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ince the 1920s, Brazil has aimed to provide free and universal health care coverage initially with the creation of protection mechanisms through social insurance.1,2 The provision of universal and free quality health care in a country-continent like Brazil with more than 8 million km2 and 200 million citizens and a complex administration, hierarchically formed by federal, state (26 state governments plus the Federal District) and currently 5598 municipal governments, is an enormous challenge. For nearly a century, many health policies and managerial schemes have attempted to achieve this goal. The development of Brazilian health policies and their attempts to achieve free and universal health coverage are illustrated in Figure 1.Among the highlights of this development were the following: The initiation in 1923 of social protection in Brazil with social insurance, health care and medicines. In 1942, the Special Public Health Service (Serviço Especial de Saúde Pública) was formed following an agreement between Brazil and the United States intended to provide healthcare
1. O. A. Mercadante, “Evolução das políticas e do Sistema de saúde no Bra-sil,” in Caminhos da Saúde Pública no Brasil, ed. Jacobo Finkelman (Rio de Janeiro: Editora FIOCRUZ, 2002), 237–313.
2. For a more complete list of references, see E. Cruz, S. Cruz, E.J.P. da Silva Filho, C. Boaretto, M.G Rosa-Freitas, “The pursuit of health care for all Brazilians,” Science Postprint, 1 no. 1 (2014). Accessed January 16, 2015,
doi: 10.14340/spp.2014.10R0001. Fig.1 Hallmarks in the development of health policies in Brazil (Credit: Authors)
to distant and disadvantaged Brazilian regions that were of importance to the production of war supplies during World War II. This Special Public Health Service brought innovative health care management methods, such as the use of planning, planning evaluation and training methods for public health personnel, and was a pioneer in home-based primary care through the use of auxiliary staff. The Special Public Health Service implemented hierarchical networks of integrated health care, providing preventive and curative services with the possibility of hospitalization in basic medical specialties in its health units (see note 1).
The Domiciliary Urgent Medical Service (Serviço de Assistência Médica Domiciliar de Urgência) was created in 1949, with 3 key innovative features: i) home medical care provided by the public sector, previously carried exclusively through private practice, ii) consortium funding among the various retirement and pension institutes and, iii) the universal characteristics of medical care even though limited to emergency and urgent cases.
The National Social Security Institute (Instituto Nacional de Previdência Social) was created in 1966 and, although through a different regimen, it extended health coverage to rural areas. An attempt at universalization of health coverage was carried out in 1968 with the launch of the National Health Plan and the following National Health System Plan (Plano Nacional de Saúde e Sistema Nacional de Saúde). Both Plans were nonetheless cancelled due to strong resistance from various sectors to the privatization of the public health network and the free choice of professionals and hospitals envisaged by this plan (see note 1).
In the 1960s the influence of the Primary Health Care movement began to be felt in Brazil and with it the idea that health care should be carried out with the use of simple, low-cost techniques applied without risk or difficulty by elementary-level personnel recruited in their own communities and remunerated in accordance with local standards.3
In 1976, health care programs were formalized (Programa de Interiorização de Ações de Saúde e Saneamento), funded by the Ministry of Welfare and Social Assistance (Ministério da Previdência e Assistência Social ) and the Healthcare Fund (Fundo de Atendimento à Saúde), and initially applied in Northeastern Brazil and extended to other regions in 1979. These assistance programs marked an administrative paradigm shift in Brazil. Previously, social security acted directly through its own network, having been concentrated in major centers and almost entirely indirectly through contracts with private networks. With the assistance programs, the formalization of agreements was then made directly with state health departments.
At the end of the 1980s the Plan of Ready Action was launched, consisting of a set of mechanisms whose purpose was to gradually reach the target of universal health coverage. Improvements in medical care were accompanied by policies to expand social rights, such as the extension of rural worker pensions and the creation of a monthly benefit for non-taxpaying senior citizens. Nonetheless, a continuous and deep economic crisis of the late 1970s that
3. M. Cueto, “The Origins of Primary Health Care and Selective Primary Health Care,” American Journal of Public Health 94, no. 11 (2004).
lasted for two decades led to managerial disorganization, lack of materials and lack of skilled staff in the Brazilian health system. It was in the shadow of this deep economic crisis that the movement for health reform began in Brazil.
