Access to and financing of health care in Brazil


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access to and financing of health care in brazil 2010 1 access to and financing of health care in brazil s Ão pau lo au gust 2010 editionsspecialsvo lu meihea lt h


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2 supervision antônio britto presidente-executivo generalcoordin at i o n octávio nunes gerente de comunicação institucional missieli rostichelli assistente de comunicação institucional tel 55 11 5180-2395 communic at ionliaison burson-marsteller selma hirai tel 55 11 3040-2403 burson-marsteller tel 55 11 5180-2305 interfarma editorial project nebraska composição gráfica tel 55 11 5505-7043 edition iolanda nascimento ­ mtb 20.322 revision verônica rita zanatta ­ mtb 31.538 printing formag s gráfica e editora ltda run 63.000 exemplares photos banco de dados interfarma aboutinter fa rmaa interfarma ­ associação da indústria farmacêutica de pesquisa ­ é a entidade que congrega as indústrias farmacêuticas instaladas no brasil responsáveis por promover e incentivar a pesquisa e o desenvolvimento de novos medicamentos fundada em 1990 a interfarma reúne 36 laboratórios que representam 57 do mercado brasileiro de medicamentos.


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access to and financing of health care in brazil 2010 3 health is not everything but without it the rest is nothing schopenhauer


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access to and financing of health care in brazil 2010 5 introduction the constitution of 1988 was a milestone in our country s recent history the rights of brazilian citizens were duly guaranteed through the mobilization of society represented by legislators imbued with civic and democratic spirit with regard to health article 196 stipulates that this is a right for all and an obligation of the government in this important year of presidential elections the issue of public health has become one of the main concerns for the candidates interfarma believes this is a timely moment to strengthen the rational dialogue concerning the health issue in brazil looking towards the future where not only the candidates but also the authorities politicians entrepreneurs sector leaders scholars researchers and service providers can each give their contribution by promoting the seminar paths for financing and accessing health care in june 2010 in são paulo in partnership with valor econômico interfarma understood the initiative as being part of its contribution further amplified now through this publication the publication access to and financing of health in brazil will be sent to all of the candidates for president of the republic state governors and national congress for interfarma construction of an open dialogue with society concerning public health in the country should always be above political and partisan divergences and interests and it hopes that the big winner of these elections will be the health party eloi bosio chairman of the board antônio britto ceo


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6 the constitution of 1988 universality integrality and equality in access to health care creation of the single health system sus in 1988 represented one of the most significant advances in the process towards construction of brazilian citizenship in a climate of relief after the country s redemocratization with the idealism of constructing a new modern and more just society legislation bearing a brand of renewal received multi-partisan support in the national constituent assembly it was with this renewed spirit that the federal constitution of 1988 guaranteed every brazilian citizen the universal integral and equal right of access to health care however more than 20 years after enacting the constitution the model drawn up by the legislators is still far from attending to all as determined by law making matters worse during this same period brazil s population grew nearly 40 million practically an argentina increasing to more than 190 million people the constitution was appropriate but the legislators forgot that all this needs financing and the government needs money for all this observes the president of hospital israelita albert einstein claudio luiz lottenberg our system has been suffering from a chronic problem of underfinancing that can compromise what is most precious in it which is its universal nature says the secretary of science technology and strategic inputs of the ministry of health reinaldo guimarães according to the secretary in the representatives original proposal the health system should receive one-third of total revenues destined to social security which in 2010 would be equal to a budget of nearly r 130 billion for the ministry of health more than double the projected budget says guimarães per capita spending even with the increase in government investment especially over recent years when considering public and private funds the per capita spending on health care in brazil is below the global average the analysis of the medication sector in brazil 2004-2007 published by interfarma ­ brazilian research-based pharmaceutical manufacturers association and based on world health organization who and datasus data shows that health care spending per brazilian inhabitant was us 715 in 2007 whereas the global average was us 857 in argentina it exceeded us 1.2 thousand per capita and in the united states which leads the ranking it was almost us 7.3 thousand in countries with a similar health care model to brazil health care spending are almost fourfold greater as in the case of spain us 2.6 thousand per capita or almost sevenfold as in canada us 4.9 thousand see figure 1 economist maria cristina sanches amorim head professor of the department of economics and the graduate studies program in business administration at pontifícia universidade católica of são paulo puc one of the authors of the interfarma study says that this scenario does not change much when compared to 2010 since a notable growth in these numbers would depend on an expressive increase in income and greater public investment which did not occur low government investment resulted in the growth of the private health care market the population yearns for a health plan because people know there is a long wait for care at the single health system sus even when we are speaking of an emergency says josé cechin executive superintendent of the institute of supplementary health studies thus the population of private health plan users has grown in the country today there are nearly 42 million people which represent 21 of the population in those countries where a universal public health system prevails this percentage is much lower around 10 this adherence to health plans in brazil demonstrates that health needs are not being met says cechin.


