Document(s) 8 de 14

Introduction

This chapter will analyze the effects of health care reform, as described in the previous chapter, on the organization of the health care system in Brazil.

Part I will present some general socio-demographic and epidemiological information on the population. It will then describe the major structural characteristics of the system concerned with financing and delivery, as well as the structure of the main subsystems within the health care system as a whole.

Part II will analyze the changes brought about out by the reform by reviewing the dynamics of the health care systems that prevailed from the 1970s to the 1980s and throughout the 1990s, with respect to financing, modes of payment, management, and regulation.

Structural Features

Socio-demographic and epidemiological aspects

During the last two decades, Brazil has undergone major socio-demographic changes. According to the censuses, the Brazilian population grew from 93.14 million to 146.83 million from 1970 to 1991, an increase of nearly 58%. During the same period, the proportion of the population living in urban areas grew from 55.9% to 76.0%.

The composition of the population has also changed significantly. First, there is clear evidence that the population is aging. In 1970, individuals under 20 years of age represented more than 50% of the total population. Now, they make up less than 45%, even though the rate of child mortality in the period has decreased from 95.0 to 49.7 per 1 000 live births. This is mainly due to a decrease in fertility and rise in life expectancy. The fertility rate fell from 5.76 to 2.66 between the two censuses. At the same time, life expectancy rose from 52.49 to 65.62 years (Tables 1 and 2).
 

Table 1. Socio-demographic dynamics - Brazil.
	1970	1991	% increase
Population, millions (a)	93.14	146.82	57.64
Urbanization rate (b)	55.92	76	35.91
Literacy rate (b)	60.34	73.38	21.61
Infant mortality rate per 1 000 live births (b)	95	49.7	47.68
Life expectancy at birth (b)	52.49	65.62	25.01
Fertility rate (b)	5.76	2.66	53.82
Sources: (a) Fundação IBGE (1970b, 1991b) (b) Fundação IBGE (1995) and World Bank (1993).

 
 

Table 2. Distribution of population by age - Brazil.
Age groups (years)	1970 (%)	1991 (%)	% Change 1970-91
0-4	14.83	11.25	-24.14
5-9	14.45	11.86	-17.92
10-14	12.73	11.61	-8.79
15-19	11	10.22	-7.09
20-24	8.89	9.23	3.82
25-29	6.98	8.6	23.2
30-39	11.55	13.98	21.04
40-49	8.68	9.5	9.45
50-59	5.62	6.4	13.88
60-69	3.23	4.36	34.98
70 or over	1.83	2.93	60.11
Age unknown	0.2	-	-
Source: Fundação IBGE (1970a, 1995).

Although the aging of the population is a common trend in many developing countries, the distinctiveness in Brazil is the speed with which it has occurred. The effects are already evident in the epidemiological profile of the population and in health care demands. Nevertheless, it is only recently that this new population profile has been taken into consideration by social and health policymakers. The issue is not yet well understood and strategies to deal with it are still in their infancy. Moreover, the epidemiological characteristics vary considerably between the various regions of the country: for example, life expectancy on the North is still about 55 years.

The epidemiological profile of the Brazilian population has also gone through major changes and is now more complex than ever, including both chronic diseases and a persistence of diseases associated with poverty and social inequality (Table 3). Infectious and parasitic diseases no longer feature among the main causes of mortality in the country as a whole, but are still important in the poorest regions. On the other hand, deaths from external causes are rising, reflecting a major problem of violence in urban areas and in areas of intense conflict over possession of land.
 

Table 3. Principal causes of mortality - Brazil.
1979	1985	1991	1995
Cardiovascular diseases	Cardiovascular diseases	Cardiovascular diseases	Cardiovascular diseases
Symptoms and diseases of uncertain definition	Symptoms and diseases of uncertain definition	Symptoms and diseases of uncertain definition	Symptoms and diseases of uncertain definition
Infections and parasitically diseases	Injuries	Injuries	External causes
Injuries	Neoplasms	Neoplasms	Neoplasms
Neoplasms	Respiratory diseases	Respiratory diseases	Respiratory diseases
Source: Data from the Internet homepage of Ministério da Saúde, Datasus (data system of the Sistema Unico de Saúde), 1997.

The percentage of deaths from unknown causes remains high, indicating a deficiency in the reporting system. In some states, more than 50% of all registered deaths are attributed to uncertain causes. This high percentage is probably due to infant mortality and deaths from infectious or parasitic diseases. But it may also be indicative of lack of access to and use of health services.

Social inequality thus remains the main health and social policy issue in Brazil. Although the ninth largest economy in the world, the country’s social indicators are still cause for concern. According to the United Nations Report on Human Development (IPEA 1996), in 1995 Brazil ranked one of the worst of 55 countries in terms of social inequity. The average income among the richest 10% was about 30 times the average income among the poorest 40%. In most countries this ratio is usually 10 times at most.

Moreover, there has been a rise in the concentration of income, even though the number of people with no income or whose income was less than the official minimum wage decreased.Two phenomena must be mentioned here. The first is that all strata of society enjoyed an increase in income following periods of economic. This increase was greater, however, at the upper-income levels. Thus, it is correct to say that in Brazil there was a direct relationship between the growth of the economy and the growth of total income. This was without doubt a major factor in reducing poverty. But, it is also correct to say that economic growth did not reduce social inequalities. On the contrary, it concentrated income in the higher income brackets. The proportion of total income of the poorest 50% of the population has decreased continuously between 1960 and 1980, in contrast to that the richest 20% (Table 4).
 

Table 4. Income distribution - Brazil.
Year	Richest 20%	Poorest 50%
1960	54	18
1970	62	15
1980	63	14
1990	65	12
Source: Barros et al. (1995), cited in IPEA (1996).

The other phenomenon worth mentioning is the so-called urbanization of poverty. This means that poverty is no longer predominantly rural, but that the majority of poor people are now concentrated in urban areas. There are also vast differences between the various regions of the country, where the number of poor people is related to other social indicators. The human development index confirms these differences. Although the southeast region may be compared to the countries of high human development, the northeast is comparable to a country of low human development (Table 5).
 

