The denial of health rights to the poor in Venezuela: An interview with Dr. Marino J. González R.

 

On May 29, 2023, the president of Brazil, Luís Ignacio Lula da Silva, when inviting his admired friend Nicolás Maduro, highest authority of the Venezuelan government, to a bilateral meeting between the two countries in Brasília, hinted, in his public speech welcoming his friend, that democracy thrives in the neighboring country, and condemned those who consider Venezuela a dictatorship, defining them as builders of a false narrative. In this way, it became clear to everyone that Lula considers Venezuela as a democracy, even been ruled by a government that took control of the legislative power through authoritarian means and subordinated the judicial power to its interests and whims. Is this Lula's ideal recipe for democracy?

What happens is that, by maintaining sham elections, international observers have documented numerous facts that demonstrate the lack of transparency in the elections in Venezuela since the beginning of this century. In the last 25 years, there have been more than 15 thousand political arrests of individuals who tried to demonstrate freely or who were opposition candidates in elections at all levels of government, and The Human Rights Watch denounced the repression and torture of political prisoners and proceedings against civilians in military courts.

The subordination of the government and citizens to the interests of an authoritarian kleptocracy in Venezuela has generated record impoverishment of its population, with the return of hunger and previously eradicated endemic diseases. Therefore, it is estimated that by 2024, almost 8 million Venezuelans will have left the country since the beginning of the Chaves Government, with the majority having immigrated to other Latin American countries.

But what are the consequences of what Lula considering “democracy” in Venezuela on that country’s health system and the health of its population? To talk about this topic, we invited one of the country's greatest authorities on health policy issues - Dr. Marino J. González R.

​Marino Gonzáles is Full Professor of Public Policy at the Simón Bolívar University (USB) and corresponding member of the National Academy of Medicine of Venezuela since 2016. He also belongs to the Academy of Sciences of Latin America (ACAL) since 2020. He is an associate researcher at the University of La Rioja, from the Health Economics Research Group in Spain (where he lives) and member of the Advisory Board of the PhD in Sustainable Development at USB.

His areas of specialization are public policies, social policies, and health policies. Since 1999 he has directed more than 50 research and technical assistance projects. He has published 149 specialized works relating to public policy, social policy, health policy and health economics. To date, he has supervised 23 completed doctoral theses and 17 master's projects in public policy. He was a consultant for the World Health Organization (WHO), Pan American Health Organization (PAHO), World Bank, IDB, ECLAC, UNFPA and CAF. He has experience as an international consultant in Ecuador, Paraguay, Honduras, Dominican Republic, Guatemala, Mexico, and Panama. He was president of the Venezuela Chapter of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) and member of the Board of Directors of the “Federation for International Cooperation of Health Systems and Services Research Centers (FICOSER)” between 1990-1994 and between 2002 -2006.

Furthermore, he has a doctorate from the Central University of Venezuela and a specialization in Public Health from the same university and a master’s degree in political science from USB, in addition to a specialization in Public Policy from the University of Colorado in Boulder, United States. He completed his Ph.D. at the Graduate School of Public and International Affairs (GSPIA) at the University of Pittsburgh, United States. With you the words of Dr. Marino Gonzáles.

 

Health Monitor (MS) – Reports from the beginning of the last decade show that the Venezuelan government has corroded the country's health infrastructure, threatening the public health of its people. For example, between 2009 and 2015, the infant mortality rate increased from 14.4 to 20.2 per 100 live births. Maternal mortality rates, estimated at 92 per 100,000 live births in 2000, reached, according to PAHO and UNICEF estimates, 259 per 100,000 live births in 2020. The rate of low-birth-weight children increased from 8.7 % to 9.7% between 2003 and 2017. But since 2016, the Venezuelan Ministry of Health has stopped publishing crucial public health statistics. Given the blackout of statistical data, how can we, even externally, monitor the public health disaster caused by the Chaves-Maduro dictatorship in the country? Are there civil society institutions interested in monitoring the health status of the Venezuelan population?

