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Brazil's health catastrophe in the making

2018; Elsevier BV; Volume: 392; Issue: 10149 Linguagem: Inglês

10.1016/s0140-6736(18)30853-5

1474-547X

Katarzyna Doniec, Rafael Dall’Alba, Lawrence King,

Global Maternal and Child Health

Brazil's political and economic crises are diverting attention from the resumption of a neoliberal model of health care by its government. Here we briefly summarise the health reforms and their likely long-term implications. The new policies can be seen from three perspectives: austerity, privatisation, and deregulation. Firstly, the country's Government introduced one of the harshest set of austerity measures in modern history. The constitutional amendment passed in December 2016, called PEC-55, freezes the federal budget, including health spending, at its 2016 level for 20 years.1Brasil Ministério de Desenvolvimento SocialInformações do projeto de lei orçamentária anual 2017.http://www.camara.leg.br/internet/comissao/index/mista/orca/orcamento/or2017/lei/Lei13414-2017.pdfDate accessed: March 10, 2018Google Scholar Furthermore, in 2017, for the first time in nearly 30 years, the government undershot the minimum health budget guaranteed by the Constitution by R$692 million (approximately US$210 million).2Instituto de Pesquisa Econômica Aplicada: Ministério do PlanejamentoNota técnica: número 28.http://www.ipea.gov.br/portal/images/stories/PDFs/nota_tecnica/160920_nt_28_disoc.pdfDate accessed: March 10, 2018Google Scholar, 3Collucci C Tamanho do SUS precisa ser revisto, diz novo ministro da Saude.Folha de São Paulo (São Paulo). May 17, 2016; http://www1.folha.uol.com.br/cotidiano/2016/05/1771901-tamanho-do-sus-precisa-ser-revisto-diz-novo-ministro-da-saude.shtmlDate accessed: March 10, 2018Google Scholar Other health-related sectors, such as education and science, also face spending cuts: up to 45% cuts in scientific research and 15% in public universities.4Angelo C Brazilian scientists reeling as federal funds slashed by nearly half.Nature. April 3, 2017; https://www.nature.com/news/brazilian-scientists-reeling-as-federal-funds-slashed-by-nearly-half-1.21766Date accessed: March 10, 2018Crossref Google Scholar, 5Angelo C Scientists plead with Brazilian government to restore funding.Nature. Oct 4, 2017; https://www.nature.com/news/scientists-plead-with-brazilian-government-to-restore-funding-1.22757Date accessed: April 27, 2018Crossref Scopus (8) Google Scholar, 6G1MEC prevê orçamento 15% menor para universidades federais em 2017.https://g1.globo.com/educacao/noticia/mec-preve-orcamento-15-menor-parauniversidades-federais-em-2017Date accessed: March 10, 2018Google Scholar Brazil's government is gradually withdrawing from the key social protection plan, Brazil Without Extreme Poverty (Brasil Sem Miséria), which has provided financial support, access to basic goods, and services to vulnerable populations through over 70 specialised programmes. Many social assistance programmes, supplementing preventive health care and reducing inequalities, are experiencing budget cuts. In 2017 over 1 million families were excluded from the Family Allowance Programme (Bolsa Família), aimed at the eradication of poverty and famine by direct, conditional cash transfer to the poorest households.7Brasil Ministério do Desenvolvimento Social e AgrárioBase de dados do Programa Bolsa Família.https://aplicacoes.mds.gov.br/sagi/RIv3/geral/index.php?relatorio=153&file=entradaDate accessed: March 10, 2018Google Scholar According to prognoses by Rasella and colleagues, austerity measures suffered by the programme are likely to exacerbate child morbidity and mortality within the next decade.8Rasella D Basu S Hone T Paes-Sousa R Ocké-Reis CO Millett C Child morbidity and mortality associated with alternative policy responses to the economic crisis in Brazil: a nationwide microsimulation study.PLoS Medicine. 2018; 15: e1002570Crossref PubMed Scopus (107) Google Scholar The National Programme for the Strengthening of Family Agriculture (PRONAF), which involves functions such as rural education, water supply, and job creation, and was one of the main forces behind Brazil's removal from the World Food Programme's global hunger map, has now been seriously compromised.1Brasil Ministério de Desenvolvimento SocialInformações do projeto de lei orçamentária anual 2017.http://www.camara.leg.br/internet/comissao/index/mista/orca/orcamento/or2017/lei/Lei13414-2017.pdfDate accessed: March 10, 2018Google Scholar The Water Tanks Programme (Programa Cisternas), bringing access to safe drinking water to impoverished, rural communities, has lost over 90% of its funds.1Brasil Ministério de Desenvolvimento SocialInformações do projeto de lei orçamentária anual 2017.http://www.camara.leg.br/internet/comissao/index/mista/orca/orcamento/or2017/lei/Lei13414-2017.pdfDate accessed: March 10, 2018Google Scholar Given that one of the leading causes of violent crime in rural communities is conflicts over access to water, shutting down the programme