By: Daniel Greca & Dr. Edward Fitzgerald
Brazil has made huge strides towards building a public health system, enshrining provision as a constitutional right, yet the scale of opportunities and challenges continues to provide a complex balance. Daniel Greca, KPMG in Brazil's Managing Partner for Healthcare, spoke with Dr. Ed Fitzgerald, KPMG's Global Healthcare Executive, about his view on the future issues facing the Brazilian health system, and their impact on the wider healthcare market.
Acclaimed for huge gains in population health over recent decades, the Brazilian constitutional right to healthcare has provided a beacon for the benefits of universal health coverage around the world. Yet despite a promising outlook, building on this is becoming more difficult, and the health system now needs to embrace the power of data and digital health services to drive up quality and serve the most remote and poor parts of the country.
As the fifth largest country by area and population, there are huge challenges in providing quality healthcare to all Brazil's 209 million citizens. The south-east around Rio de Janeiro is relatively prosperous while much of the north of the country is far poorer in terms of education, economic output and access to care. Maternal mortality rates are significantly higher in the north-east.
In 1988 the establishment of Sistema Único da Saúde (SUS) promised `health for all' - universal and comprehensive access to services free at the point of use. It is one of the biggest and most ambitious health programs in the world. Around three-quarters of the population is dependent on SUS, while the rest use the private sector.
Since SUS was established, Brazil has seen an increase in life expectancy from around 64.4 years to 75.3 years in 2017 - although this is still lower than countries such as Argentina, Ecuador and Chile. Despite outbreaks in recent years of yellow fever, dengue, measles and the Zika virus, Brazil has made good progress in reducing infectious diseases. Like virtually every country it is now struggling with lifestyle-related illnesses such as diabetes.
From a healthcare workforce perspective, Brazil's doctor/patient ratio is low, at an estimated 2.1 doctors per 1,000 people in 2017. Spending per head is also low at US$848 per person annually, according to the Economist Intelligent Unit, but total healthcare spending amounts to 8.6% of GDP, which compares favourably with many countries.
In 2016 progress on healthcare was hit by the imposition of harsh austerity measures, freezing the federal budget for 20 years. The following year the health budget fell short of the minimum promised in the constitution.
The bedrock of SUS has been the primary care-based family health programme - Programa Saúde da Família (PSF). It provides preventative and treatment services through Family Health Teams which typically consist of one physician, one nurse, one assistant nurse and four to six community health workers. Each team looks after around 4000 people.
Brazil has prioritised the training of family doctors over specialists. In 2013 the government introduced a programme called Mais Médicos (More Doctors), designed to hire physicians to work in underserved and remote areas. With many Brazilian doctors unwilling to relocate, thousands of Cuban doctors were hired instead. In November 2018, Cuba announced their withdrawal after a row over their status with incoming president Jair Bolsonaro. Brazil is now endeavouring to replace them with local staff.
The impact Bolsonaro will have on healthcare is not yet clear, but he has promised to increase investment in primary care and there may be a greater role for the private sector in providing public services.
The state healthcare system is run by the 5,570 municipalities, which are required to invest at least half the tax they collect in healthcare. Funding also comes from the federal government and the 26 states.
Some public healthcare is provided by not-for-profit organisations, which make up around 38% of the hospitals. To qualify as not-for-profit at least 60% of the work must be for the public sector.
Brazil has a staggering 6500 hospitals. Many of the municipal hospitals have just a few dozen beds, while the six large federal hospitals are important for clinical training. According to Global Health Intelligence, more than 70% of hospitals are in the private sector. With so few public beds, municipal and not-for-profit hospitals are often overcrowded, with shortages of staff and equipment.
With 80% of the municipalities having fewer than 30,000 population, they do not have the volume of work or the money to run hospitals and many community services. So the challenge is to find ways for municipalities to work together in clusters, maintaining the successful model of decentralised primary care while having one hospital to serve several communities. Canada is a country of comparable scale with many small, quite isolated communities that has adopted this approach successfully.
Brazil's private health insurance market is the second biggest in the world after the United States, according to the Economist Intelligence Unit, covering more than 50 million people. The private and public systems operate almost entirely separately, apart from SUS contracts to private companies for services such as diagnostics. There are also some low-cost walk-in clinics.