Marino González (MG) - To understand what happens with data in Venezuela, the political and governmental context is very important. Over the past 25 years, Venezuela has suffered a significant deterioration in democratic capabilities, especially government responsibilities. This deterioration is manifested in a very noticeable way, but not exclusively in its impact on the rule of law and the lack of balance of powers, but mainly in the lack of respect for the processes that guarantee Human Rights. Thus, Venezuela currently has very low indicators of democratic governance on the global stage.

In the recent years worsened conditions, monitoring processes and the quality of public policies assume secondary importance for government management. Thus, what the country built over decades in terms of the quality of social measurement systems was mostly lost. This is why there is no regular, quality information on basic aspects of health policies. Mortality figures have not been published since 2016, but demographic data has not been updated since 2012 (almost 12 years). The last weekly information on notifiable diseases was published at the end of 2016 (seven years ago).

Facing these immense gaps in information, initiatives have been generated by universities, civil society organizations, research centers and public opinion monitoring companies, with the aim of mitigating, to a certain extent, these gaps in information for policy evaluation. Obviously, these initiatives are subject to resource constraints, meaning that they are often uncomplete and irregular, but they play a fundamental role in a situation in which the public sector has practically abandoned its constitutional mandate of guaranteeing the best policies for citizens.

 

MS – The progressive elimination of sanitary and epidemiological surveillance processes in Venezuela has increased outbreaks of communicable diseases in the country to alarming proportions, while at the same time dismantling vaccination strategies for preventable diseases, such as measles, diphtheria, and tetanus. In 2016 and 2017, Venezuela had the highest rate of increase in malaria in the world and tuberculosis rates in 2015 were the country's highest in 40 years. How is this situation currently? Is there interest or political will to improve the health of the poorest and most disadvantaged population? Is a lack of interest in the health of the poorest a strategy to eliminate the poor population that does not feel represented by the Venezuelan dictatorship and that is unable to immigrate to other countries?

MG – The government started in 1999, and which continues today, had the fight against poverty as one of its main messages. This long period of greater impoverishment that followed in the country is a demonstration that the government did not have a modern and intelligent strategy to correct development imbalances. The false premise that it was possible to concentrate wealth in the State and that, therefore, everything would be resolved, is at the heart of this monumental failure. In 1999 it was known that countries do not improve because the State absorbs all political, economic, and social functions.

This is the reason why Venezuela recorded the largest increase in the proportion of households in extreme poverty, reaching 75% in measurements from high-quality technical surveys. This increase in poverty began before the hyperinflation that began in 2017 and increased further throughout the entire period of hyperinflation (one of the longest reported in the world). Therefore, it can be said, with complete certainty, that there was no political will nor technical and institutional capacity to overcome poverty in the country. The evidence of Venezuela's social and economic deterioration is the most notable in the last fifty years in the world. Unfortunately, they are worldwide visible. The migration of more than 7 million Venezuelans out of a total of 30 million is the greatest proof of this extraordinary disaster in the country's public management over the last quarter of a century. It's really dramatic.

 

​MS – Venezuela has been using, for a long time, the strategy of importing family doctors from Cuba, paying the country with oil. Many claim that the main function of family doctors in Cuba has been, at least in the past, a surveillance and political propaganda function, identifying potential people who could threaten the regime and propagating the government's benefits to have the support of the population out of conviction or fear. In the case of Venezuela, did doctors imported from Cuba also fulfill this role? Was the adoption of Cuban family doctors beneficial to the health of Venezuelans? Did their action cover the entire Venezuelan population or just the people living in areas identified as supporting the Chavo-Madurista regime?

