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Making the Right to health a Reality in the Context of Social Inequalities and Rapid Economic Change in Brazil

Author(s): V. S. P. Coelho*1, A. Shankland2
Affiliation(s): 1Citizenship and Development Group, Brazilian Centre of Analysis and Planning, Sao Paulo, Brazil, 2IDS, Falmer, United Kingdom

SUS, the brazilian public health system; rights; social excluded groups; decentralization; PSF Family Health Program; health councils, accountability


In the two decades since Brazil recognised access to healthcare as a Constitutional right, the country has undergone wide-ranging transformations that have left their mark on the profile of the population and on the country’s health system. Initially, a brief overview of the changes that have taken place in recent years in the socio-demographic and epidemiologic profile of the Brazilian population is presented, showing the challenges facing the healthcare system. We go on to present a brief overview of the system, which includes both the publicly-funded services provided by the SUS (Unified Healthcare System) and those financed and provided by the private sector. Our analysis concentrates on the public sector, which is the sole source of healthcare for approximately 70% of the country’s population.


We outline the chief mechanisms – programs, financing and management – that have ensured the SUS’s capacity to respond to the challenges pointed out previously. We argue that two of the key mechanisms are the establishment of transparent financing mechanisms for promoting universal coverage within a highly decentralised health system where most service delivery responsibilities lie at the municipal level, and the innovative approaches to democratic accountability.
Some 32% of Brazil’s population of 184 million people are considered to be living in poverty. Despite a recent decline in overall income inequality, indicators show expressive inequalities in both income and life expectancy between rural and urban populations, and between the population as a whole and minority ethnic populations, in particular Afro-descendent and indigenous groups. It should also be noted that 85% of Brazil’s population lives in cities, with metropolitan areas expanding rapidly throughout the country. In this context, a key challenge is to overcome urban bias in health system organisation and healthcare models, ensuring the realisation of the universal right to healthcare among minority populations living in remote rural areas where municipal service delivery capacity is weakest.


Since it was established in the late 1980s as a public health system with universal and unconditional coverage, the SUS has achieved a rapid expansion in access to services. A key driver of this expansion has been the system of direct central government transfers to the municipal level, tied to the delivery of priority packages such as the Family Health Program or PSF (Programa Saúde da Família). The statutory participation and accountability institutions, known as Health Councils (Conselhos de Saúde) have facilitated coordination between health system managers, service providers and civil society groups. However, both the transfer system and the accountability institutions have been less successful in guaranteeing service quality, and in particular in ensuring that service provision models such as the PSF are adapted to address the specific health needs of the most marginalised and vulnerable population groups. In this presentation we focus on the ways in which the SUS is dealing with these challenges, and the innovative approaches emerging from ongoing change processes such as the reforms in health service provision for indigenous peoples.

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