Despite the focus on SUS, the proportion of health spending accounted for by private healthcare stands at around 57%, according to the World Health Organization. Over half of private spending comes from out-of-pocket payments, largely for pharmaceuticals. But going private is no guarantee of quality.
While the public sector was hit by austerity, the economic slowdown also hit the private sector, with 2.6 million people having their health insurance cancelled either because they lost their jobs and benefits or could no longer afford the premium.
The private sector is entirely based in hospitals, not in primary care. Its disconnection from primary care means hospitals are focused on patching up people who are ill rather than being part of a system to keep them healthy.
The private sector market is consolidating rapidly, with major interest from overseas investors since restrictions on foreign investment in the health market were relaxed. Deals include US-based UnitedHealth Group paying US$4.9bn in 2012 to buy Amil Participações, Brazil's biggest private health insurer, and US private equity group Bain Capital buying insurer Notredame Intermedica for US$620m in 2014.
The big opportunities for Brazilian healthcare are to harness the power of its data to drive quality and to harness the potential of digital services to reach remote and poor communities and encourage people to manage their own health.
Computers are still a rarity in primary care clinics and are not even found in every emergency department or hospital, while the data that is generated across the health system is not systematically collected and structured. This means that analysis, let alone exploiting the opportunities of artificial intelligence, are still a long way off.
Beyond a few basic metrics there is no effective measure of hospital quality such as mortality rates, and the data that is collected is not readily available to the public, so people have little clue as to the quality of a hospital based on its outcomes. When it comes to accreditation, Brazil still has still a long way to go. Out of the 6,500 hospitals in Brazil, less than two percent are Joint Commission International (JCI) accredited.
Alongside systematic collection and analysis of data, digital tools need to be brought to primary care and the family health programme. Family doctors and the local health teams should have all of a family's information in front of them on digital devices. This would enable them to provide prescriptions and book appointments, greatly improving the chances of addressing health problems early.
The Ministry of Health has launched several apps to provide access to personal health records but there is a long way to go. Building on the success of earlier public health programmes, Brazil now needs to use smart phone technology to provide access to care, particularly among poor and remote communities, and to encourage people to take greater responsibility for their own health. With WhatsApp already a routine way of communicating for somewhere in the region of two-thirds of Brazilians, the potential is obvious.
For some years Brazilian doctors were resistant to using telemedicine for consultations, but acceptance is growing and restrictions on its use have eased. In recent weeks the country's Federal Council of Medicine has proposed new regulations for telemedicine which both control and encourage it. This includes a requirement that the use of online appointments usually follows an initial face-to-face consultation, although this may be less rigidly enforced in remote areas.
Telemedicine is beginning to improve access to specialist hospital services, such as the digital ophthalmology service TeleOftalmo, launched by Brazilian telehealth service TelessaúdeRS in with the Universidade Federal de Rio Grande do Sul and the state government of Rio Grande do Sul in the south. Digital infrastructure is supported by the Telemedicine University Network, Rute, which connects universities and teaching hospitals, and Telessaúde Brasil Redes, the national telehealth network programme run by the Ministry of Health to provide digital services to primary care. A handful of digital connections are reaching remote parts of the Amazon.
Brazil is rightly proud of the progress it has made towards providing healthcare for all, built on the solid foundations of primary care. It now needs to maintain momentum by exploiting the potential of digital, while marshalling the power of data to embed a culture of quality improvement.
Daniel Greca is the Managing Partner for Healthcare with KPMG in Brazil. With a background in health and an MBA in Healthcare from USP, Daniel has been working in the healthcare market for 13 years. He began his career in the laboratories at Hospital de Clínicas do Paraná, where he published international scientific journal papers. After working for 8 years in leadership positions providing solutions for diagnostic medicine, Daniel joined the Healthcare and Life Sciences consulting business in 2013 in Brazil and the US. He is currently the Market Executive responsible for the development of healthcare, and responsible for projects oriented to Value Based Care, Patient Experience and Care System Redesign.
Dr. Ed Fitzgerald is KPMG's Global Healthcare Executive, and brings 12 years' clinical experience of hospital-based work in the NHS and international health systems prior to KPMG. Ed leads global healthcare research and thought leadership, working internationally to support KPMG's health practice across more than 45 countries. His experience of the world's healthcare systems and services helps him share the latest best-practice insights with clients globally.