The health reform’s main demands were the improvement of the health of the population, the establishment of health as a universal right, the responsibility of the State to provide health care, including complete care from basic to tertiary attention, equality in attention and the decentralization of actions and services.4 The complete lack of activities in the area of preventive family health, however, was noted by various specialists as the major drawback of the entire structure of basic health care programming in Brazil.
The main health care goals were revisited in the 1986 VIII Health Conference and the National Constituent Assembly. The promulgation of the Brazilian Constitution of 1988 brought about the creation of the current Unified Health System, Sistema Unificado de Saúde (SUS), as a milestone which continues to exist today. For the first time in the history of Brazil, health as a social right was established as a new model for State action. The 1988 Brazilian Constitution defined the policies to be adopted and the public health actions and services to be given within a regionalized and hierarchical network as a single system, the SUS, organized according to the following four pillars:
i) universalization, ii) decentralization, iii) regionalization and full services, with priority given to preventive health
4. S. Arouca, Conferências Nacionais de Saúde: Contribuições para a construção do SUS, VIII Conferência Nacional de Saúde (1986). Accessed November 16, 2014, http://www.ccms.saude.gov.br/conferenciasnacionaisdesaude/
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activities, but non-detrimental to assistance services, and iv) social control through community participation.
Despite all of these plans and projects in Brazil, however, public health treatment in the public sector advanced little in the 1990s and 2000s. In 1999, the private sector owned 87 per cent of Brazil’s 723 specialized hospitals, 67 per cent of its general hospitals (66.5 per cent from a total of 7806 hospitals) and 95 per cent of its diagnosis and therapy units (see note 1). On the other hand, 73 per cent of Brazil’s health units that addressed basic health care belonged to the public sector.The third sector, largely consisting of non-profit social organizations, was incorporated into the Brazilian Health System by the end of the 1990s.
Long lines and wait times for care continued, and the lack of hospital beds was a common scene from health centers to large hospitals. New management models were planned and implemented by the municipalities to circumvent difficulties and municipal governments became the centers of decision-making for all health actions. The municipalities ceased to be health providers and became health managers, incorporating innovative managerial models, delegating health programs, actions, service supervision, and expenditures. By 2001, 99 per cent (or 5516) of Brazilian municipalities had complete responsibility for the management of resources in health, covering a population of 172.1 million individuals (see note 1).
The Family Health Program was created in 1994 and redefined as the Family Health Strategy in 1997 to pursue the goal of providing free access for the population to
integral assistance by a multidisciplinary team. In 2009, there were 30,328 family health teams deployed in Brazil, covering more than 50 per cent of Brazil’s population.5 By 2012, for a total of 5,293 Brazilian municipalities (95 per cent of municipalities), there were 80,170 family health strategy teams and 488,745 community health agents (see note 5). In 2013, 60 per cent of the Brazilian population were followed by family health strategy teams, a huge accomplishment. It has been recently observed that the mortality caused by cardiovascular diseases decreased by 18 per cent and heart diseases by 21 per cent in the municipalities where the Family Health Strategy was implemented.6
While improvements in the SUS of Brazil are sought,7 political, administrative and social developments in the last hundred years have led to free and complete health services available for all Brazilian citizens.
5. Ministry of Health Brazil. Ministério da Saúde Brasil. Departamento de Atenção Básica. Atenção Básica Saúde da Família [Department of Primary Care. Primary Care Family Health] [article in Portuguese]. Accessed Janu-ary 16, 2015, http://dab.saude.gov.br/portaldab/historico_cobertura_
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6. D. Rasella, M.O. Harhay, M.L. Pamponet, R. Aquino, M.L. Barreto, “Im-pact of primary health care on mortality from heart and cerebrovascular diseases in Brazil: a nationwide analysis of longitudinal data,” BMJ 348 (2014). Accessed January 16 2015, doi: http://dx.doi.org/10.1136/bmj.
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7. L. Bahia, “SUS trocado por miúdos” [SUS in detail}, O Globo News-paper, Coluna Ligia Bahia, September 1, 2014. Accessed November 15, 2014, http://oglobo.globo.com/opiniao/sus-trocado-por-miudos-13776980?topico=ligia-bahia
Dr Hooman Momen Memórias do Instituto Oswaldo Cruz, Instituto Oswaldo Cruz-FIOCRUZ Rio de Janeiro, Brazil
Dr Maria Goreti Rosa-Freitas Laboratório de Mosquitos Transmissores de Hematozoários-LATHEMA, Instituto Oswaldo Cruz-FIOCRUZ, Rio de
Janeiro Brazil