Ligia Bahia

The Brazilian health system: history, advances, and challenges

Brazil is a country of continental dimensions with widespread regional and social inequalities. In this report, we examine the historical development and components of the Brazilian health system, focusing on the reform process during the past 40 years, including the creation of the Unified Health System. A defining characteristic of the contemporary health sector reform in Brazil is that it was driven by civil society rather than by governments, political parties, or international organisations. The advent of the Unified Health System increased access to health care for a substantial proportion of the Brazilian population, at a time when the system was becoming increasingly privatised. Much is still to be done if universal health care is to be achieved. Over the past 20 years, there have been other advances, including investments in human resources, science and technology, and primary care, and a substantial decentralisation process, widespread social participation, and growing public awareness of a right to health care. If the Brazilian health system is to overcome the challenges with which it is presently faced, strengthened political support is needed so that financing can be restructured and the roles of both the public and private sector can be redefined.

Health conditions and health-policy innovations in Brazil: the way forward.

Brazil is a large complex country that is undergoing rapid economic, social, and environmental change. In this Series of six articles, we have reported important improvements in health status and life expectancy, which can be ascribed largely to progress in social determinants of health and to implementation of a comprehensive national health system with strong social participation. Many challenges remain, however. Socioeconomic and regional disparities are still unacceptably large, reflecting the fact that much progress is still needed to improve basic living conditions for a large proportion of the population. New health problems arise as a result of urbanisation and social and environmental change, and some old health issues remain unabated. Administration of a complex, decentralised public-health system, in which a large share of services is contracted out to the private sector, together with many private insurance providers, inevitably causes conflict and contradiction. The challenge is ultimately political, and we conclude with a call for action that requires continuous engagement by Brazilian society as a whole in securing the right to health for all Brazilian people.

Planos privados de saúde: luzes e sombras no debate setorial dos anos 90

Este trabalho examina interfaces publica-privadas do mercado de planos e seguros no Brasil, procurando questionar as relacoes de autonomia e dependencia das empresas de assistencia medica suplementar com o SUS e alguns dos pressupostos que orientam o processo de regulacao governamental. A analise desse mercado se apoia em referenciais extraidos da literatura e sobre informacoes provenientes de fontes oficiais, empresas de consultoria, dados de empresas de planos e seguros e depoimentos de seus dirigentes. Sugere-se a necessidade de ampliar a agenda de debates e pesquisas sobre o mosaico publico-privado que estrutura o sistema de saude brasileiro.

O sistema de saúde brasileiro entre normas e fatos: universalização mitigada e estratificação subsidiada

This paper will focus on recent changes in the relationships between the public and the private sector within the health assistance network, by analyzing selected information on health services and on legal rules related to supporting the private assistance subsystem. This approach recasts analyses which articulate the simultaneous examination of both the material and political instances that permanently redefine the range of activity of SUS. Considering the limitations of the empirical bases here analyzed, one questions the implied assumptions in the meanings of autonomy sustained both in the public and in the private components, departing from hypotheses on the delineation of independent tendencies toward the expansion of universal coverage and he restratification of supply and demand.

Segmentação da demanda dos planos e seguros privados de saúde: uma análise das informações da PNAD/98

Este artigo apresenta uma investigacao preliminar da presenca da selecao adversa e do risco moral (moral hazard) na demanda ativa por planos de saude no Brasil, a partir dos dados da PNAD/98. O presente estudo compara individuos cujas coberturas decorrem do vinculo de trabalho, com aqueles cujos planos resultam de uma demanda individual as empresas que os comercializam e os que nao tem acesso a esquemas assistenciais alternativos ao SUS. A elaboracao de uma tipologia de planos de saude, combinada com variaveis relacionadas com as condicoes de saude, utilizacao de servicos e gastos com saude, sugere a existencia de falhas de mercado. A percepcao de uma condicao de saude mais desfavoravel parece estar associada a busca de cobertura e o tipo de cobertura com o maior uso de servicos de saude. Quando analisadas atraves de dois modelos de regressao logistica com multiplos controles, onde a variavel de desfecho e indicadora de selecao adversa ou moral hazard, essas diferencas se atenuam, com excecao dos gastos com saude. Os resultados nao evidenciam uma inquestionavel assimetria de informacoes, mas sinalizam a necessidade de aprofundar o conhecimento sobre as relacoes entre morbidade, utilizacao de servicos de saude, gastos com saude e tipo de cobertura.

Cobertura de planos privados de saúde e doenças crônicas: notas sobre utilização de procedimentos de alto custo

Com o objetivo de contribuir para especificar a origem das fontes de remuneracao dos procedimentos de alto custo, relacionados com a assistencia a doencas cronicas, o presente trabalho examina a utilizacao de procedimentos medicos selecionados por clientes vinculados a planos privados de saude e pelos segmentos populacionais cobertos exclusivamente pelo SUS. O estudo se baseia na comparacao entre taxas de utilizacao dos procedimentos selecionados, obtidos por meio de informacoes solicitadas a empresas de planos de saude, consultas as fontes oficiais e estimativas fornecidas por informantes-chave. Apesar de possiveis problemas de classificacao, as taxas de utilizacao dos clientes de planos privados de saude para revascularizacao do miocardio, angioplastia, artroplastia de quadril, e cirurgia de obesidade morbida sao mais elevadas do que as estimadas para os segmentos populacionais exclusivamente cobertos pelo SUS. Por outro lado, as proporcoes de transplantes hepaticos e terapias renais substitutivas remuneradas diretamente pelo SUS variam de 89% a 96%. Tais resultados sinalizam uma divisao de atribuicoes entre as esferas publica e privada no que se refere as fontes de remuneracao dos procedimentos de alta complexidade.

