As Brazilian President Jair Bolsonaro visits New Delhi this Republic Day, one interesting field of cooperation to explore in the strategic partnership is healthcare. Achieving universal health coverage is a very complex task, especially for developing countries. Here, the example of Brazil, the only country where more than 100 million inhabitants have a universal health system, is worth studying. It can also provide lessons for Ayushman Bharat, currently the world’s largest and most ambitious government health programme.
Following the end of military rule, the Brazilian society decided to achieve universal coverage by establishing a government-funded system. The Unified Health System (SUS), which guaranteed free health coverage that included pharmaceutical services, was written into the new Constitution in 1988.
Progress over 30 years
In the last 30 years, Brazilians have experienced a drastic increase in health coverage as well as outcomes: life expectancy has increased from 64 years to almost 76 years, while Infant Mortality Rate has declined from 53 to 14 per 1,000 live births. In terms of service provision, polio vaccination has reached 98% of the population. A 2015 report said that 95% of those that seek care in the SUS are able to receive treatment. Every year, the SUS covers more than two million births, 10 million hospital admissions, and nearly one billion ambulatory procedures.
This has been made possible even amidst a scenario of tightening budget allocation. While universal health systems tend to consume around 8% of the GDP — the NHS, for instance, takes up 7.9% of Britain’s GDP — Brazil spends only 3.8% of its GDP on the SUS, serving a population three times larger than that of the U.K. The cost of the universal health system in Brazil averages around $600 per person, while in the U.K., this number reaches $3.428.
A study conducted by the Brazil-based Institute for Health Policy Studies (IEPS) forecasts that public health spending in Brazil will need to increase by nearly 1.6 percentage points of the GDP by 2060 in order to cover the healthcare needs of a fast-ageing society.
Achieving universal coverage in India, a country with a population of 1.3 billion, is a challenge of epic proportions. Hence, the advances in this field should be seen not in binaries but judged by its steady growth and improvement. For instance, India must record details of improvement in terms of access, production and population health on a year-by-year basis. A starting point for this daunting task is funding. Public health expenditure is still very low in India, at around 1.3% of GDP in the 2017-2018 fiscal year.
Establishing wellness centres
The Brazilian experience can also inform the design of the expansion of primary care that underlies Ayushman Bharat, that is, the creation of 1,50,000 wellness centre by 2022. The Family Health Programme ( Programa Saúde da Família ), which relies on a community-based healthcare network, is the backbone of the rapid expansion of coverage in Brazil. The strategy is based on an extensive work of community health agents who perform monthly visits to every family enrolled in the programme.
These agents carry out a variety of tasks. They conduct health promotion and prevention activities, oversee whether family members are complying with any treatment they might be receiving, and effectively manage the relationship between citizens and the healthcare system. The strategy works: a large body of research shows that the programme has drastically reduced IMR and increased adult labour supply. Equally impressive has been its expansion, from 4% of coverage in 2000 to up to 64% of the overall population in 2015; it was able to reach even the rural areas and the poorest States of the country.
Both Brazil and India are composed of large States with a reasonable degree of administrative autonomy. This fact implies great challenges and opportunities. The major challenge is that a one-size-fits-all approach for such heterogeneous regional realities is inconceivable: Tamil Nadu, Sikkim, and Bihar differ in so many ways and this diversity must be met by an intricate combination of standardised programmes and autonomy to adopt policies according to their characteristics. Moreover, regional disparities in terms of resources and institutional capabilities must be addressed. This diversity, nevertheless, can be a powerful source of policy innovation and creativity.
Miguel Lago is an executive director at the Brazil-based Institute for Health Policy Studies, where Arthur Aguillar works as a public sector specialist