Table 5. Poverty by regions - Brazil.
	Number of poor (thousands)	% poor	Partici- pation in country	GNP per capita ($)	Life expectancy at birth (%)	Literacy rate (%)	Human development index
North	2 220	43.2	5.3	3 747	68.4	75.4	0.706
Metropolitan	395	43.4	0.9	-	-	-	-
Urban	1 825	43.2	4.4	-	-	-	-
Northeast	18 894	45.8	45.1	2 559	59.1	62.4	0.548
Metropolitan	3 187	43.4	7.6	-	-	-	-
Urban	7 745	43.8	18.5	-	-	-	-
Rural	7 962	49.1	19	-	-	-	-
Southeast	13 988	23	33.4	7 212	68.8	87.7	0.838
Metropolitan	7 481	26.9	17.8	-	-	-	-
Urban	4 519	17.7	10.8	-	-	-	-
Rural	1 988	27.1	4.7	-	-	-	-
South	4 349	20.1	10.4	5 388	70.9	88.2	0.844
Metropolitan	855	17.6	2	-	-	-	-
Urban	1 879	16.8	4.5	-	-	-	-
Rural	1 615	28.9	3.9	-	-	-	-
Centre-East	2 469	24.8	5.9	5 440	69.1	83.3	0.826
Metropolitan	343	22.4	0.8	-	-	-	-
Urban	1 492	23.2	3.6	-	-	-	-
Rural	633	31.8	1.5	-	-	-	-
Brazil	41 919	30.2	100	5 240	66.3	79.9	0.797
Metropolitan	12 261	28.9	29,2	-	-	-	-
Urban	17 198	26.8	41.7	-	-	-	-
Rural	12 198	39.2	29,1	-	-	-	-
Source:IPEA (1996).

The data on education show a substantial change in the last two decades, with the literacy rate rising from 60.3% to 73.4% (Table 1). Here too, however, the differences between regions are impressive. In rural areas in the northeast, for example, 67.6% of heads of families are illiterate (IPEA 1996). Among children, there has been a 10% increase in the rate of education between 1981 and 1991, but there are still 4 million children from 7 to 14 years of age who do not go school. Also, although the great majority (97%) of children from families whose income is more than twice the minimum wage are students, this percentage declines to 75% among children from poor families (IPEA 1996).

Social and health expenditures

Official data on private expenditure is provided through income tax declarations. It is therefore biased in scope toward the wealthy, who are more likely to file tax returns. The increase noted in social expenditure is certainly due to an increase in private expenditure. Although per capita social expenditure increased about 170% during the period, the public portion of it did not increase more than 5.5%.

Recent research on household income and expenditure confirms that there has been a significant increase in private expenditure over the last decade, at least for education and health. Health expenditure has tripled as a proportion of the Brazilian household expenditure (IBGE 1997).

Health expenditures have, in fact, followed the trend of increased social spending, with a decrease in the proportion spent on public health services. Per capita expenditure on health grew from US $36.3 to US $100.5 between 1980-81 and 1990-95, or about 177%. This is even more than the growth in per capita expenditure on social services as a whole. The increase in public health expenditure was only 6.6%.

This trend can be confirmed by considering only the public expenditure per capita, which did not increase, but was subject to wide fluctuations between 1981 and 1990 (Table 7). These fluctuations were even more evident in the spending pattern of the Federal Government (Table 8).
 

Table 7. Public expenditure on health (US$ per capita, 1990) - Brazil.
1980	1891	1982	1983	1984	1985	1986	1987	1988	1989	1990
81.44	75.44	76.64	61.7	61.04	71.57	78.35	92.06	77.34	100.89	87.87
Source: World Bank (1995).

 
 

Table 8. Central government expenditure on health (% of total revenues) - Brazil.
1980	1981	1982	1983	1984	1985	1986	1987	1988	1989	1990	1991	1992
11.9	11	10.5	9.5	12.2	10.9	9.7	14.8	15.7	16.8	13	13.2	10.8
Source: Médici(1993).

Two other important aspects must be noted in the process of health care reform. First, a considerable increase in expenditure occurred in 1987 as a result of the decentralization begun during the 1980s. In 1990, however, there was a decrease that corresponded to the first year of the first elected government after the military regime, when social and health expenditures were cut considerably. The other important feature is the effect of decentralization on the increase of expenditures by municipalities, evident in Table 9.
 

Table 9. Public expenditure on health (%) by government level - Brazil.
	1980	1981	1982	1983	1984	1985	1986	1987	1988	1989	1990
Government	74.88	73.87	74.38	72.34	74.60	71.65	68.76	83.06	91.34	77.45	72.73
State	17.81	18.50	17.21	19.13	17.95	18.85	20.78	8.86	-6.11	11.60	15.43
Municipal	7.19	7.62	8.39	8.51	7.43	9.48	10.44	8.06	14.77	10.93	11.83
Source: Data calculated from World Bank (1995).

Coverage

The Constitution of 1988 gave the entire population the right to use any public health service in the country. In reality, it is estimated that the public system covers about 70% of the inhabitants. This percentage was calculated by estimating the proportion of people who have any kind of private coverage and therefore do not use public system. Some of them, however, are known to use public services for procedures not covered by their private plans.

The data on the private health sector are not official. According to the associations of private health companies, 42 million people are affiliated with some kind of voluntary health plan. They are mostly employees in the formal market, mainly in the industrial and services sectors, who are entitled to coverage through the companies they work for. Some are families or individuals who contract directly for private service.

Some people in the voluntary health sector are covered by more than one private company, as well as by the public system. An individual may have more than one employer, may be a dependent of more than one entitled person, and may also be covered by a health plan contracted directly, to complement an employer’s plan. The following paragraphs describe the private health sector in more detail.

Subsystems

The Brazilian health care system may be divided into two subsystems. The first, the Sistema Único de Saúde (SUS, unified health system), incorporates a host of public providers and comprises hospitals and primary health centres that belong to federal, state, and local governments. It also includes private profit and nonprofit providers under contract to the public system.

The second system is known in Brazil as the "supplementary medical system." It includes the private plans with voluntary affiliation as well as prepaid health plans and insurance companies.

Unified health system

According to the Constitution of 1988, the Sistema Único de Saúde (SUS, unified health system) comprises all health care and services provided by public institutions of the three levels of government, as well as private institutions that provide services under contract. In principle, the whole population is entitled to universal health care. SUS is regulated by the Lei Orgânica da Saúde (LOS, Health Organization Law), which is actually two laws - Law 8.080 and Law 8.142 - both passed in 1990.

Responsibility for SUS is shared by the three levels of government - the Ministry of Health and the state and municipal councils, as well as their respective secretariats, which comprise an equal representation of providers and users. Integration between the different levels of government is carried out through an inter-management commission, composed of authorities from each.

The Constitution of 1988 determined that SUS should be financed from the social security budget, which is funded through salary-based compulsory contributions by employers and employees; general taxation through federal, state, and municipal budgets; and other sources.