As contradições entre o SUS universal e as transferências de recursos públicos para os planos e seguros privados de saúde

Trailing the whole group of trends and changes in the scenario of relations between the public and the private, this article analyses the effects of the rise in the rates of return of health plan operators and health insurance companies in 2007. Special attention is given to the segmentation of the system, the complaints about the naturalization of inequitable access to health services and to the depreciation of the original concepts of the Unified Health System. The study also gathers information regarding the production of knowledge about supplementary care with the intent to systemize the bases and methodological approaches adopted by a selected sub-group of scientific papers. Finally, the article develops conjectures and hypotheses with regard to possible associations between growth and stability of the health plan and insurance market and as refers to the nature of scientific production about this issue, taking into consideration the contradictions between the political and economical circuit in which the health plan and insurance companies are operating and the universality of the Brazilian Health System.

O mercado de planos e seguros de saúde no Brasil: uma abordagem exploratória sobre a estratificação das demandas segundo a PNAD 2003

A partir dos dados do Suplemento Saude da PNAD 1998, diversos estudos evidenciaram a presenca de diferencas significativas nos padroes socioeconomicos, acesso, utilizacao de servicos de saude e condicoes de saude entre os segmentos populacionais cobertos e nao cobertos por planos de saude. Buscando contribuir para aprimorar o acervo dos conhecimentos sobre a estrutura e a dinâmica do mercado de planos e seguros de saude no Brasil, admite-se e procura-se evidenciar a heterogeneidade dessas demandas. Para tanto, foi definida uma tipologia de planos de saude, fundamentada nas origens institucionais das demandas e, subsequentemente, pelas relacoes de dependencia com titulares de planos e seguros de saude, integrada por tres categorias principais: os planos empresariais privados, os planos empresariais publicos e os planos individuais. As caracteristicas etarias, socioeconomicas e de condicoes de saude variam segundo os diferentes tipos de plano, sugerindo a presenca de padroes distintos de demandas, especialmente entre os planos empresariais privados e os planos individuais.

The International Classification of Functioning, Disability and Health: a systematic review of observational studies

OBJECTIVE To systematically review the use of the International Classification of Functioning, Disability and Health (ICF) in observational studies. METHODS This study is a systematic review of articles that use the ICF in observational studies. We took into account the observational design papers available in databases such as PubMed, Lilacs and SciELO, published in English and Portuguese from January 2001 to June 2011. We excluded those in which the samples did not comprise individuals, those about children and adolescents, and qualitative methodology articles. After reading the abstracts of 265 identified articles, 65 met the inclusion criteria. Of these, 18 were excluded. The STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) adapted Checklist, with 15 items needed for observational studies, was applied to the 47 remaining articles. Any paper that met 12 of these criteria was included in this systematic review. RESULTS 29 articles were reviewed. Regarding the ICF application methodology, the checklist was used in 31% of the articles, the core set in 31% and the ICF categories in 31%. In the remaining 7%, it was not possible to define the applied methodology. In most papers (41%), qualifiers were used in their original format. As far as the area of knowledge is concerned, most of the studies were related to Rheumatology (24%) and Orthopedics (21%). Regarding the study design, 83% of the articles used cross-sectional studies. CONCLUSION Results indicate a wide scientific production related to ICF over the past 10 years. Different areas of knowledge are involved in the debate on the improvement of information on morbidity. However, there are only a few quantitative epidemiological studies involving the use of ICF. Future studies are needed to improve data related to functioning and disability.

O papel da Justiça nos planos e seguros de saúde no Brasil

A grande quantidade de reclamacoes dos consumidores de planos e seguros privados de saude se tornou frequente no setor suplementar, com reflexos sobre o Poder Judiciario. Essa problematica fez surgir a necessidade de regulacao desse mercado privado, que se iniciou em 1998, por meio da Lei no. 9.656. Um dos desafios que a Agencia Nacional de Saude Suplementar (ANS) enfrenta e a resistencia das operadoras perante a legislacao, alem do fato de ainda existirem contratos nao regidos pela referida lei. O objetivo do estudo foi analisar recursos de decisoes judiciais que concederam ou nao o pedido liminar da antecipacao da tutela solicitado pelo consumidor de plano de saude, julgados nos Tribunais de Justica do Rio de Janeiro e de Sao Paulo. Os principais dados pesquisados foram: Tribunal que proferiu a decisao; reu; tema debatido; posicionamento de 1a e de 2a Instâncias e fundamentacao juridica. Verifica-se que o Poder Judiciario continua sendo um importante espaco de reivindicacao dos consumidores de planos de saude. O papel da ANS e importante para preencher algumas lacunas que ainda nao foram solucionadas pela regulacao do setor.