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access to and financing of health care in brazil 2010 7 figure 1 in 2007 health care spending in brazil was comparatively low compared to the 15 countries researched and to the global average for total per capita spending on health care smaller slice the ministry of health s budget for 2009 did not reach 1985 s says cardiologist and former minister of health adib jatene if we look at the portion of security set aside for the health sector in 1995 we had 22 of the total budget in 1998 we had 18 in 2009 we had 14 it s clear the resources are decreasing says jatene pointing out that over this period the population grew has been aging more and the incorporation of technology has no precedents if we had 35 of the total security budget like the representatives wanted we would not be discussing the lack of funds for health today ensures the former minister a more current portrait of this scenario with a specific eye on federal government spending shows that in 2008 the health budget was r 54.1 billion and in 2009 it was r 59.8 billion for 2010 the bill sent to congress set the budget at r 62.5 billion an increase of 4.5 over 2009 this sum left the health sector in third in terms of distribution of social security revenues which includes spending for guaranteeing citizen rights to health social security and welfare social security got more than half 55.6 of the r 456.7 billion total and health only 13.7 management problems the interfarma study points out failures in the system which needs to be reformed to gain efficiency according to the survey the system is inoperant does not know how to properly invest funds and spends poorly there are countless examples of waste for example paying for services provided visits and procedures it s like running a campaign to get rid of dengue fever and paying per dead mosquito for example there would certainly be many people raising mosquitoes says economist maria cristina amorim observing that data from the national health confederation cns indicate the occupancy rate for hospital beds today is 38 while hundreds of people are waiting in the corridors for source who who/whosis and datasus/sãops


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8 an opening in hospitals that is an example of process failure federal deputy and former secretary of health of rio grande do sul osmar terra joins the numbers who believe resources must be well invested at every public level when i was secretary of health in rio grande do sul i could not explain to the population why spending on admissions in the public system were six times higher than in the best private hospital in porto alegre there must be rationalization and that is a great challenge he says according to the secretary of science technology and strategic inputs of the ministry of health reinaldo guimarães management failures are not an exclusive problem of that ministry and result from the rigid and obsolete rules that govern personnel policy in the brazilian public sector even more substantial revenue from the social contributions created by the constitution of 1988 remaining intact and under full federal control the social contributions constitute a privileged source of revenue when compared to other taxes the reasons 1 they correspond to more than half the federal tax revenue 2 they are not subject to the principle of annuality federal constitution art 150 iii b and can be collected ninety days after their creation or alteration federal constitution art.195 § 6 3 since they are destined for a social cause they are better accepted by society than tax burden increases without any specific destination 4 since they have a more encompassing collection they tend to grow more than other taxes health never had its own exclusive and stable funds adjusted to its needs in the mid-1970s more than 68 of available tax revenues belonged to the union states and municipalities received 23.3 and 8.6 respectively the constitution of 1988 reversed that centralization establishing a new tax division that favored the states and municipalities especially the latter to the detriment of the union in 1993 at the end of the gradual execution of this decentralization process the percentages were 57.8 union 26.4 states and 15.8 municipalities thus while relative participation of the union fell ten percentage points states and municipalities saw an increase in available funds of around 13.3 and 83.7 respectively however union losses were limited to the scope of income tax and the tax on industrialized products which comprise the state participation fund fpe and the municipality participation fund fpm with the as or one explanation for the greater relative growth of the gross tax burden compared to social welfare and security transfers and subsidies taps is the increase social contribution revenues cofins cpmf csll etc had compared to spending on welfare and security this increase in revenue led to the implementation of a mechanism for unbinding the budget created in 1994 soon after implementation of the real initially by the social emergency fund fse and later the unbinding of union revenue dru the dru stipulated that 20 of revenues collected with those contributions are free and thus should not be obligatorily allocated to the areas of social security social welfare and health the justification for implementing the dru was a excess budget rigidity derived from free revenues equivalent to just 15 of the budget which limited the possibility of the government to schedule new public policies b avoid spending with an excess of funds tied to them while others have shortages of funds c permit financing of irreducible spending with additional union indebtedness and most especially d make it possible to obtain primary surpluses to meet fiscal goals in the budget guidelines law ­ ldo.