Because neither the Constitution nor the social security budget specifies the amount of resources designated for health, the Lei de Diretrizes Orçamentárias (LDO, budget directives law) has fixed a minimum equal to 30% of the social security budget. This minimum has not been met, however, since 1993, when the Social Security Institute suspended the transfer of resources to the Ministry of Health. This caused a deep financial crisis in the sector. In 1992, for instance, resources from compulsory contributions represented 55% of the public budget for health.

From 1993 on, SUS began to rely upon extraordinary contributions and central government transfers to make up its budget, which amounted to 60% of its total resources in 1995. A special tax on banking transactions was imposed in 1996 to solve the problem. On the other hand, states and municipalities have increased the allocation of their own resources to finance the system.

Supplementary medical system

This system includes various models of private prepaid health plans and health insurance companies. It enrolls people voluntarily or employees through contracts with their firms. Although legally all the health services rendered in the country come under the framework of the Sistema Único de Saúde (SUS, unified health system), the supplementary medical system is still not integrated with SUS. Also, regulation of this system has only very recently come under the responsibility of the public health authorities.

Because of this lack of regulation, information about this subsystem is very sketchy. Estimates consider that it includes, at present, some 1 360 companies, with 42 million beneficiaries. Its total revenues are estimated at US $14.8 billion (Table 10).
 

Table 10. Coverage and revenues of the voluntary contract subsystem, 1989-96 - Brazil.
Private service	1989
	Insured inhabitants (thousands)		Revenues (US$ millions)		Insured inhabitants (thousands)		Revenues (US$ millions)
	Number	%	Number	%	Number	%	Number	%
Medicine groups	17 250	55.3	1 000	42.2	17 300	40.9	3 700	25 .0
Medical cooperatives	5 110	16.4	567	23.9	10 000	23.6	3 500	24 .0
Self management and administrative plans	7 898	25.3	659	27.8	9 000	21.3	4 600	31 .0
Health insurance	944	3.0	146	6.1	6 000	14.2	3 000	20 .0
Total	31 202	100.0	2 372	100.0	42 300	100.0	14 800	100.0
Source: Médici (1990), Abramge and Folha de São Paulo, 14 Sep. 1997.

There are four main types of supplementary medical coverage: group medical companies, medical cooperatives, health insurance companies, and self-managed health plans. This last type of plan deals exclusively with health services for the employees of a given enterprise, usually a large public or private corporation. It often offers a larger variety of services, including dental care. In recent years, the other types of supplementary medical plans have tended to become more homogeneous in terms of their service offer, contract options, and forms of payment to providers.

Group medical practice companies offer prepaid plans in which the services differ according to the contract made. The services may be provided through a network of facilities and professionals belonging to the company; free choice of provider followed by reimbursement; or through various combinations of the two. Premiums are paid monthly and prorated by age. In 1996, there were 700 companies, with 17.3 million people enrolled. Their revenues were approximately US $3.7 billion.

Medical cooperatives are organized by professionals to render services based on prepaid arrangements. They work in a way similar to the group medical companies, although they restrict the use of services to their own professionals. On the other hand, they usually offer a larger number of providers. In 1996, there were 320 enterprises, with 10 million people enrolled. Their revenues were approximately US $3.5 billion.

Health insurance companies function rather differently in Brazil than in some other countries, because they incorporate both the functions of reimbursement and service delivery. Although they are based on a free-choice system, most of them offer a network of services and professionals, which makes similar to the previous systems. Their growth in recent years is due to the enrolment of large enterprises, which in the past bought services from the previous two models. Even more recently, traditional financial institutions have assumed part of this market through association with firms providing smaller insurance plans. In 1996, there were 40 such companies, with 6 million people enrolled. Their revenues were about US $3 billion.

Self-managed plans allow employers to offer employees and their families access to health services through differentiated assistance plans. They use two models: either they enroll providers, creating their own network of services, or they contract the services from another firm, which acts as a intermediary responsible for the management of services. This method is increasing and has stimulated the growth of the so-called "representation" companies, acting as intermediaries between payers and providers.

Organization and provision

Health facilities

This section will describe the general characteristics of the whole health care system. The data are presented according to the type and ownership of the health units, public or private, and not according to their financing or management. Thus, private sector here refers to the ownership of the unit, whether the public or the private sector finances the service. This distinction is important because privately owned units provide the majority of services financed by the Sistema Único de Saúde (SUS, unified health system).

In 1990, Brazil had 35 701 health facilities, including basic units, health centres, polyclinics, emergency clinics, and hospitals (Table 11).
 

Table 11. Health facilities - Brazil, 1990.
Classes	Public			Private			Total
	n	%	%(a)	n	%	%(a)	n	%	%(a)
Basic units	6 038	25.0	98.0	131	1.0	2.0	6 169	17.0	100
Health centres	14 129	59.0	98.5	189	2.2	1.5	14 318	40.0	100
Polyclinics	2 126	11.0	25.5	6 170	52.0	74.5	8 296	23.0	100
Emergencies	188	0.7	65.5	98	0.8	34.5	286	0.8	100
Hospitals	1377	6.0	21.0	5 155	43.5	79.0	6 532	18.0	100
Total	23 858 (67%)	100.0		11 843 (33%)	100.0		35 701 (100%)	100.0	100
Source: Fundação IBGE (1976, 1992) (a) Roll %

The public sector comprises the largest network of primary health care providers, especially in the poorest regions. On the other hand, most of the secondary and tertiary health institutions (polyclinics and hospitals) are private, and are located in the most affluent and populated regions. In some of these areas, the predominance of private hospitals is very high. For example, in the state of Sao Paulo, 82% of the hospitals belong to the private sector. Public hospitals, particularly those that offer tertiary care are, however, better equipped and possess the most advanced technology.

This distinction between the public and private sectors is more evident when we consider hybrid institutions such as health centres, which provide both primary and secondary care. This kind of establishment fulfills the need for services in rather simple units with a few beds to provide general care, minor surgery, and gynecological and emergency services. In Brazil, such health centres are predominantly public and concentrated in the poorest regions. Emergency units, too, occur primarily in the public sector.

The private sector owns the majority of small- and medium-sized health facilities, but it is particularly involved in hospital ownership. Recently, however, it seems that the private sector is following the international trend toward reducing the number of large general hospitals in favour of small, specialized units.

Beds

During the period under study, two main changes occurred concerning beds. The number of beds increased in absolute terms while the number of public beds decreased, indicating a trend toward the growing predominance of the private sector in inpatient care. In 1976, public beds made up 26.8% of the total, but in 1992, they made up only 24.8% (Table 12).
 