MG - The arrival of doctors from Cuba began in 2002. That year, when the political crisis had already begun, it was essential for the Chávez government to regain its popularity, because the management of the first years did not have much to offer (for example, the medical care program maternal and child services that served more than 500 thousand children and pregnant women was eliminated in the first months of its administration). In this context, the Venezuelan government copied in practice the concept of the missions that had been implemented in Cuba ten years ago. And one of those missions was called Barrio Adentro, which included Cuban doctors coming to Venezuela.

Therefore, the objective of this mission was not public policy. It was rather a strategy to face the 2004 recall referendum, which the government won. The services that were developed in this mission had more advertising effects for the government but had no effects in terms of health policies. The country's health indicators did not improve due to this mission. To the point that infant and maternal mortality increased in those years (there are currently no official figures, but international estimates indicate that these indicators have worsened significantly in the country). Many of the Cuban doctors who entered Venezuela joined the millions of Venezuelans who migrated, either to Colombia and other Andean countries, or to the United States. At this moment, no one is talking about this mission.

 

MS – Between 2014 and 2023, around 7.7 million Venezuelans migrated from the country, which represents the highest immigration rate from a South American country in history. Among the factors that contribute to migration are hunger and lack of health care for the population. For example, between 2017 and 2018, most HIV-infected patients discontinued therapy due to lack of medication. Many of the HIV patients were able to migrate to access treatment that was denied to them by the Venezuelan government. In your point of view, how has the deterioration of the health system influenced the migration strategies of the Venezuelan population?

MG – They totally influenced it. Since 1999, there has been a sustained increase in private health financing sources in Venezuela. Family health expenditure estimated by national health accounts has become one of the highest in the region. This process coincides with the deterioration of the country's productive capacity, with the closure of many companies, and the consequent loss of jobs. In the middle of the last decade, 50% of the population did not have any type of health insurance (neither public nor private). In three years (2017), right at the beginning of hyperinflation, this percentage rose to 70%. It is evident that this situation worsened during the years of hyperinflation, clearly influencing the large wave of migration that occurred in those years. On the other hand, public opinion surveys have consistently highlighted the importance that families attribute to health, as a fundamental problem in their daily lives.

A related aspect is that pension coverage for the elderly population does not exceed 50% of those who should receive it and, on the other hand, the value of pensions for this population did not exceed 5 dollars per month for a long time. These pensions are financed with tax resources, as they do not discriminate based on the work activity carried out. For many elderly people, with greater restrictions on migration, part of the survival strategy considers that their children or grandchildren can emigrate to increase family financing in the country by sending remittances. The costs of healthcare for this population without any type of financial protection is, without a doubt, a factor that promotes the migration of their family members. Migration, in practice, is a demonstration of the immense failures of health and social security policies experienced in the last 25 years in Venezuela.

 

MS - Since November 2021, the International Criminal Court (ICC) has opened an investigation into possible crimes against humanity in Venezuela, while a United Nations fact-finding mission has found sufficient reason to believe that crimes against humanity were committed as part of a state policy of repression against opponents. According to this investigation, the country's judicial authorities participated in or were complicit in abuses, serving as a mechanism of repression, including the failure of millions of people to access adequate medical care and nutrition. What will be the follow-up to this investigation and what consequences could it have for the government? Could this research bring elements to reverse the crisis in the Venezuelan health system that affects the poorest who do not support the regime?

MG – The evolution of health conditions in Venezuela, especially in the context of the complex humanitarian emergency that has lasted for eight years, has justified multiple investigations in international organizations, both to monitor human rights and their effects on people's lives. It is desirable that all these investigations serve to prevent new situations and compensate for the damage committed. These investigations, due to their own characteristics, have deadlines and processes that must be complied with.

I believe that improving the concrete situation of citizens, including, of course, health, involves a process of institutional and political changes that are very complex in Venezuela. The demands to modify current guidelines are notable and progress is not keeping pace with needs. We hope that in the coming months we can identify points that will allow us to improve. The international community and national actors are convinced of the seriousness of the situation and the consequences for the daily lives of all Venezuelans, those who live in the country and those who live abroad.

