Tuesday, August 2, 2011

Some thoughts on the healthcare system in Brazil


I have been repeatedly impressed with the “universal healthcare” system here in Brazil. That being said, coming from the US and our/their “get insurance or get screwed” system, it may not take much to impress me. Things here are not a bed of roses, for sure, but there are some important plusses and minuses.

On the plus side is the language in the Brazilian constitution that says (essentially):

Article 6. Education, health, work, leisure, security, social security, protection of motherhood and childhood, and assistance to the destitute, are social rights, as set forth by this Constitution.

Article 196. Health is a right of all and a duty of the State and shall be guaranteed by means of social and economic policies aimed at reducing the risk of illness and other hazards and at the universal and equal access to actions and services for its promotion, protection and recovery.

In short - healthcare is a citizen's right and it is the duty of the government to provide it.

The healthcare matrix here in Brazil is a complicated mix of public and private providers. Only about 25% of Brazilians have private health insurance, the rest access public clinics and hospitals (which vary wildly in terms of quality and efficiency depending mostly on whether they are in urban or rural areas). More than half of registered nurses and nearly half of doctors are public employees.

The stated principles of the Unified Health System (Sistema Único de Saúde or SUS) are universality, integral care, health promotion, and community participation, with public funds to provide free health care to all Brazilian citizens.

That’s the good news. And for many, many Brazilians it has been very good news. According to this summary article, over the past three decades infant mortality decreased by about 6.3% a year, and life expectancy increased by 10.6 years. Mortality due to infectious disease decreased from 23% of total deaths in 1970 to less than 4% in 2007.

But then there is the bad news. Well, let’s remember that nothing is perfect.

There is a wide gulf in service and efficiency between those with private health insurance, accessing private hospitals, and those going to public facilities. This is certainly not always the case, but in many poorer areas (urban or rural), the conditions at the “hospital” can be alarming.

But I think what I’ve found more disturbing in my reading on this subject is that there is an insidious dynamic at play within the university education system that is broadening the gap between public and private healthcare. No surprise, really, but it’s a bummer to see it studied and articulated.

Capitalism. There it is again, f*cking things up. Early on I saw the irony of the public university system here. It’s free, but only the privileged can access it (with notable exceptions, of course). Competition to get in is fierce and students take expensive preparatory classes to score their best on the entrance exam. No money, no prep course – no high score, no free university. The poor and working class pay to attend private universities.

But that’s not the real problem. The problem seems to be the ethos among the privileged class that financial reward and status are the end goal and working in the public sector is viewed essentially as a lower-paid job with little status. So many educated professionals are self-selecting out of the national healthcare system in favor of the more profitable private system. Many people will tell you that there is a shortage of healthcare providers in the public system.

So we have the ever-corrosive dynamic of private enterprise and personal desire for wealth working against the common good. Nothing too strange about that – but it would be a shame if it erased the benefits gained to date seen with the public healthcare system here in Brazil. I would prefer to see the momentum moving in the other direction.

So tell me – if you can afford it, would you choose to buy private health insurance here in Brazil? Why or why not? While it is cheap by USA standards, it still costs a lot. Is it worth it when you have universal coverage provided by the government? Is it necessary, or just a convenience?

[To view Brazil’s constitution in English, go here. It’s a good read.]

20 comments:

Ray and Gil said...

