21th January 2020 : The Hindu Editorials Notes : Mains Sure Shot
Question – Analysing the healthcare system of Brazil, another developing country, that has achieved universal health coverage, can India take a few notes? If so highlight the major takeaways.
Context – Brazilian President Jair Bolsonaro is visiting New Delhi this Republic Day, one interesting field of cooperation to explore in the strategic partnership is healthcare. Because achieving universal health coverage is a very complex task, especially for developing countries and Brazil is the only country where more than 100 million inhabitants have a universal health system.
Can we compare healthcare systems in India and Brazil?
- Despite its many problems, Brazil’s revamped public health system has brought quality health care to millions of poorer inhabitants who were previously denied even basic care.
- Until the 1970s, Brazilians used to joke that they had to die before the authorities paid any attention to them. Dr Hugo Coelho Barbosa Tomassini recalls how they used to have a full-time “death secretary” to administer funerals in the city of Niterói, where he was once the municipal health secretary, but only one health unit to care for the living.
- But The vision of a system providing “health for all” emerged towards the end of the military dictatorship that started in 1964 and during the years of political opposition that was to a large extent framed in terms of access to health care. This struggle culminated in the 1988 constitution, which enshrined health as a citizens’ right and which requires the state to provide universal and equal access to health services.
- Also Brazil is the only developing country where more than 100 million inhabitants have a universal health system, so it is worth studying. It can also provide lessons for Ayushman Bharat, currently the world’s largest and most ambitious government health programme.
- But achieving universal coverage in India, a country with a population of 1.3 billion, is a challenge of epic proportions. Hence, the advances in this field should be seen not in binaries but judged by its steady growth and improvement. For instance, India must record details of improvement in terms of access, production and population health on a year-by-year basis.
- A starting point for this daunting task is funding. Public health expenditure is still very low in India, at around 1.3% of GDP in the 2017-2018 fiscal year.
- Still there are many lessons that can be learnt.
The healthcare system in Brazil:
- Following the end of military rule, the Brazilian society decided to achieve universal coverage by establishing a government-funded system. The Unified Health System (SUS), which guaranteed free health coverage that included pharmaceutical services, was written into the new Constitution in 1988.
- As a result, in the last 30 years, Brazilians have experienced a drastic increase in health coverage as well as outcomes: life expectancy has increased from 64 years to almost 76 years, while Infant Mortality Rate has declined from 53 to 14 per 1,000 live births.
- In terms of service provision, polio vaccination has reached 98% of the population. A 2015 report said that 95% of those that seek care in the SUS are able to receive treatment. Every year, the SUS covers more than two million births, 10 million hospital admissions, and nearly one billion ambulatory procedures.
- This has been made possible even amidst a scenario of tightening budget allocation. While universal health systems tend to consume around 8% of the GDP — the NHS, for instance, takes up 7.9% of Britain’s GDP — Brazil spends only 3.8% of its GDP on the SUS, serving a population three times larger than that of the U.K.
- Under a subsequent health reform in 1996, Brazil established a health system based on decentralized universal access, with municipalities providing comprehensive and free health care to each individual in need financed by the states and federal government.
- Key to this strategy was primary health care. Today, primary health care remains one of the main pillars of the public health system in this country of 190 million people.
- Promoting health, preventing sickness, treating the sick and injured, and tackling serious disease; these are the cornerstones of the public health system.
- About 70% of Brazil’s population receives care from this system, while the remainder – those that can afford to avoid the queues and inconvenience of the public system – opts for private care. De Sousa says that before Brazil’s “health-care revolution” a much greater proportion of the population was excluded.
- All three systems of government in Brazil – federal, state and municipal – have worked hard to encourage the poor to use and benefit from the health system through initiatives, such as the Family Health Programme and through the deployment of auxiliary health workers or agentes de saúde working with the poor.
- Created in 1994, the Family Health Programme – Brazil’s main primary health care strategy – seeks to provide a full range of quality health care to families in their homes, at clinics and in hospitals.
- Today, 27 000 Family Health teams are active in nearly all Brazil’s 5560 municipalities, each serving up to about 2000 families or 10 000 people. Family Health teams include doctors, nurses, dentists and other health workers. The annual resources for primary health care have increased in the past 13 years to about US$ 3.5 billion, with US$ 2 billion of that money devoted to the Family Health programme out of an overall government health budget of about US$ 23 billion.
What can India learn?
- The Brazilian experience can inform the design of the expansion of primary care that underlies Ayushman Bharat, that is, the creation of 1,50,000 wellness centre by 2022. The Family Health Programme (Programa Saúde da Família), which relies on a community-based healthcare network, is the backbone of the rapid expansion of coverage in Brazil. The strategy is based on an extensive work of community health agents who perform monthly visits to every family enrolled in the programme.
- These agents carry out a variety of tasks. They conduct health promotion and prevention activities, oversee whether family members are complying with any treatment they might be receiving, and effectively manage the relationship between citizens and the healthcare system. The strategy works: a large body of research shows that the programme has drastically reduced IMR and increased adult labour supply. Equally impressive has been its expansion, from 4% of coverage in 2000 to up to 64% of the overall population in 2015; it was able to reach even the rural areas and the poorest States of the country.
Overall / Way forward:
- Both Brazil and India are composed of large States with a reasonable degree of administrative autonomy. This fact implies great challenges and opportunities.
- The major challenge is that a one-size-fits-all approach for such heterogeneous regional realities is inconceivable: Tamil Nadu, Sikkim, and Bihar differ in so many ways and this diversity must be met by an intricate combination of standardised programmes and autonomy to adopt policies according to their characteristics.
- Moreover, regional disparities in terms of resources and institutional capabilities must be addressed. This diversity, nevertheless, can be a powerful source of policy innovation and creativity.
- Note – Today there is another article titled ‘Redesigning India’s ailing data system’. It is mostly a critic of the government. This has already been covered in a different angle. Refer to the article of 24th October.