A response on Brazil's health care system

Maureen Lewis and Andre Medici of the World Bank respond to "Brazil's Public Option," a Foreign Policy Web piece by Eduardo J. Gómez from Sept. 2. 

The article "Brazil's Public Option" from Foreign Policy's Web site captures some of the highlights of the country's public health-care system. But it contains some errors and omits some of its most important lessons.  

First, like the rest of Latin America, Brazil is committed to free, universal health care. The government revamped the health-care system when it wrote a new constitution in 1988, at the demise of two decades of military dictatorship. Before 1988, the health-care system was based on two centralized arrangements: a social security-based system tied to formal sector employment, and a public system for everyone else. The Single Unified System (SUS) brought federal financing and provision into a single entity, and decentralized facilities and funding (through transfers) to over 5,500 municipalities. It is hardly comparable to the current movement in the United States to effectively adjust the system and make it more fair.  

The problems of public systems (waiting lists, political interference, and deteriorating and outdated infrastructure) are not unique to Brazil. What is different is the adaptability and creativity that has emerged. It is not lack of federal oversight of municipalities that has proved problematic, but the lack of management and capacity, a problem never addressed. As a result the states have taken the lead in revamping and improving the health-care system. State experimentation to deal with the rigidities and poor incentives of public health care include innovative contract mechanisms that have upgraded quality and reduced costs through management contracts that include removal for nonperformance; public sector reforms that rely on performance contracts with line departments; and radically new delivery models in violence-prone slums where normal health-care delivery is no longer viable.

It should also be pointed out that Brazil's large and vibrant private insurance sector isn't new. Even in the 1990s a quarter of Brazil's population purchased private health insurance.

What is missing from the article are the innovations and creativity brought to bear at the state and local level (mostly with federal funds) to improve efficiency and effectiveness, an evolving evaluation culture in service delivery that has spurred prevention and outreach (something lacking in the United States), and the willingness to adapt a public system to new circumstances. These are possibly the best lessons for the United States.