Jim,

I can speak for my experience in Sao Paulo. I am not familiar with other parts of Brazil.
My parents and my grandmother decided to rely on the Public Health care system in the mid 90's and they stopped paying for their private Health Insurance at the time.
They were disapointed with the Public system for a while, mainly because they had to wait 3 or 4 months to see a certain doctor and they couldn't choose the doctor they wanted and if my mother stayed in the Hospital, she couldn't have a private room, and for her, that was important, so my father could stay with her.
So, mostly for a convenience, they decided again to go back and purchase private health insurance again. So when my mother needs to stay at the Hospital, she can stay at a private apartament, and receive visits at any time. Private rooms are more relax with visitation hours and such, also she could choose the doctors she wanted and she could go to get lab exams and x-rays at small private clinics closer to home.
Long story short, they decided to go back to private Health Care for conveniences and faster service.
Having said that, in recent years, there has been a HUGE improvement in the PUBLIC health care system in Sao Paulo.
My parents and my granmother who is now in her late 80's are receiving regular doctor visits at HOME, a doctor and a nurse comes to visit them once every 3 months and check to make sure their health is ok.
Despite the fact that they do pay for Private Health Insurance, they are receiving EXCELLENT home care, with nurse and doctors visits.
Just today my mother told me the "state" doctor is sending a "nutricionist" to review my grandmother's eating habits because they think she is loosing too much weight.
The Public Doctor requested 3 complex exams and my father took my grandmother to the Private Clinic, just because they could have all 3 expensive complex exams done in one week opposed to 1 to 2 monts wait at the state facilities.
They are also now receiving medication for chronic health care issues for R$1,00 per month and also my grandmother just started using diapers and the state is supplying those for free. My parents were spending a small fortune buying diapers and appreciated the news they were going to have regular diaper deliveries at home for FREE.
This is excellent if you ask me. It looks like it's just getting better everyday.
But they still use their private health care insurance for the conveniences.


Ray

Rachel said...

I have used both public and private heathcare here in Brazil. We luckily get our private care paid for by my husband's job. Get this, they pay for the entire family!

All and all, it comes down to ease. I don't have to wait 8 hrs to try to see a doctor, arriving at 6am (or maybe even 5am). Although I do hear the public system works fabulously in small cities.

The doctors usually work for both. My kids' pediatrician works at a public hospital half the time and his practice the other half.

Of course there is the growing group of doctors who are only private ie. pay in cash. I fully blame the expats for this one. They like the big pretty offices and the English speaking doctor in Brazil. And yes, hard to blame one group but it was not nearly as profitable before the city was inundated with expats. There were few doctors who went 100% payment only.

Now my pediatric urologist is following suit since his partner is forcing him into a corner. I called a bit of bullshit on that one but one sassy American client is not going to make a difference.

Danielle said...

To be fair to the Brazilian doctors (that's my job, since I'm married to one), the real problem is not that they "want wealth" (don't we all?) -- it's that the money allotted to the public system ends up in politican's pockets instead of in the system itself. So doctors working in the public sector get paid pennies, have horrible working conditions, and have difficult and uneducated patients. So they are obviously going to avoid it if they have an opportunity to work in the private sector. For example, an OBGYN in the public system has a ridiculous schedule, and gets paid only 200 reais for a natural birth, no matter how long it takes or what complications arise. The public system does not offer c-sections unless in an emergency (a completely different debate). So in the private hospitals, an OBGYN works with the other OBGYNs in the dept to make fair schedules, and they get paid around 1200 reais (10 times as much) to deliver a baby, also with better working conditions and supplies, and the majority of their patients want c-sections. What would you choose? The public health system has the funding available, but the rampant corruption is to blame for its problems, not the doctors who have no incentive to work for it.

Corinne said...

I have always had private insurance here in Brazil. Mostly for convience but also because we had some mixed experiences with the public health system (they misdiagnosed my mother's broken wrist at Miguel Couto, for example). Also, even though BH had a great center for MS patients, it got frustrating retelling her entire disease history (30+ years) to a new intern each month. My employer (the federal government) does not pay for my health insurance, but they do give me a large subsidy to purchase it that covers about 70%. Also, my experience has been that doctors work in both systems. You can always go see a doctor and pay "particular", but it is too expensive, especially when so many doctors accept most types of insurance.

Jim said...

Ray - that's pretty much been our experience too. The public system (Luiz's cancer care) has been excellent, but time consuming. And there have been many social services brought to our attention via the social workers at INCA. But we still buy insurance to avoid painful waits, should it ever be necessary.