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access to and financing of health care in brazil 2010 9 figure 2 total gross tax burden components and main taxes [1995-2008 in of gdp year total gross tax burden taxes on products cofins others other taxes tied to production education salary contribution contribution to sesi sesc senai and senac s system taxes on income property and capital income taxes ir provisional contribution on financial transactions cpmf social contribution on corporate net profit social security contributions contributions to official social security institutes fgts and pis/pasep social security contributions from civil servants others 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 26.5 11.6 1.9 9.6 1.2 0.3 0.3 6.1 3.6 0.7 0.8 7.6 7.3 0.4 1.2 27.4 11.4 1.8 9.7 1.3 0.2 0.3 6.8 4.2 0.8 0.7 7.9 7.6 0.4 1.4 28.4 12.6 2.9 9.7 1.1 0.2 0.2 6.7 4.3 0.7 0.6 8.0 7.6 0.4 1.4 30.4 13.7 3.3 10.5 1.0 0.2 0.2 7.6 4.1 1.2 0.7 8.0 7.1 0.9 1.7 31.9 14.3 3.5 10.9 1.2 0.2 0.2 8.1 4.5 1.3 0.7 8.3 7.3 1.0 1.8 32.4 13.9 3.5 10.5 1.2 0.2 0.2 9.0 5.1 1.4 0.8 8.3 7.2 1.1 2.0 31.9 13.5 3.4 10.2 1.3 0.2 0.2 8.8 4.9 1.4 0.9 8.3 7.3 1.0 2.0 32.8 14.2 4.0 10.3 1.3 0.2 0.2 8.7 4.7 1.4 1.0 8.6 7.5 1.1 2.1 33.8 14.3 4.0 10.3 1.3 0.3 0.2 9.6 5.3 1.4 1.2 8.7 7.7 1.0 2.1 34.1 14.2 3.8 10.4 1.3 0.3 0.2 9.5 5.2 1.3 1.1 9.2 7.9 1.3 2.2 34.7 14.1 3.8 10.3 1.4 0.3 0.3 9.8 5.4 1.4 1.3 9.4 7.8 1.6 2.2 35.2 15.0 3.9 11.1 1.5 0.3 0.3 9.1 5.8 0.0 1.4 9.6 8.1 1.5 1.2 source márcio bruno ribeiro an analysis of gross tax burden and social welfare and security transfers in brazil from 1995 to 2009 evolution composition and its relations to regressiveness and income distribution ipea text for discussion 1464 jan 2010 according to estimates presented by the national association of fiscal auditors of brazil s federal internal revenue service anfip 2009 the dru diverted more than r 145 billion of social security budget revenues to other purposes between 2005 and 2008 since the text of the constitution of 1988 did not ensure a specific binding of resources to health destination of finances was left up to the oscillations in the economy only in the transitory constitutional dispositions act ­ adct was it determined in article 55 that until the budget guidelines law is approved a minimum of thirty percent of the social security budget excluding unemployment insurance shall be destined to the health sector the budget guidelines laws of 1990 to 1993 reproduced what was stipulated in article 55 of the adct but the annual budget laws did not comply with what was stipulated in the respective ldo culminating in health s financial crisis of 1992 a crisis that was only abated after a loan from the workers support fund fat in 1993 and 1994 the imperative need for complementary funds for health to overcome the crisis led to the creation of the provisional contribution on financial transactions cpmf in the beginning article 18 of law no 9.311 of october 1996 stipulated that the totality of collections would be exclusively destined to the national health fund but after 1999 with constitutional amendment 21 the cpmf began to destine part of its resources to social security


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10 and the eradication of poverty thus the destination of the provisional contribution on financial transactions cpmf was gradually diverted from its original intention removal of the cpmf in 2008 caused an immediate reduction of approximately r 16 billion which had to be covered by budget free revenues figure 3 for illustration purposes in 2008 the ministry of health received r 54.1 billion only half of what it would have received if 30 of the social security budget had been applied as stipulated in article 55 of the transitory constitutional disposition act adct and the budget guidelines law of 1990 tax burden hampers access say specialists according to a survey by the national health confederation cns the federal state and municipal governments collected r 30.4 billion in taxes from the health sector in 2009 compared to r 27.5 billion in 2008 compared to 2003 when the sector contributed with r 14.3 billion there was a real increase of 57.19 and a no figure 3 execuction of the ministry of health by source cpmf and other sources 1995 to 2008 updated by the average ipca of 2008 source financing and public spending on health history and tendencies 1995 to 2008 ­ ipea 2009 authors luciana mendes santos servo andréa barreto de paiva sérgio francisco piola and josé aparecido ribeiro.


