The Brazilian Society of Family and Community Medicine (SBMFC) takes the opportunity of the 21st WONCA World Conference of Medical Doctors, which puts together professionals and their experiences in more than 100 countries, to once again make a statement about the funding of brazilian health system.
SBMFC is a scientific society which has as its main role the development of a medical speciality that provides care with excellence to the most prevalent clinical conditions of people and populations. The family and community doctor, however, depends on the context where is ed to express its whole power on contributing to people feeling better, relieving their suffering, and eventually having their health problems solved. The Health System where these doctors are ed and how Primary Health Care works are, therefore, essential to define our practice.
What international experiences have demonstrated, and Professor Barbara Starfield is a fundamental reference on the subject, is that countries that organized universal health systems, funded by general taxes, health insurances or both, and strongly based in Primary Health Care (with family and community doctors) are the ones who get better health results using their financial resources in a more adequate way.
Until 1988 Brazil built a health system similar to other countries (Germany, Netherlands, Japan, USA) based on health insurance. Formal workers had an insurance funded by their payments and by their employers, regulated by the state through National Institute of Medical Care and Social Security (INAMPS).
In 1988 Brazil has created its Unified Health System (SUS) proposing the universalization of health care without health insurance and funded by general taxes, as United Kingdom and Spain. In these 28 last years, SUS had grown a lot, giving access to the system to millions of brazilians who used to rely on charity to get health care. Nowadays about 3/4 of the population regularly uses Health Units, Family Health Teams, referral clinics and hospitals (public or private) in SUS. At the same time, we maintained the logic of health insurances based on employment, strongly supported by Workers Unions. Most of the medium and huge companies fund private health insurances, including public institutions like Banco do Brasil and Caixa Econômica Federal (the national state banks), Petrobras (national state oil company), Fiocruz (federal health research foundation), Federal Universities and other federal, state and municipalities’ institutions like Parlaments, Law Courts and Army. Because of this, the most frequent situation is that health professionals of the public sector receive public resources to fund their private health insurances.
The contradiction of brazilian health system public funding is also supported by tax exemptions to millions of brazilians who their private health expenditures.
Resuming, brazilian state funds SUS, who has universal access and is based on solidary funding to provide health care to 150 million people, and also contributes with private health funding through tax exemptions or supporting public workers’ health insurances. We also count on millions of brazilians who pays huge out-of-pocket expenditures for their private insurances.
Brazil spends about 9.2% of its Gross Domestic Product (GDP) in health, a proportion similar to european countries, even with a slightly less nominal value. In a comparative way, considering our GDP, we should spend the double (from 200 to 400 billion/year). Therefore, there is a need of raising our nominal expenditure (per capita) in health to offer conditions for a more adequate universal system to provide healthcare to all 200 million brazilians. The challenge is that we have different subsystems, struggling for space, resources and professionals. With the exception of a small percentage which corresponds to out-of-pocket expenditure to pay for medication, consultations and exams, brazilian state regulates though the Ministry of Health less than 50% of total health expenditure, while regulates in a different way the other 50% through National Agency of Supplementary Health (ANS).
The Constitutional Ement Proposal 241 (PEC 241) suggests a new tributary regime based on the definition of a limit to the rising of primary expenditures of the government to a 20 years period, only yearly corrected by inflation of the previous year, with zero real rising. In health expenditures it modifies the constitutional rules which defined minimal funding based on current net revenue (CNR).
The Brazilian Society of Family and Community Medicine firms its position against PEC 241 and considers that any shortage of SUS funding or even a smaller progression of the budget than we were having in the last years will threat brazilians’ health, specially repealing legal rules that we consider as historical social conquers. This threat, however, is inclined to become real on this and on the next governments as it is very unlikely that Brazil goes beyond 10% of GDP in health funding.
If the current challenge is the guarantee of no shortening in health budget with this or other proposals, in a long term the challenge is how to reach a universal coverage health system, and SBMFC does not want to stay out of this discussion. Therefore it seems mandatory to discuss all brazilian health subsystems, their financial basis, solutions to their integration in a model regulated by state and different ways to rise the nominal expenditure in health, which includes, as example, the tax exempts we currently have.