poses a serious threat to the security of these communities. Funding for the Acquisition of Food Programme (Programa de Aquisição de Alimentos), purchasing food produced by family farms for redistribution among the poor, has been reduced by 99%.1Brasil Ministério de Desenvolvimento SocialInformações do projeto de lei orçamentária anual 2017.http://www.camara.leg.br/internet/comissao/index/mista/orca/orcamento/or2017/lei/Lei13414-2017.pdfDate accessed: March 10, 2018Google Scholar Such drastic changes in the direction of social policies will probably reverse the social progress that has been made over the past two decades, which has brought 28 million people out of poverty and 36 million into the middle class. Secondly, the Government plans to introduce commercial health plans (Planos Populares), meant to replace functions previously performed, free of charge, by the National Health System (Sistema Único de Saúde [SUS]).9Brasil Agência Nacional de Saúde SuplementarPortaria número 8.851.http://www.ans.gov.br/aans/noticias-ans/sobre-a-ans/3805-planos-acessiveis-gtDate accessed: March 10, 2018Google Scholar Commercial plans offer a narrower scope of services than the minimum offered by SUS and are subject to less regulatory scrutiny, which generally results in poor service quality and high out-of-pocket costs.10Instituto de Pesquisa Econômica AplicadaCrise econômica, austeridade fiscal esaúde: que lições podem ser aprendidas? Relatório número 26, Brasília.http://www.ipea.gov.br/portal/images/stories/PDFs/nota_tecnica/160822_nt_26_disoc.pdfDate: Agosto de 2016Date accessed: March 10, 2018Google Scholar Thirdly, states and municipalities have so far been obliged to invest federal resources, via so-called financial blocks, in strategic areas of health care, including primary health care and sanitation. New regulations free the regional administrations from adhering to such spending discipline11Brasil Ministério da SaúdeGabinete do MinistroPortaria número 381 de 6 de Fevereiro de 2017.http://bvsms.saude.gov.br/bvs/saudelegis/gm/2017/prt0381_06_02_2017.htmlDate accessed: March 10, 2018Google Scholar by investing specified amounts into strategic areas of health care, which might contribute to the deterioration of SUS and to regional health inequalities. Moreover, new regulations diminish the obligatory numbers of doctors in emergency wards12Brasil Ministério da SaúdeGabinete MinisterialPortaria número 10, de 3 de Janeiro de 2017.http://pesquisa.in.gov.br/imprensa/jsp/visualiza/index.jornal=1&pagina=34&totalArquivos=72Date accessed: March 10, 2018Google Scholar and of personnel in primary health units,12Brasil Ministério da SaúdeGabinete MinisterialPortaria número 10, de 3 de Janeiro de 2017.http://pesquisa.in.gov.br/imprensa/jsp/visualiza/index.jornal=1&pagina=34&totalArquivos=72Date accessed: March 10, 2018Google Scholar including the reduction of the obligatory number of community health agents. Such reorganisation of primary care not only gives more power to the private sector than before, by diminishing the quality of public services, but also reduces SUS's capacity for effective emergency management, prevention, and health promotion. The weakening of the public sector has also taken a toll on vaccination coverage and sanitary surveillance, resulting in a recent outbreak of measles.13Estados enfrentam surto de sarampo, que volta a ameaçar o Brasil.Jornal Nacional. July 7, 2018; http://g1.globo.com/jornal-nacional/noticia/2018/07/estados-enfrentam-surto-de-sarampo-que-volta-ameacar-o-brasil.htmlDate accessed: July 7, 2018Google Scholar These actions show that Brazil's government is backing away from the core principles of universal health care, despite it being a constitutional right. Neoliberal health policies, combined with the deregulation of labour laws,14Casa Civil, BrasilLaw número 13.467.http://www.planalto.gov.br/ccivil_03/_ato2015-2018/2017/lei/l13467.htmDate accessed: March 10, 2018Google Scholar amid severe economic crisis are not only working against the idea of social justice, but also are likely to exacerbate two major public health concerns of the country: socio spatial and socioeconomic inequalities in health and the high homicide rate. We hope that this letter will stimulate debate on the systemic crisis of health care in Brazil, and contribute to rigorous scrutiny of neoliberal trends in public health policies and their effects around the world.15Stuckler D Basu S The body economic: why austerity kills. Penguin, London2013Google Scholar We declare no competing interests. Burden of disease in Brazil, 1990–2016: a systematic subnational analysis for the Global Burden of Disease Study 2016Health improved from 1990 to 2016, but improvements and disease burden varied between states. An epidemiological transition towards non-communicable diseases and related risks occurred nationally, but later in some states, while interpersonal violence grew as a health concern. Policy makers can use these results to address health disparities. Full-Text PDF Open Access