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

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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% 70
OHE Consulting Report for PhRMA 5 January 2011 o Out-‐of-‐pocket expenditure as percentage of private expenditure on health: 58.8% The public healthcare system is universal and covers 100% of the population. In practice, people covered by the private health care system do not use the public system, except for the access to drugs not covered by the private system. The private healthcare system covers 22% of the population. This coverage also varies by region, to health care services. This access is heterogeneous among regions in Brazil, being higher in the South and Southeast regions when compared to the Mid-‐West, North and Northeast regions (ANS, 2010). A1.2 Public Healthcare Financing Financing comes from taxes charged on the revenue and profit of companies, and these are responsible for almost 70% of the federal health budget. From the year 2000 onwards, after the constitutional amendment number 29, States must allocate 12% of their revenues from taxes to healthcare, and municipalities should allocate 15% of their revenues from taxes to healthcare. Budget Allocation The budget is allocated for five different categories: I. Basic Attention Budget is allocated from the federal government to municipalities based on a fixed per capita value named as Fixed PAB (Basic Attention, “PISO”—a fixed minimum value per capita), used for basic health care focused on strategic assistance areas, related to health problems of national coverage (women’s health, men’s health, child health, control of hypertension, and diabetes); and a variable PAB, allocated to priority and strategic programs, namely: -‐ -‐ -‐ -‐ -‐ -‐ Program of Family Health Communitarian Health Agents Oral Health Compensation for Regional Specificities Factor for Incentive of Basic Attention to Natives (Indians) Health Attention to Penitentiary Health These services are provided by municipalities. Municipalities may also define other areas for investment depending on the peculiarities of each municipality. II. Medium and High Complexity of Ambulatory and Inpatient Care 71
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The Evolution of HTA in Emerging Markets Health-Care ... - TREE

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