Table 12. Beds in hospitals by subsector - Brazil.
	1976		1992		Change 1976-92
	n	%	n	%	%
Public	119 062	26.82	135 080	24.81	13.5
Private	324 826	73.18	409 277	75.19	25.98
Brazil	443 888	100.00	544 357	100.00	22.63
Source: Fundação IBGE (1976, 1992).

The other important change was the growth in the number of public beds at the municipal level. The municipalities were, in fact, responsible for the growth in the number of public beds during the period, Indeed, the number of municipal public beds increased by 238%, while the number of federal public beds decreased by 14.9%, and the number of state public beds by 6.6% (Table 13). Many of the federal and state facilities were transferred to municipalities, but the latter also invested in new units and renovated others.
 

Table 13. Public beds in hospitals per government level - Brazil.
	1976		1992		Change 1976-92
	n	%	n	%	%
Federal	27 982	23.5	24 072	17.82	-14.9
State	80 476	67.6	75 147	55.63	-6.6
Municipal	10 604	8.9	35 861	26.55	238.0
Total	119 062	100.0	135 080	100.00	13.5
Source: Fundação IBGE (1976, 1992).

The two changes are both consequences of the reform process. On the one hand, the reform process stimulated the privatization of health services and, on the other, strengthened the role of local government in providing health services. However, only the latter was actually outlined in the reform proposals, through the principle of decentralization.

Hospitalization

Paradoxically, the decrease in the number of public beds was accompanied by an increase in the number of public hospitalizations. The percentage of hospitalizations in public units increased from 15.6% of the total in 1976 to 23.3% in 1992, for a relative growth of 49.3% (Table 14), while the participation of private units in the number of hospitalizations decreased from 84.4% to 76.7%, or by 9.1%.
 

Table 14. Hospitalizations by subsector - Brazil.
	1976		1992		Change 1976-92
	n	%	n	%	%
Public	1 872 440	15.58	4 622 480	23.27	146.9
Private	10 149 509	84.42	15 241 961	76.73	50.2
Total	12 021 949	100.00	19 864 441	100.00	65.2
Source: Fundação IBGE (1976, 1992).

Actually, the increase in public hospitalizations was only apparent, caused by the new form of payment within the Sistema Único de Saúde (SUS, unified health system). After 1990, all services delivered by public and private providers began to be paid under the same system. This led to a change in reporting because the public units, which had previously been financed through budgets, now had to itemize services rendered in order to get paid. As well, many private providers stopped serving SUS because it reduced the prices it paid for services.

Office visits

The public sector has always been responsible for most of the office visits in the country. However, in the period under study, its relative weight also decreased when compared to the private sector. In 1976, 61.7% of office visits were provided through public units, whereas in 1992 the percentage was 59.7% (Table 15).
 

Table 15. Distribution (%) of office visits - Brazil.
	1976	1992	Change 1976-92
Public	61.66	59.75	-3.1
Private	38.33	40.24	5.0
Source: Fundação IBGE (1976, 1992).

Human resources

The ratio of doctors per 1 000 inhabitants in Brazil was 1.46 in the period from 1988 to 1992 (World Bank 1993). The doctors were very unevenly distributed among regions and between urban and rural areas, with a clear concentration in the cities. Recent research shows the ratio of doctors per 1 000 inhabitants in rural areas as 0.53, whereas in urban areas it reached 3.28 (CFM/FIOCRUZ 1996).

The ratio of registered nurses-to-doctors, was 0.1 during the same period (1988-1992), lower than the average in Latin American countries (World Bank 1993). The human resource structure still retains some biases inherited from the 1960s and 1970s, when the demand for physicians grew quickly and the system responded by increasing their numbers. When considering practical nurses, the difference is also high: in 1992, there were still nearly twice as many doctors as non-registered nurses - 171 561 doctors to 95 027 nurses (Table 16) - a minor increase over the growth in the number of doctors.
 

Table 16. Human resourcesa - Brazil.
	1976		1992		% Change 1976-92
	Public	Private	Public	Private	Public	Private
Physicians	54 201	62 259	65 205	106 356	20.3	79.8
Nurses	30 833	40 200	46 785	48 242	51.7	20.0
Source: Fundação IBGE (1976, 1992). aNumbers of jobs.

The private sector continues to employ an increasingly higher proportion of doctors than the public sector. During the period under study, the number of doctors employed in both sectors grew by 47.3%. However, the number of doctors in the public grew by 20.3% while the number of doctors in the private sector grew by 79.8%.

Evidence of the growing importance of supplementary medical care within the private sector is that at least 75% of the doctors were totally dependent on the services provided to these companies (CFM/FIOCRUZ 1996).

Transformations in the Health Care System

Health care reform in Brazil has succeeded in changing the health system’s organization. According to the categories used by the Organisation for Economic Co-operation and Development (OECD 1992), the health care system that prevailed from the 1970s to the 1980s was composed of three subsystems: a public contracting subsystem, the predominant one of the period; a public integrated subsystem, which was secondary; and a voluntary contracting subsystem, which was marginal.

The present system comprises a public contracting subsystem, resulting from the fusion of the two former public subsystems into a single new one; and a voluntary contracting subsystem, with a more important role to play in the provision of services.

Although a new system is emerging, it has not yet taken on a definite shape because the process of reform is not yet over. There are many ongoing changes that can only be expressed by comparing the dynamics of the subsystems before and after the reform.

To best present these dynamics, the subsystems will be described in terms of the relationships between payers and providers, between patients and providers, and finally between the population and the payers.

Organization of the health care system - 1970s to 1980s

During this period, three systems existed: a public contracting subsystem; a public integrated subsystem; and a voluntary contracting subsystem.

The public contracting subsystem was funded by compulsory salary-based contributions from employers and employees. Entitlement was restricted to people who paid contributions and their families. Services were provided through public facilities owned by social security and through other public or private providers with direct contracts from the payer. Payment for services was varied according to the type of provider and type of service rendered.

The public integrated subsystem was financed through general taxation. Providers were paid through prospective budgeting and salaries.

Although they were supposed to function under a single system, until the reform these two subsystems were totally independent from one another. They differed in terms of financing, payment of providers, range of services delivered, and entitlement (Figure 1).

Figure 1. Brazilian health system in the 1970s.