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access to and financing of health care in brazil 2010 11 hope in amendment 29 statistics indicate that the country s option for the public health model did not correspond to prioritizing union state and municipality spending in 2000 congress approved constitutional amendment ec 29 which increased minimum spending on health for the union a 5 increase was defined over the sum spent in 1999 and for 2001 to 2004 a readjustment was stipulated in accordance with the variation in gross domestic product gdp in the case of states the amendment established a minimum percentage of 12 of tax collections and 15 for municipalities however the readjustment defined was not complied with because the amendment has yet to be enacted more than a dozen states infringe the determination and that can all be discussed because ec 29 has yet to be regulated says sérgio francisco piola coordinator of the health area at the directorate of social studies of the institute of applied economic research ipea piola says if all the states complied with ec 29 the brazilian health system would have received at least r 2 billion per year since 2003 the ipea coordinator figures that just the regulation of projects that propose more federal resources for health would have increased the ministry of health s budget by r 7.5 billion in 2009 to more than r 65 billion and that doesn t move the gross domestic product gdp one point says piola affirming that investment in the brazilian health system is around 3.5 of gdp whereas others with similar integral and universal systems invest closer to an average of 6.5 just a regulation is not going to bring more resources for health above all else it is necessary to increase public spending on health equivalent to the gdp he says senator flavio arns psdb closely accompanies the allocation of resources and is one of those in government who advocates complying with the constitution unfortunately the government does not want to discuss the health budget which is absolutely insufficient if the required minimum were applied there would already be an impact on people s everyday lives says the senator one of the main arguments for not complying with the law is the absence of a public health actions and services concept as well as the different criteria for accounting for revenues that should be tied to health there are always attempts at inserting spending in the health item that are not directly related such as sanitation explains economist raul velloso specialized in public policies there are many states and municipalities entering a series of actions in the health account from water treatment to food for the prison system because they allege they are beneficial for health for example treated water avoids disease and the well-nourished prisoner and all this with the indulgence of many audit courts says public health physician gonzalo vecina neto business superintendent of the hospital sírio-libanês and former president of the national health surveillance agency anvisa despite the difficulty in applying the projected minimum since 2002 there is a proposal in congress to increase investments in health the text explains the concepts and revenues that should be considered for investing in health and also stipulates that the union should invest a minimum of 10 of the sum collected from taxes in the sector users of the single health system sus are mobilizing to approve the project we are fighting for the federal government to invest the 10 which will mean a r 12 billion increase for the area says attorney sérgio metzger director of institutional relations for the juvenile diabetes association adj


