Quality of health care--growing awareness in Brazil.

Abstract

The World Bank published in 1994 a report on the orshows tremendous internal disparities. The HDI in the South, ganization, delivery and financing of health care in Brazil. Its Southeast, and Central-West regions places them in the chapter on quality was entitled ‘The forgotten component: upper ranges of human development, whereas the North and quality of care’ [1]. Tracing back the two decades preceding Northeast regions are at an intermediate level, with the latter its publication no comprehensive programme dealing with region bordering on lower levels of the index [4]. Table 2 quality issues could be identified. Regulatory norms issued shows the differences in life expectancy at birth and infant by the Ministry of Health (MOH) and by professional boards mortality rates in the Brazilian regions in 1991. were identified but only very localized initiatives were detected The Brazilian public health care system, known as the in the fields of quality management, clinical guidelines, ac‘Unified Health System’, is formed by the federal, state and creditation, consumer satisfaction or defence. Only in the municipal services working in an integrated way, but with early 1990s, more specifically from 1995, did quality of sole authority at each level of government. care initiatives become more and more widely disseminated In 1992 there were 7430 hospitals in Brazil, of which 4433 throughout the country. This report tries to trace this new had no more than 50 beds, 2127 had 51 to 150 beds and environment in Brazil where a growing awareness of quality 870 more than 151 beds. Of these hospitals 72% are private in health care can be detected among consumers, providers, and 28% belong to the public system. Regarding hospital financial planners and government representatives. admissions in the Unified Health System, 40% are to private hospitals, 33% are to non-profit hospitals, 27% are to public hospitals and 10% are to university hospitals. Ambulatory care is provided mostly by public and teaching The country services, the institutional composition varying according to the type of care being offered. Brazil has an area of 8.5 million km and shares borders with Public revenues for health care come from the federal, state all the countries of South America except Ecuador and Chile. and municipal governments. In 1996, public expenditures Its political and administrative organization includes the three amounted to US$ 18.0 billion; 76% came from federal sources, branches of government – executive, legislative, and judicial 13% from state sources and 11.3% from municipal sources. – as well as 26 states, 5508 municipios, and the Federal District In addition to the Unified Health System, there is a (the seat of government). The total population was a little private sector, consisting mostly of voluntary complementary over 157 million inhabitants according to the 1996 population insurance schemes, which covers 20% of the population, census. chiefly in the larger urban centres. In 1996 these plans spent The country is divided into five major regions. The North, about US$9.0 billion. These complementary schemes provide the largest region, occupies 45% of the national territory, but services through their own providers, through contracted has only 7% of the population; the Southeast occupies 11% providers or by free choice of the customer. Service provision of the territory and has 43% of the population. The South includes group medicine, medical co-operatives, private health is the smallest region, with 7% of the territory and 15% of insurance and company-based health services. In 1998 these the population. Each of the other two regions occupies schemes came under the regulation of the MOH. approximately 18% of the territory, but the Northeast has Brazil’s extreme diversity in social, economic and health 29% of the population, and the Central-West has only 6%. conditions is also reflected in its health care delivery systems. Basic indicators of Brazil are given in Table 1. One can find high quality services and facilities side-by-side The human development index (HDI) of the United Nations Development Program applied to Brazilian regions with very poor ones. Places like Rio de Janeiro, Sao Paulo