Rachel - I was told by a doctor student of mine that anesthesiologists, as a professional group, have moved to the pay me in cash system because they refuse to cooperate with insurance companies that pay so little for their services (although I never got a real bill from the guy who put me under for my recent surgery.

Danielle - I appreciate your loyalties, and I partly agree with you. But the things I read would suggest that the medical school 'system' i.e. the curriculm, training, etc. focuses more on individualistic care and specialization. The values of community health and collective care are not emphasized front and center. I'm suggesting that this contributes to the self selecting out of the public system by many medical professionals.

Jim said...

Also - can anyone clarify: are health insurance premiums tax deductable? How about prescriptions? I heard somewhere something about this. What do you know?

The Reader said...

We have private health insurance, provided by The Chemist's employer (well, I'm sure we pay something, but it's deducted from the paycheck and was not an optional thing...).

I'd say it rates in the convenience category and not the necessity category.

Certain things are not covered by the private health insurance anyway, at least not the plan we have. And, doctors in the private sector choose to accept or not accept the insurances offered, so you still run into that.

We've recently sampled the public system (on accident) and found the medical care on par with what we get in the private sector. I don't know if we just lucked out, because it was a teaching hospital (thus all the med students have to cycle through there), or if that's the norm for our metro area.

But so far, where we live, private has just been a convenience. And even at that, we've had to pay for things that weren't covered; maybe if we'd searched out the public sector for some of that we could have saved money. I don't know.

In a more rural area, I'd probably opt for private, but with access to a large, public, teaching hospital I think we could get by without it here.

The Reader said...

Forgot my favorite thing (and after reading Rachel's, maybe our insurance *is* paid for....) -- The Chemist's employer contracts with a doctor who comes out to their facility and he sees patients there. So, the employees don't have to take off work to be seen by the doctor, he sets up times there at their offices.

What's great is that he will consult on minor issues for the whole family. Kid has a cold, what's the best drug for it? He'll write a prescription for us. Wife has an ear infection? Call me in the middle of the night if it happens again (he chewed us out once because I talked a drug store into giving me antibiotics rather than call the doctor, at home on a Friday night of a holiday weekend).

He's private sector, but I love love love that The Chemist can discuss minor issues with him, for the whole family, and he'll either make a referral for us if it's something big or he'll write a script for whichever med. We have his home number, cell number, and office number. And he insists we use them.

Love that.

Hate -HATE- the "cash only" docs. We have those here, too, and yep, totally an ex-pat thing. -sigh- I opt for Portuguese rather than uber inflated prices.

Jim said...

Reader - the amazing services can be mind boggling. As US Americans we are not used to health services being user friendly.

GingerV said...

Jim, I love this discussion. the original post is excellent and all the comments useful and informative.
We fall in the middle of this issue. I have an international health insurance policy for catastrophe (15K deductible) even that is now getting to be too expensive. Coming in at 4500 USD last year (that is an annual cost.) so I may be stopping it. In all other issues I pay cash. We go to a Unimed doctor but pay cash. It has not been expensive. My last dermatology exam - have had some skin cancers and have semi-annual checkups for that - was R$75.00 and I was in with him for at least 40 minutes. He doesn't though do a complete body check or keep notes like I am used to from a US doctor - If I tell him a have a bothersome spot he carefully checks it out.... but he really should be looking for trouble before I notice it.
Camillo on the other had has not been sick, in the 8 years here he has gone for complete exams twice - it is about R$1500.00 to get all the labs and ex-rays required. Because we do not have real health issues we have not had real experience with the system. I did take my grandson to an ENT doc in Ipanema once and it was $R350.00 to find out he had sand in his ears and we were sent to a homeopathic outlet for drops. that where about $R10.00. big discrepancy.
Lucia our maid has been on a waiting list for surgery for a knee injury in February - she has gone from 75th to about 30th since she got onto the list....torn ACL with pain is considered non emergency so you are place between the emergencies - I guess those would be broken bones.
thanks for initiating the discussion. Did you see my Facebook entry with the definition / explanation of democracy?