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12 minal increase of 112.73 at the federal level collections totaled r 7.6 billion in 2003 doubling to r 15.7 billion in 2008 and reaching r 17.4 billion in 2009 the ceo of interfarma antônio britto observes that in the case of medications the tax burden in brazil is higher than for taxes on diamonds or veterinary products for example this is curious because it makes the government s purchases of these medications more expensive he says britto adds the most perverse data is that the government collects practically the same sum from taxes on medications as it spends on purchasing them it is a reasonably simple sum to make the brazilian market is around r 35 billion and when the tax load is applied to this sum which is always difficult because the country s tax system is very complex we find a sum of at least r 5 billion in taxes imbedded almost the same amount as is destined for purchasing medications by the ministry of health on average the tax load on medications in the country reaches nearly 34 whereas in most of the world it is under a single digit however former minister of health adib jatene points out that if the tax load were reduced there would be even less for investing in health since only 10 of the federal government s total budget is destined to the area plus education infrastructure programs and funding income concentration index better than only nine countries four from the americas haiti bolivia honduras and colombia and five from africa botswana namibia comorros angola and south africa although there has been a recent reduction in inequity this improvement in unequal distribution of income in brazil mainly results from social income transfer policies without questioning the undeniable merit of these transfers to mitigate the immediate impact of poverty this perpetuates the fiscal illusion of the least favored classes who believe they pay few if any taxes this illusion results from the high and complex indirect tax load that makes the true onus of taxes little transparent in the products consumed by the population¹ marcelo liebhardt director of economics at interfarma says because of the indirect tax load the group of families earning up to two minimum wages is burdened with almost twice the gross tax load if compared to families earning more than 30 minimum wages see figure 4 the social welfare and security transfers and subsidies taps reached 15.4 for a gross tax load ctb of 34.7 of gdp in 2007 according to figure 5 brazil has a gross tax load and taps very similar to those in portugal and poland the surprising difference is due to the very high net interest bill paid by brazil the interest payment corresponds to more than 30 of the net tax load for a net public sector debt of almost 43 the gross domestic product brazil paid 6.2 of the gdp in interest this percentage represents 138 more than the average net interest paid in the euro zone and 229 more than the average paid by organization for economic cooperation and development oecd countries for an equal net debt level.² if on one hand the economic areas of governments tend to argue that a net tax load interest of 13.1 does not leave much room to maneuver for allocating supplementary resources for health due to the range of other public 1 in england as in other developed countries the net effect of taxation is neutral as pointed out by glennerster 2006 p 25 indirect taxes have had a growing part to play in counteracting the equalizing effect of direct taxation since they fall most heavily on the poor the redistribution role is up to social policies the welfare state in brazil s case as will be seen besides the distribution gains from social policies ­ or better from government monetary transfers ­ being much more modest they are neutralized by the regressive taxation result as mentioned this result is mainly due to the composition of the taxation in terms of direct and indirect taxes and not because they are progressive or regressive silveira fernando gaiger tributação previdência e assistência sociais impactos distributivos ­ phd thesis unicamp campinas sp [s.n 2008 p 125 2 according to silveira it is worth underscoring that public debt and its financing are the main causes for increasing the tax load where it can be affirmed it is a regressive income transfer mechanism and thus reinforces our standards of inequity silveira fernando gaiger tributação previdência e assistência sociais impactos distributivos ­ phd thesis unicamp campinas sp [s.n 2008 p 125 inequity poor distribution of income and the tax system hamper access to health care for the most needy brazil has made some progress but it still maintains a high concentration of income when compared to other economies especially the most developed ones in the united nations human development report of 2009 out of a list of 182 countries brazil presented an


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access to and financing of health care in brazil 2010 13 figure 4 brazil ­ distribution of the gross tax load as per minimum wage bracket monthly income family up to 2 mw 2 to 3 3 to 5 5 to 6 6 to 8 8 to 10 10 to 15 15 to 20 20 to 30 more than 20 mw ctb as per cfp/dimac gross tax load 2004 48.8 38.0 33.9 32.0 31.7 31.7 30.5 28.4 28.7 26.3 32.8 gross tax load 2008 53.9 41.9 37.4 35.3 35.0 35.0 33.7 31.3 31.7 29.0 36.2 days needed to pay taxes 197 153 137 129 128 128 123 115 116 106 132 policies that need to be implemented the potential of additional resources that can be released is also clear improving for example the administration and cost of public debt international comparison brazil falls short of expectations in health care for its population an analysis of the global health statistics published in 2009 by the world health organization who with data from 2006 involving 193 countries permits some sources tax load by income bracket 2004 zockun et alli 2007 gross tax load 2004 and 2008 cpf/dimac/ipea tax load by income bracket 2008 2008 and days needed to pay taxes own elaboration figure 5 gross ctb and net clt tax load social welfare and security transfers and subsidies taps and net interest payment in brazil and selected countries in 2007 países germany brazil canada south korea spain united states france greece hungary ireland italy japan norway new zealand poland portugal united kingdom sweden ctb 39.2 34.7 33.1 26.8 32.7 28.4 42.3 31.6 39.9 30.8 42.5 28.1 42.0 36.5 34.1 36.5 36.5 46.8 taps 18.1 15.4 10.9 3.6 13.4 12.6 18.9 18.5 16.9 10.3 18.6 12.1 13.5 10.5 14.9 16.8 13.8 16.5 ctl ctb-tabs 21.1 19.3 23.2 23.2 19.3 15.8 23.4 13.1 23.0 20.5 23.9 16.6 28.5 26.0 19.3 19.7 22.7 30.3 juros liquidos 2.4 6.2 0.7 -1.5 1.2 2.1 2.5 0.1 5.0 -4.6 4.5 0.7 -13.3 -0.9 1.6 2.9 1.8 2.6 ctl juros 18.7 13.1 22.5 24.7 18.1 13.7 20.9 13.0 23.5 25.1 19.4 15.9 41.8 26.9 17.7 16.8 20.9 27.7 source ipea ­ net tax load and actual public spending capacity in brazil communiqué from the office of the president no 23 brasília july 2009.