 

​MS – One of Venezuela's biggest problems is the food crisis, which in addition to being one of the main factors for migration, affects everyone in the country. In a context of poverty and very low wages, food prices increased by 315% between September 2022 and September 2023. Many countries have contributed with donations to resolve the humanitarian crisis which, in addition to hunger issues, involves domestic violence, violence against women and violence against LGBT minorities. How has the government faced and/or intends to face these problems?

MG - National organizations that participate in support tasks within the scope of the complex humanitarian emergency recently expressed that less than 10% of the population in need is being served. Although there are resources available to increase this coverage, they emphasize that multiple obstacles prevent the situation from improving. In general, there is great dissatisfaction because these difficulties have not been overcome. The responsibility of government management in this aspect is a fundamental factor.

MS – Venezuela is currently one of the countries with the lowest public spending on health (1.7% of GDP and 4.9% of total public spending). Why is health not a priority in the public budget in Venezuela?

MG – As in many areas of social policies, health is affected by this lack of priorities in public management. Short and medium-term management objectives involve other aspects, including political supremacy and obtaining resources for activities in the political sphere. Therefore, the priority for the design and execution of quality health policies is not the main issue. This would require the implementation of consultation and agreement processes for which there is no political or technical competence and, furthermore, are not a priority. The only way to transform this situation is through a new political phase that focuses sustained efforts on improving democratic institutions. This is the biggest challenge, in my opinion, that Venezuelan society faces.

 

MS – How do you see the health situation in Venezuela for 2024, including issues of epidemiology, functioning and financing of the health system?

MG – The entire situation in 2024 is influenced by the presidential elections, which still do not have a defined date. This event will affect the political situation and will have social and economic consequences. The absence of quality policies, for the reasons indicated, is the predominant factor. Therefore, there can be no modifications to this course of action without improvements in democratic institutions. In the worst-case scenario, if there is no progress in the political sphere, what could happen is that economic restrictions will increase, and the complex humanitarian emergency will be worsened. I think all the alarms continue to ring in Venezuela. It is a deep and systemic crisis, with wide repercussions in the region and, fundamentally, a global crisis in the conditions of Venezuelans. It must be a situation of utmost concern for everyone, for national leaders and the international community. It is a very critical year for the future of Venezuelan society. I have no doubt.

 

 

The Health Sector in The First 100 Days of the Third Lula Government in Brazil

                                                                  Andre Medici and Joaquim Cardoso

Why the First 100 days of Government matter to the Health Policies?

The Great Depression of the 1930’s was the scenario where, at first time, a president used the phrase “first 100 days” to address early new government progress. This was Franklin Delano Roosevelt, president of the United States, which make a sound radio speech in 1933 addressing how he was conducting his plan to combat the American crisis of the century. He followed through on his promises, passing major bills in the Congressional sessions along the first 100 days of his government, including taking the country economy off the gold standard and creating public-works relief programs. In total, Roosevelt passed 76 laws and issued 99 executive orders in his first 100 days, a record that still stands[i].

Democracy requires governments to demonstrate how they are conducting their duties to achieve their political campaigns´ promises. Since Roosevelt initiative, other elected presidents, not only in United States but everywhere, have tried to emulate this success by using their first 100 days to push through ambitious campaign promises while their approval ratings are typically at their highest.

However, how to prove progress along the first 100 days in specific sectors, such as health? This exercise should start before the government be launched. To improve health system performance, policy makers must have a clear situational diagnostic to measure and understand the gaps and policies require prioritization and resource allocation. This can be achieved through regular monitoring and assessment of health systems, which are essential for finding data and relevant information in systematic bases. It also requires listening and interacting with key stakeholders of the health sector to understand their perspectives, strategies, and ways of collaboration. Both – assessment of the health systems and dialogue with stakeholders – are essential to determine what are the current strengths, weaknesses, opportunities, and threats for the prioritization and implementation of the health policies.