Ray and Gil said...

Jim,

I have been away from Brazil for almost 15 years, so please double check this info. But if I remember well, medical, dental and medicine expenses are tax deductable.
The reason most Brazilian doctors like to keep a "foot" in the door with keeping a job at the Public Health care system is because the PUBLIC RETIMENT BENEFITS ARE GREAT.
My parents know a very good geriatric specialist who went CASH ONLY, he charges R$380,00 per office visit, and R$480,00 for home visits.
We only took grandma to see him once.


Ray

Ray and Gil said...

Oops, Retirement...

Corinne said...

Jim,

Yes, what you pay in health insurance is deductible as is physical therapy. To get it you need to file the long form with itemized deductions instead of the simple form. Your insurance company should send you a form around tax time telling you the amount spent that year. If not most have a way to access the info on their website (I know Unimed does, which has a practical monopoly on health insurance here in BH). You can also deduct nursing home expenses in some cases and I believe medicine too. The Receita Federal website is pretty helpful and the on-line form for tax filing explains a lot.

--jenna said...

We get health insurance through my husband's job, and we've seen friends purchase private insurance as well. My friend who just recently got health insurance couldn't be happier-for R$140 a month, she has access to doctors, exams, etc. that she would have spent all day waiting in line for in the public system. We'll never see equality between public and private systems; after all, if it was equal, why would anyone PAY for private care? However, I think Brazil has the best healthcare combo of any country I've seen (barring a few notable exceptions like teeny tiny European countries).

--jenna said...

Oh, and I should point out, the insurance companies pay ludicrously small sums for doctor's visits and procedures, which may explain why many doctors are going cash-only or accepting few plans. The physical therapist was only going to get paid R$8 per session to work on my husband's recently operated shoulder! Both my doctors are off plan, but I do get reimbursed for most of it and what isn't covered after the fact can be deducted off income taxes. FYI.

--jenna said...

Goodness, I keep forgetting things. As RayandGil said, some doctors keep a foot in the public system. So if you know you want a doctor, but don't want to pay, find out what public hospital they're associated with...and you can probably get in to see them for free!

Mallory said...

hmmm like you said it depends on where you are. I have UNIMED because of the company my husband works for. this being said hell yes i go to the private doctors but mainly because the private hospital i can go to is 10x nicer than the public one--which isnt bad, but it does look 60 years outdated. the private hospital also has a completely separate birthing center which i think is nice. also, im an athlete and find myself relying on a PT at least two or three times a year, having private insurance allows me to do that, to go straight to the specialists and get the one on one appointments i need, which is how we are used to in the us right? so in this city i really benefit from having private insurance. but still compared to the US its not as nice--UNIMED treats you like a criminal here and make you go to the insurance office to have expensive procedures approved before you can do them. that is ridiculous. i had an MRI on my knee and they made me jump through so many hoops even though it was requested by my doctor. nothing is perfect in brazil, but im not sure how much sports PT i would be able to do (if any?) using the public health system.

SN said...

Our insurance is considered private even though we are on an international plan. Anywhere we go in the world we are 100% covered including homeopathic therapies, acupuncture and massage. The only problem is having to pay upfront in cash.

Here in Brazil we have run into the problem of having very expensive doctors. Throughout my pregnancy I pay 400R per visit with my OB and the consult with my pedi cost 500R.... I am nervous to see the end bill from the hospital. God forbid my child ever get sick.

Sara

Jim said...

Mallory - I get it. The quality of the experience at private hospitals and clinical facilities is often much better than public institutions.

When we go to the public hospital to pick up my MIL's breast cancer meds (free) I am reminded of the long waits people endure.

Sara - wierd - you seem to have the worst of both worlds in terms of cost (although I understand you are reimbursed). But you have choice of providers - that's huge.

Let us know when you have your sweet new baby girl...

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