The Evolution of HTA in Emerging Markets Health-Care ... - TREE

OHE Consulting Report for PhRMA
5 January 2011
The current Brazilian public health care system dates from 1988, with the creation of the Unified
Health System (SUS). With the new constitution, health was declared to be a citizen right and a duty
of the State. SUS was created to provide universal, comprehensive, and equitable health care to the
Brazilian population. To this day, the discussion about which right—universal coverage vs.
comprehensive coverage—should prevail has not been answered, since without enough funding,
one or both of these will be affected.
The Brazilian healthcare system has gone through a number of changes over the years. In 1923, the
landmark Eloi Chaves Law was passed, which brought into existence a form of ‘regulated citizenship’
where social welfare benefits were restricted to private sector workers with regular wages. Social
security and coverage of healthcare benefits (based on compulsory contributions from employers
and employees and delivered mainly through the private health sector) were tied to the workplace:
an outcome similar to the situation in the US. This left millions of agricultural and informal sector
workers uninsured. Elias and Cohn (2003) have argued that as long as the Eloi Chaves Law governed
the structure of the Brazilian health system, implementation of the principles of universality and
equality (in healthcare access and provision) was impeded.
However, the new constitution that came into effect in 1988 changed the existing two-­‐tier
healthcare system that operated. The new constitution paved the way for SUS, based on a
regionalized and decentralized framework—under which the private sector’s involvement in
medicine was relegated to a ‘complementary function’ with priority given to philanthropic and not-­for-­‐profit
organizations. However, the SUS is not a single payer healthcare system covering the
whole population. People may buy private insurance but cannot opt out of the public system, and
they must continue to pay taxes devoted to health care. In effect, the reform moved from one two-­tier
system to another two-­‐tier system (SUS plus the Supplementary Health Care System), but with
obviously a different mode of operation. This ‘new’ form of segmentation created opportunities for
adverse risk selection into the publicly-­‐funded SUS (Elias and Cohn, 2003).
The provision of health services was decentralized with a hierarchy among the federal level, state
level, and municipal level. The rules of provision are: 1) integral care, with priority to prevention
activities without damage to assistance activities; 2) decentralization with unique direction in each
level of government; and 3) participation of the community. The SUS was defined as composed by
the actions and health services provided by public bodies and institutions at the federal, state, and
municipal levels. Private institutions may participate in SUS as a complement, but philanthropic and
not-­‐for-­‐profit organizations are given preference.
Population and Coverage
Population: 193 million people (IBGE, 2010)
Total health care expenditure per capita in 2007 (WHO, 2010): US$ 606 (average exchange
rate) or $ 837 (PPP int $)
Total health care expenditure (WHO, 2010) = 8.4% of Gross Domestic Product
o Private expenditure on health as percentage of total expenditure on health: 58.4%
o Private prepaid plans as percentage of private expenditure on health: 39.4%
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