The Ministry of Social Security and Social Assistance was the central institution in the public contracting subsystem. Its main agency, the Instituto Nacional de Assistência Médica da Previdência Social (INAMPS, national institute of medical care and social security), was established in 1977 and responsible for contracting and providing individual health care throughout the country.

The Ministry of Health was the central institution in the public integrated subsystem, in charge of public health and providing services related to prevention and chronic diseases.

The third subsystem was the voluntary contracting subsystem. It was limited to some large public and private enterprises that provided services to employees and their families, directly or through contracts with medical care providers. Employers, employees, and social security participated in financing the system. In exchange for not having to provide services to these beneficiaries, social security transferred a fixed amount per insured person to the enterprise through INAMPS. There were few enterprises with this type of agreement with social security (122 in 1977) and the agreements were suspended in 1979. Although fairly insignificant in the voluntary contracting subsystem, this form of contract was the model for the group medical companies that have become the main type of provider within the present voluntary contracting subsystem.

Relationship between payers and providers

In the public contracting subsystem, there was only one financing entity: the social security agency, Instituto Nacional de Assistência Médica da Previdência Social (INAMPS, national institute of medical care and social security). The type of provider determined the form of payment, and regulation was restricted to the services established under contract. For the network of hospital and primary health centres owned by social security, the means of payment was an annual global budget, established by the central government according to historic expenditures. The professionals were paid salaries.

Private hospitals were the main providers. Their services were contracted directly by INAMPS to provide services to social security beneficiaries. Payments were preset on a fee-for service basis. Fee-for-service financing stimulated the use of services and poor management by INAMPS made it vulnerable to fraud. Contracts were not clear about objectives and results, there was almost no supervision, and no limits were set on providing services. To be reimbursed for complementary services or equipment that a provider had to buy from another provider, such as a prostheses for example, the provider needed only to present a receipt. The prices for the same product could vary by as much as 600% between regions (Cordeiro 1991).

Prices for services were defined by INAMPS, but the negotiations included participation by representatives of providers. The relationships between the association of private hospitals Federação Brasileira de Hospitais (FBH, Brazilian federation of hospitals) and INAMPS provides an example of the special relationship between the bureaucracy and private interests that existed during the dictatorial period and was known in Brazilian sociology as “bureaucratic rings” (Cardoso 1977). The significance of the sums paid by INAMPS to the contracted providers can be seen in the fact that 90% of the services delivered in the country were directly or indirectly related to that agency. Moreover, between 1969 and 1975, 90% of agency expenses were allocated to pay for services provided under contract.

During the social security crisis of the 1980s, limits were set on payments for services, in spite of strong resistance by doctors and private institutions. Private sector profits fell considerably. The constant devaluation in the price of services carried out during this decade was the main reason the private sector lost interest in providing services to social security. However, this process only became significant in the second half of the decade.

INAMPS also contracted for services provided by states and municipalities to their own civil servants; by professional associations to their members; and by public universities and nonprofit institutions for social security beneficiaries. These contracts were actually agreements between INAMPS and the providers. For states and municipalities, payments were based on global transfers and for nonprofit institutions and associations on fixed incentives.

The universities, although public, were governed by the Ministry of Education and paid on the basis of hospital admissions. The agreements with the universities had been important as a political instrument in the question of favoring private or public providers; however, their capacity to provide complex and specialized services was abused because they ended up taking on the patients with expensive-to-treat conditions who were refused by the private sector.

Nevertheless, these providers (states and municipalities, professional associations, public universities, and nonprofit institutions)had a minor share within the system compared to the for-profit private sector. Only the rural syndicates turned out to be of significance, once rural workers were included as beneficiaries of social security.

Finally, another type of contract was established directly between INAMPS and the doctors - specifically the general practitioners, pediatricians, gynecologists, and obstetricians - in a given region. They worked in their own private clinics and were paid under fee-for-service agreements.

Various changes were carried out within the public contracting subsystem throughout the 1970s and particularly after the fiscal crisis in social security. Changes in the payments to providers, in the people insured by social security, and in the providers enrolled altered the proportions of the different providers in the total expenditures of INAMPS.

For example, in 1981, prior to the introduction of restructuring measures, the roles of providers and forms of payment were as described earlier. In that year, INAMPS’ health expenditures were as follows: 61.4% to for-profit private hospitals; 20.5% to social security’s own services; 2.5% to universities; 5.7% to other central government agencies; 3.7% to nonprofit private institutions; 3.4% to businesses; and 2.85% to associations. This distribution shows the importance of the private sector in the provision of health services in the country.

Under the public integrated system, the provision of services was very restricted because of the low priority assigned to health care activities affecting major portions of the population and to preventive health. Payments by salaries and global budgets, as well as the tidy and bureaucratic structure of the Ministry of Health, also contributed to restricting the relationship between payer and providers to the bureaucratic hierarchy within the Ministry of Health.

The voluntary contracting subsystem had, as its main providers, medical groups contracted by businesses to provide services to their employees. For the medical groups, services were prepaid on a per capita basis; for hospitals, on a per diem rate for inpatient care and on a fee-for-service basis for outpatient care. This subsystem was quite small until the second half of the last decade.

Relationship between patients and providers

The contributions required by social security for insurance and guaranteed access to health care divided the population into the insured and the uninsured, each receiving different levels in terms of type of services and quality of care.

Until 1966, social security services were restricted to the members of specific professional categories, and people with the highest incomes received the best services. Many of these differences were maintained, even after the unification of the former Institutos de Aposentadorias e Pensões (IAPs, retirement and pension institutes) into a single institution, based primarily on the political influence of certain professions or occupational categories.

The process carried out during the 1970s that extended coverage to new groups of people did not end the differences. On the contrary, it deepened them. As the extension of coverage was not accompanied by a change in the system’s funding, nor a change in the structure for providing service, a good part of it remained restricted to the people who were originally insured. This segmented provision structure provided better quality service to the top sectors of the workforce - public servants and the military - and poorer quality service to the recently insured - rural, domestic, and self-employed workers. The rest of the population continued to depend on the scarce public services of the Ministry of Health or on charitable institutions.

In 1974, coverage for emergency care was extended to the whole population. The demand increased, not only in terms of volume but also in terms of range, as people quickly learned to turn every situation into an emergency. This new demand was covered mainly by private providers. The lack of control associated with the fee-for-service mode of payment encouraged a curative, hospital-centered approach to care, resulting in the misuse or “over-medicalization” of services, particularly on the part of the uneducated, and especially low-income, groups.

