 0 0
3000
50 0 0
GDP Per Capita
70 0 0
9000
Regional Innequalities Regarding Health Expenditures on
States and Municipalities
Regional (State and Municipal) Percapita
Health Expenditure x State Percapita GDP
1996 (US$)
Regional Percapita Health
Expenditure
• State and Municipal Percapita
Health Expenditure is closer
correlated with Percapita GDP
than Federal Health
Expenditure
• Rich States and Municipalities
trend to present bigger levels of
percapita health expenditures
18 0
16 0
DF
MT
AP
14 0
SP
12 0
10 0
RO
80
60
40
20
0
10 0 0
3000
50 0 0
GDP percapita
70 0 0
9000
Infant Mortality Rates x Percapita Public Health
Expenditures in Brazilian States
•
•
There is a inverse correlation between Infant Mortality Rates x Percapita Public Health
Expenditures - 1996 (US$)
infant mortality rates and percapita
public health expenditure
But the related data is weak to explain a
strong correlation. Many states expend
90
more than others to achieve worse
80
results in the reduction of infant
70
mortality.
60
Infant mortality is closer correlated
50
with general life conditions than health
40
expenditures.
Infant Mortality Rates
•
30
20
50
10 0
15 0
200
250
Percapita Public Health Expenditure
Correlation between infant mortality and GDP percapita
in Brazilian States
Infant Mortality Rates x Percapita GDP
at state level - 1996 (US$)
Infant Mortality Rates
• This inverse correlation is
stronger. Infant mortality
depends more on the state
income level
90
R2 = 0.6175
80
70
60
50
40
30
20
10 0 0
3000
5000
GDP percapita
7000
9000
Correlations among infant mortality rates and quality
of Health Information Systems
R2 = 0.5539
70
60
50
40
30
20
10
0
20
40
60
80
Percentage of deaths with known
death cause
Correlation between death with known
death causes and Percapita Public
Health Expenditure
Percentage of deaths
with known death
causes
Infant Mortality Rate
Correlation between infant mortality
rate and known information about
death causes
R2 = 0.7205
50
40
30
20
10
0
50
10 0
15 0
200
250
Percapita Public Health Expenditure
Best Practices to Improve Equity, Efficiency
and Sustainability of Public Health Policies
•
•
•
•
•
•
Use the epidemiological evidence as the rule to plan public health sector
needs;
Separate the roles of financing, organization and provision of services;
Use supply subsides just in the case when exist restrictions in the supply of
health facilities and use demand subsides when there is a multiplicity of
organizers and providers in a regulated competitive environment;
Target the public subside for people without means to pay and use fees
and co-payments to recovery costs and moderate the demand of people
with sources to pay for health services;
Use public subside to finance a package of cost effective services covering
the epidemiological, demographic and socioeconomic health profile of the
population without means to pay;
Use, complementary, public subside to finance a package of high costs or
risks that could not be supported by the population or private health
insurance.
Main achievements of the SUS
• Increase the capability of States and Municipalities to manage health
systems;
• Increase the fiscal compromise of States and Municipalities with health
systems;
• Use of block grants to transfer sources from central to local
government levels:
• Compromises with promotion, prevention and primary care and better
definition regards the use of high complexity and hospitals;
• Better integration among central, regional and local level on the use of
public health facilities;
• High quality of the health information
• Increase of social participation
Problems that still remain
•
•
•
•
•
•
•
•
High superposition on tasks performance among government levels;
The system is financed by supply side and not by demand side;
Federal funds are distributed without considering epidemiological needs and
financial shortness of states and municipalities.
Few flexibility to use public funds to contract private management solutions
for health care;
Lack of coordination between the SUS and the private plans. Users of private
plans are also users of SUS generating a public subside for private sector and
rich families;
There is no external audit system. The audit is done by the public sector and
do not manage interest conflicts;
There is no opinion polls about consumers satisfaction and few evidence about
the system performance for the population;
The health workers corporatism is over represented in the social participation
mechanisms;
The political economy of the SUS
• The SUS need to be understood as a political movement against
the militar dictatorship. The SUS has roots on the academy, on
the medical and health professional unions and in the public
sector;
• The 1988 Constitution incorporate several of these positions.
Some of the SUS principles conflicts with the eficiency and
equity needs of the health system;
• To face these interests, health reforms in Brazil had been slowly
driven.
• The main problem is to revert municipalization in
regionalization, with a mayor role of the states
Some solutions to improve the SUS
in a health federalism framework
• Integrate the SUS with the Private Health Plans (the creation of ANS)
• Use of equity formulas to distribute federal sources among states and
municipalities. These formulas need to pay attention to
epidemiological needs, fiscal capability of each state and adequate
incentives;
• Increase the management flexibility of the SUS. Use diversified
models of public and private management to search for better
efficiency on the sources allocation;
• Use the public subside for the poorest population and increase the
possibility to cost recovery for the people who has capability to pay.
• Increase the use of demand driven payment mechanisms to providers;
• Use financial incentives based in outcomes, not in processes