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14 rather significant observations to contextualize each society s commitment to its population s health in most health spending indicators brazil only occupies intermediate positions in share of total health spending in gdp brazil is ranked 57th whereas in public spending on health in the gdp 3.6 it is only ranked 89th the unfortunately negative highlight is that brazil is ranked 151st in share of government spending on health in relation to total government spending 7.2 thus private spending on health in relation to total spending on health is high in that item the country is ranked 28th data confirm the criticism by specialists both public and private that public spending on health is still insufficient in brazil total spending on health is about 7.5 of gross domestic product gdp but the share of public spending is only 3.6 of gdp which creates a disproportionate onus for the needy population due to the unequal concentration of income and regressive tax load greater government participation an analysis of national health systems reveals an interesting fact the government is increasingly occupying more space as a service provider or as market regulator or service financer the recent american experience is a good example according to a document from the institute of supplementary health studies iess until 1965 health care was the responsibility of the american citizen who contracted the service directly in the private sector in 1965 the government began to guarantee access to health care for the elderly and poor paying the service providers directly in the 1970s a public fund was instituted to subsidize part of the private plans for those unable to pay however the high costs forced the government to reform the system in 1990 health spending was us 713 billion and rose to us 2.3 trillion in 2008 committing 16 of gdp and now it has become obligatory to contract health insurance and the government will subsidize contracting private plans so people s income is not compromised by this cost increasing health costs are a global phenomenon spain saw its spending on health grow fivefold from 1960 to 2006 the country which in 1960 spent the least on health 1.5 of gdp saw it rise to 8.1 in 2006 in canada the health system is structured on five axes universality integrality accessibility public management and transferability ­ federal funds are transferred to province governments which handle the care to the population about 70 of canada s health system financing is guaranteed by public funds from fiscal revenues the provinces and territories prioritize on average more than 30 of their budgets o finance health services in france copayment a system where the government subsidizes part of the cost is made according to the therapeutic classes and pathologies discounts reach 100 for serious disease medications 65 for the most consumed medications and 35 for the rest in portugal the medications included in the copayment program are divided into levels those classified as a have discounts of 100 and represent those indispensable for patient survival or those used in treating chronic disease level b includes international models in an international comparison brazil s total spending on health 7.5 of gdp is below the world average 9.7 of gdp but the fact that calls most attention is the low public share in total spending public spending on financing health 48 of the total equals 3.6 of gdp which is not compatible with a health system that intends to be universal and have full care in these conditions private funding is needed to complement the remaining 52 of total spending that is 3.9 of gdp with the population s own resources given the unequal income distribution and regressive tax burden the smaller participation by the government strongly penalizes the least favored classes paradoxically and considering the scale of income the relative participations of public and private spending is similar to those seen in the united states a country considered a paradigm for private health care.


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access to and financing of health care in brazil 2010 15 figure 6 in 2007 total spending on health in brazil were comparatively low in relation to other countries in terms of percentage of gdp source who 2009 essential medications used for treating serious diseases or that are for prolonged use with discounts of 70 those classified as level c have discounts of 40 average of 60 in public spending and 40 in private spending some studies indicate that this greater investment could have higher returns than those estimated for developed countries considering that after a certain level marginal returns for spending per capita in health can become descending thus countries with lower spending and worse health indicators can expect more additional benefits for each additional monetary unit of spending on health than countries that spend a lot and have better indicators.³ brazil is still far from reaching a stage where it can argue the existence of a sufficient level of spending the existence of adequate infrastructure or a satisfactory performance of its health system insufficient public resources join insufficient spending on health which is recognized by analysts both in and outside the single health system but although it is necessary to persistently and permanently try to increase efficiency this does not presuppose accepting the argument that generally pops up in the dispute for budget resources that health must always do more with the already available resources the simultaneousness of the problem cannot be disregarded that it is necessary to spend more at least initially for example invest in the qualification of managers at all three levels create procedures improve health information systems and their interoperability correct related price distor3 marinho a cardoso s de almeida v brasiland oecd evaluation of efficiency in health systems ipea rio de janeiro january 2009 pg 46-48 brazil needs greater commitment from the government with public spending on health despite recent improvements our country s health indicators are still bad when compared for example with organization for economic cooperation and development oecd countries and even some countries in latin america such as argentina chile and costa rica with a still very low per capita spending level around us 630 per annum no doubt there is still plenty of room for more investments in the brazilian health system in order to reach the international average for health spending 9.7 additional public investments of 2.2 of gross domestic product would be necessary this increase would also permit reaching the international



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