The crisis in the 1980s and the deep cutbacks in expenditures meant that the quality of health care deteriorated. With the devaluation of the fees for services, private providers became selective with regard to the types of patients and mix of cases that they would take on, with a view to maximizing their profits. Although all providers were supposed to care for the newly insured, private providers began to send these patients to publicly owned services, which had not been properly restructured. Successive strikes by doctors and health professionals in the public sector during this decade strained their relationship with the population. Better quality health care became an issue for social change during this period.

Indeed, never before had health issues been as important to Brazilians as they were in the 1980s. However, demands were not directed mainly at providers. Because of the centralized, obscure relationship between the principal payer, the Instituto Nacional de Assistência Médica da Previdência Social (INAMPS, national institute of medical care and social security), and the providers, the public did not make a distinction between them, and directed its demands for change toward the government.

Relationship between population and payers

During this period, the right to health care became the main preoccupation of the population, because of the strong affiliation between payers and providers under both the public contracting and the public integrated subsystems.

Better-organized groups distrusted the measures adopted during the 1980s to combat the social security crisis, which aggravated previous restrictions on services. However, the deterioration in the quality of services prompted these groups to support the proposals for reform, including the introduction of a universal system. Nonetheless, this support was followed by a search for agreements with businesses to get extra insurance from the voluntary contracted subsystem.

Organization of the health care system in the 1990s

At present, the health care system is composed of a public contracting subsystem - the result of the fusion of the two former public subsystems - and a voluntary contracting subsystem with different characteristics from the previous one.

The public contracting subsystem corresponds to Sistema Único de Saúde (SUS, unified health system) and the voluntary contracting subsystem corresponds to the supplementary medicine system as described in the first part of this chapter.

Within the public contracting subsystem, three main changes took place. First, there was the introduction of universal coverage. Second, the public institutions were integrated into SUS, ending the institutional dichotomy of the previous system. Third, changes were introduced to the financing and management of services.

The voluntary contracting subsystem increased and diversified, assuming an important role in the provision of services. New forms of contracts emerged, influencing the organization of the medical system.

The perpetuation of two subsystems with different principles and different conditions of access has not yet solved the problem of health care inequities, nor does it seem to have improved health conditions as whole. However, the mechanisms under which the reform process was carried out, especially decentralization, have contributed to improving the system.

The general configuration of this new system is shown in Figure 2.

Figure 2. Brazilian health system in the 1990s.

Relationship between payers and providers

Within the public contracting subsystem, the three levels of government are both payers and providers. The financing is still predominantly federal, although participation by states and municipalities has increased.

Transfers from the federal government to the states and municipalities are based on Normas Operacional Básicas (NOBs, basic operational norms) established by the Ministry of Health, mostly in 1993 and 1996. These principles include mechanisms to decentralize financing, which were vague both in the Constitution and in the Health Organization Law. This was due to resistance on the part of the health bureaucracy, dominated by the Instituto Nacional de Assistência Médica da Previdência Social (INAMPS, national institute of medical care and social security) up until 1993. There was also strong resistance on the part of private providers, who did not want to lose their privileged relationship with the INAMPS bureaucracy, and from the municipalities, who were afraid of taking on new responsibilities.

The legal rules published in 1993 and 1996 were to be based on the principle that transfers should be oriented by technical and epidemiological criteria, as well as the needs of the population. However, these mechanisms have not yet been totally implemented, because of difficulties in overcoming the legacy of the previous system. Thus, most transfers are still based on the volume of services rendered, even though two important changes have been introduced. First, there are now limits to expenditures and, second, direct transfer to municipalities specific allocations for primary care activities have been introduced.

There are two basic mechanisms for transferring resources. The first method is through direct, automatic transfer of resources to states and municipalities for primary and ambulatory care and based on population criteria. This type of transfer, although based on the 1996 Normas Operacional Básicas (NOBs, basic operational norms) of the Sistema Único de Saúde (SUS, unified health system) (Ministério da Saúde, 1996),was only authorized by the central government in December 1997. It prescribes the transfer of a fixed amount of 10 Brazilian reals (BR $1.00 = US $1.15 in 1997) per year for each inhabitant of the municipality. Special incentives for municipalities that establish basic primary health programs, such as family doctors, are also prescribed.

The second method consists of transfers for services provided, that is direct transfers to the providers, public or private, for services relating to hospital stays, highly complex procedures, and ambulatory services, especially office visits. Payment for hospital stays and highly complex procedures are based on the Autorização de Internação Hospitalar (AIH, hospital stay authorization), a system similar to the diagnostic-related groups (DRGs) in the United States. The procedures are based on the United Nation’s International Disease Classification. Fixed values are established according to the diagnosis and required procedures. Hospitals where highly complex procedures are carried out are paid extra to maintain their structures. Payment for ambulatory services is based on Unidades de Cobertura Ambulatorial (UCAs, ambulatory care units), as well as a fixed amount for each service.

There is an important difference between the two mechanisms for transferring resources. In the first, the municipality gets the total amount to develop basic activities. The second is less a transfer and more a payment for services. Provision is totally dependent on this latter mechanism, which means that an important part of the services rendered is still based on fee-for-service payments, but with limits. On the other hand, what is important is that the same method of payment to public and private providers has been adopted, requiring the same minimum efficiency from both.

The flow of resources is based on the stage of management autonomy attained by the state and municipality involved, as prescribed in the 1993, and more recently in the 1996, basic operational norms. The stage of management autonomy indicates the degree to which the state or municipality is capable of taking over management of health services provision from the federal government. The final objective of SUS is the total autonomy of municipalities in the provision of services. As described in the first section, the basic operational norms of 1993 considered three different management situations, which were actually consecutive stages in achieving autonomy and responsibility.

1. The Incipient Management Stage, whereby the municipality formed a Municipal Health Council and a Municipal Health Fund that separated health resources from other public resources. Federal resources, transferred through the states, were deposited in part in this fund, with the amount depending on the contracts, public or private, already signed by the municipality. The municipality also participated in setting the limits for inpatient and ambulatory care payments.
2. The Partial Management Stage, in which the municipality participates in the financing and was able to receive the difference between the limits on inpatient and outpatient services and what had actually been spent.
3. The Semi-complete Management Stage, whereby the municipality takes on complete responsibility for providing public and preventive health activities, as well as individual health services through public and private providers. Such a municipality received the full amount of resources up to the specified limit.

Since the basic operational norm of 1996 was approved, only two management situations remain: Complete Management of Basic Care and Complete Management of the Municipal Health System. For either of them, the municipalities must fulfill the requirements of the former Incipient Management Situation. The main difference now is in the ability to receive federal resources for the full system or only for basic care. It is impressive the number of municipalities that have qualified for the Complete Management of Basic Care (3 700 between December 1997 and May 1988, or 67% of all municipalities). The prescribed resources doubtlessly represent a lot for most of them. Meanwhile, 412 municipalities have qualified for Complete Management of the Municipal Health System, or 7% of the total.

In municipalities that have not reached either of these management situations, the resources are controlled by the state, which has the responsibility to bring them up to the level of the first management situation.

The relationship between payers and providers has changed with the introduction of the inter-management commissions, which are responsible for setting the amounts of resources for states and municipalities and for establishing their management situation. Financing has become much more transparent, because all levels of government participate in the commissions and because the commissions have strengthened technical support. The representatives of the different governments, in turn, have to account to the health councils, which are legally responsible for health policy, at the executive level.

Although there are huge differences between the states and municipalities, these inter-management commissions have formed a health-management network that has profoundly changed the former pattern of negotiations in the public health system. However, within the whole public contracting subsystem, innovations are restricted to the distribution of existing resources, as none of the inter-management commissions, nor the Ministry of Health, has any say in the amount of resources designated for the sector. This is decided by the Federal Government, specifically, the Ministry of the Treasury. This is why one of the main demands of National Health Council is the establishment of a fixed amount to be transferred to the health sector.

The relationship between government, acting as payer, and private providers has also improved. With the cutbacks in funding and the reduction in service prices, the private providers that continue to maintain contracts with SUS are those that did not succeed in modernizing sufficiently to be able to leave the public sector for the voluntary market. They have, however, lost their political power within the sector. In general, they have adapted to the new role of municipalities, have adhered to the innovations in management and regulation, such as accounting to Health Councils, and have even been partners in the demand for resources. The situation of the nonprofit institutions is similar.

However, the general situation of the private providers contracted to SUS is very bad. The quality of services and the salaries are known as the worst in the public contracting system, and private organizations are still the principal providers of services to SUS.

Some management innovations are introducing new forms of financing for services. Although recent, they will affect the organization of provision and thus the relationship between payers and providers. One innovation is the signing of contracts with third parties to provide services. The government (state or municipality) contracts with a cooperative of professionals to be responsible for care in a certain unit, paid on a per-capita basis by size of the local population. The largest experience to date has been in the city of São Paulo.

Although there has been no conclusive study on these cooperatives, which are different from those in the voluntary contracting subsystem, they have been criticized for their tendency to transfer more expensive patients to other, particularly public, units. Moreover, although they have been contracted as cooperatives of professionals, in fact, many of them are actually a group of professionals that sign the contract but subcontract the work to other professionals. These subcontracted professionals are not members of the cooperative, but rather employees hired for low wages, with no legal right to a share of the profits. This results in little commitment to the service, high employee turnover, and the possibility of professional incompetence. There has been very poor supervision of the cooperatives by the local health secretariats.

The payment of professionals within the public contracting subsystem differs depending on whether the establishment is publicly or privately owned. Public servants were paid a salary and excluded from special contracts under the former system. In some states and municipalities, production incentives were introduced but have not been well evaluated. Although their objective was to improve efficiency and avoid resignations by professionals because of the low salaries, the effect has been a decline in the quality of service because of increased volume.

In the public contracting subsystem, there are still some health units that, for political reasons, maintain different relationships and contracts with SUS. First, some highly specialized public hospitals are financed directly by the Ministry of Health and are managed autonomously, with no interference by the state or municipality. This system is referred to by the term “co-management.” Although few in number, these hospitals have considerable resources, and supplementthe salaries of their professionals.

Some states and municipalities have been reluctant to integrate with SUS and continue to try to restrict their services to their previous clientele, the civil service and the army. They will, however, care for SUS patients in an emergency. Many of them also have huge financial problems, despite the fact that they are partly financed by the institutions to which they pertain.

Within the voluntary contracting subsystem, financing comes mainly from businesses and families, although expenses are deductible from income tax, which gives them an important indirect contribution through general taxation. Contributions by employees are generally lower than payments for individual insurance. Some businesses offer different plans, and the prices may be higher.

Payments to providers are based on fees for service, according to the fees established by the Associação Médica Brasileira (AMB, Brazilian medical association), one of the associations that represents physicians. The adoption of these fees has been one of the major demands of the corporation since 1987. At present, many companies follow the AMB list of fees, but the larger ones, with many professionals enrolled, generally pay lower fees and take longer to pay.

All companies maintain a fixed number of doctors on salary. They usually have their own units, although this is more common in group-type practices that operate like the health maintenance organizations (HMOs) in the United States.

Health insurance companies have recently begun offering their own services as well, and most of them operate through prepaid plans. The insurance companies are also tending to associate with intermediary agencies that negotiate prices and services with the final providers - clinics, professionals, and doctors. Another recent trend is their association with banks, forming a triangle with health insurance companies and intermediary agencies.

With these associations, companies are able to obtain contracts with large businesses as well as to be competitive in marketing individual plans. This strategy was necessary because buying insurance has never been customary among Brazilian people, and health insurance is the most expensive form of insurance there is.

On the other hand, the medical groups have begun offering the possibility of reimbursement, which is common for insurance companies, and important in attracting upper-income clientele, that does not want to be restricted to the list of services offered.

Relationship between patients and providers

Within the public contracting subsystem, the main conflicts continue to be over access to and quality of health services. The Constitution of 1988 extended health care to a large segment of the population not previously covered, but did not follow up with investments in the health services delivery structure. Although some state and municipal governments have invested considerably in health, the situation country-wide is precarious.

Although the notion of health as a right of citizenship has been accepted, people remain passive about the poor quality of the services. Perhaps the difficulties in gaining access to services have blinded people to the poor quality of services. The fact that people complain about access, but not about service quality, means that these two aspects are still viewed separately.

On the other hand, the innovations in terms of decentralization seem to have already had an effect on services that is felt by the population. A recent public opinion survey rated municipalities under the Semi-complete Management Stage higher than others in terms of improvements in health services. Public health services were more frequently identified as a problem in municipalities that had yet to reach any stage of management autonomy. (Instituto Gallup 1996).

Nevertheless, although well received by the population, the decentralization process may have medium- or long-term effects that are already evident in some places. These are related to differences in investments between localities. There are cases where neighboring cities have huge differences in health care provision, sometimes simply because one government is improving services and the other is not. People are attracted by the better services, and because access is universal, the locality begins to feel the increased demand and begins to create mechanisms to make access more difficult. These problems are the responsibility of the states; however, initiatives to resolve them are still hard come by.

Another important issue is the need to provide more basic health units, especially in poor and suburban areas, and to strengthen the existing ones, which are generally open for only a few hours a day and never at night. Professionals, particularly doctors, are notorious for not putting in the full period they are paid for. As a result, people go directly to the emergency departments of public hospitals, where the wait is long but service is guaranteed. Thus, simple problems compete with genuine emergencies for attention.

Within the voluntary contracting subsystem, the relationship between patients and providers has also been contentious, mainly when the services are contracted directly by families and individuals. The lack of regulation has obliged users to complain to the consumer protection service, and health companies are among the services with the most complaints against them.

The complaints are mainly that the companies do not abide by the contracts. They exclude people with certain diseases and elderly people without warning. They deny care, limit the number of hospital stays, charge extra payments, and raise prices. Most companies do not cover preexisting diseases, acquired immune deficiency syndrome (AIDS), cancer, or many complex procedures. It is common practice for these companies to send expensive patients to public hospitals, usually on the referral of doctors who work in both services.

Another issue being discussed within both subsystems, but for different reasons, is the adoption of gate-keeping procedures. In the voluntary contracting subsystem, the main objective is to control the use of services. The associations that represent the companies have already suggested requiring people to enter the system through general practitioners.

In the public contracting subsystem, use is not excessive because access to services is difficult. Gate-keeping mechanisms could decrease the demand on hospitals but, as has been noted, would require a better infrastructure of basic services. Financial initiatives have recently been offered to municipalities to provide incentives for basic care. It will also be necessary to stimulate the training of general practitioners, which has not been a priority in the universities for a long time.

Relationship between population and payers

Difficulties with public services have prompted people to contract with private companies that feature low prices and few guarantees. Our study identified about 100 different health plans in the city of Rio de Janeiro, many of them limited to a single clinic. In suburban areas of large cities, where the poorest population lives, there are clinics that have revived an old practice and offer a “health plan” that covers only office visits, for an amount of, for example BR $10. These small private services are taking advantage of the breakdown in public services, by adopting the strategies of large private companies.

However, the voluntary contracting subsystem is also diversifying and searching for strategies to deal with the low-income, majority of the population. There are, at present, many different health plans, with different lists of services and prices.

Considerable changes are also occurring in the public enterprises that, in the 1980s, began to offer private health plans to their employees as a substitute for self-managed plans. These enterprises have increased employees’ financial contributions and, in many cases, introduced co-payments. For a long time, the employees of these enterprises and their dependants had access to the best private providers, and the enterprises provided most of the financing. Plans included mental health and dental care, services that are not offered in regular private plans, except under separate contract, and for which public services are extremely precarious. Employees had free choice of all services with reimbursement based on prices higher than those available from private companies, and had no limits on their use of services. The withdrawal of these special privileges has been followed by an offer of private plans to the majority of public enterprises and offices.

Within the public contracting subsystem, social participationhas been strengthened. However, it remains restricted to issues internal to the health sector, mainly management and supervision, even though it is known that many problems, such as low levels of financing, originate outside the health sector in government policies. In contrast to the 1980s, it seems that civil society of the 1990s does not relate problems in the health sector to overall government strategy. In fact, the last two governments have themselves been the main critics of the health system, identifying the problems as inefficiency and improper use of resources.

Considering the popularity of these governments, only interrupted by the impeachment of the previous elected president, and the day-to-day experience of the population with health services, at least it raises doubts about who is responsible. These governments have proposed restructuring the Sistema Único de Saúde (SUS, unified health system) and the universal right to health care; however, the few and timid comments in this direction have not found support and have been criticized even by members of the government itself. This may be why the many groups within SUS that are identified with the principles of the reform continue to protect the system from the strategies being applied by the central government in other areas, mainly privatization. There is an impasse at this point. Even if the government wanted to, it does not have the power to change the framework of SUS. The defenders of SUS, in turn, do not have enough power to improve it.

The impasse will probably be solved within the ongoing process of decentralization, as state and local governments, particularly the latter, begin to flourish as effective intermediaries between the population and the main payer of health - the central government.

Conclusion

Up to now, the reform has succeeded in changing important characteristics of the system that prevailed from the 1970s to the 1980s, but not the segmentation of access to health care, which may be even more complex now.

In the 1970s and 1980s, there were two types of segmentation. One type determined who had the right to be in the system and who had not, because coverage depended on contributing to social security which was only made possible through an official contract of employment. Another kind of segmentation occurred among those who were insured, because there were differences among the lists of services and their quality, according to the positions acquired by the various categories of insured groups.

At present, it may be said that the first distinction no longer exists; the whole population is under the Sistema Único de Saúde (SUS, unified health system). However, the segmentation remains, with more dimensions and with larger distances between the groups.

First, there is segmentation by income. With the breakdown of the public system, anyone who can afford to signs a contract with a voluntary private service. Segmentation occurs within the private system, as the offerings differ enormously from one company to another. Segmentation occurs based on hierarchical position in the formal labour market. Thus, in the same company or sector of the economy, for example, there are different levels of private coverage. Segmentation also occurs in public services, according to the services offered to the population by a given government.

Curiously, none of these services guarantees quality. On the contrary, it may be found in any of them. The exceptions, where quality really is guaranteed, are some private hospitals, some public hospitals owned by states and municipalities, and most of the public hospitals owned by the federal government.

The segmentation results in a number of different combinations of coverage being associated with SUS. Even the groups at the top maintain links with the public system because it is in the public hospitals that the most advanced technology is found and the best professionals are concentrated. Access is guaranteed through doctors, who usually charge for services in their offices, but not for those in the hospital.

This practice, however, is not limited to groups in better positions. Health services reproduce a historical characteristic of Brazilian culture: access to benefits through personal relationships. Thus, for example, it may be as useful to a home-maker to have a neighbour who is a nurse or even a cleaner in an important public hospital, as it is for a senator to have a private doctor who is also the director of that hospital. Gender may make a difference. In the first case, the relationships are mainly established by women, and in the second by men. This may be explained by the fact that in the upper groups personal relationships are established within the public sphere, which is dominated by men, whereas, within in the lower groups, relationships are established in the private sphere, which is dominated by women. But by whatever means the relationships are established, they serve as ways for people to gain access to the hospital’s benefits.

It thus seems that Brazilians continue to need more than guarantees by the state or private contracts. Either they do not believe in them, or they have more faith in personal relationships. In any case, they still seem to be insecure about what will happen when they need health care.

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