Setting health system goals along the political campaign is a critical step to promote further analysis of the past governments' performance, as it provides a framework for assess results. Across various health system frameworks, there is consensus on key health goals, such as improving health outcomes, prioritizing patient needs, promoting equity, ensuring fair financing, and increasing efficiency.

By evaluating the performance of each component of the health system and identifying areas of improvement, policy makers will be able to develop strategies to strengthen the system and achieve the proposed goals. This underscores the policy relevance of ongoing evaluation and monitoring to ensure that health system strengthening efforts are effectively improving health outcomes.

The Role of Health System Performance Assessment (HSPA) in the First 100 Days

To help governments strengthen their health systems, it is crucial to conduct health systems performance assessments that can inform policy discussions, decision-making, and the development and implementation of health strategies. These assessments will also play an increasingly important role in guiding government responses and systematic problem solving to improve the performance of health policies.

There are tools available to access the ability and response of the health systems focused on the achievement of universal health coverage at distinct levels. In 2017, the Universal Healthcare 2030 Technical Working Group (UHC2030-TWG), lead by the World Health Organization (WHO)[ii] was set up to address these challenges by bringing together and discussing solutions among diverse stakeholders. The TWG searched for developing and implementing effective health system assessments that can inform and guide policymakers in their efforts to improve health outcomes for their populations. This initiative resulted in the creation of the Health System Performance Assessment for a UHC framework (HSPA), which provides a conceptual representation of how health systems assessments can contribute for the improvement of health systems performance.

The HSPA framework is built around four critical health system functions necessary to achieve health systems goals: (1) governance, (2) financing, (3) resource generation, and (4) service delivery, as can be shown in Figure 1.

Figure 1

 (https://www.uhc2030.org/fileadmin/uploads/uhc2030/Documents/About_UHC2030/UHC2030_Working_Groups/2017_Health_Systems_Assess_Working_Group/HSPA_Framework_for_UHC.pdf)

The HSPA framework bridges the gap between HSAs (Health Systems Assessment) and health system performance by taking a three-pronged approach to address fragmentation, ownership, and performance bottlenecks. This approach offers new opportunities to analyze health systems performance more effectively in a coordinated way, supplying a basis for more cohesive and efficient action.

Overall, the HSPA framework offers a way to comprehensively evaluate health systems performance and find areas for improvement. By linking HSA information with health system performance, this framework can help to inform for a more effective decision-making, resulting in improved health outcomes and progress towards UHC. Figure 1 shows the different health system components: the health system functions, their corresponding sub-functions, the assessment areas used to evaluate the performance of the functions and sub-functions, and the intermediate aims and final goals of the health system. This framework outlines key performance linkages between the functions and sub-functions and the intermediate and final goals.

The HSPA Framework is based on the premise that any whole-of-sector assessment exercise should gather information on and assess both the functions of the health system and its performance goals. It outlines the purpose of each health system function, the sub-functions needed to fulfil that purpose, and the areas to evaluate the function's performance. By using this approach, policy makers can better find and analyze the potential causes or impact of poor performance on the specific health system outcomes.

What are the needs of Brazilian Health System's Reforms?

The main problems faced by the Brazilian health system are structural but could be addressed through internationally known and approved technical solutions. International organizations have been foreseen problems and proposed solutions for reforming the Brazilian Unified Health System (SUS) in the last decades. The World Bank, for example, issue in 2017 a document proposing an agenda for reforming the Brazilian Unified Health System (SUS), based in four kinds of reforms[i]:

 

(i)       Supply-side reforms (rationalization of the outpatient and hospital services provision, primary care coverage expansion to entire population, health services provider’s autonomy and innovative quality improvement by a social organization (OSS) model).

 

(ii)      Demand-side reforms (use of gatekeepers at primary healthcare level, use of clinical pathways and evidence-based health protocols; implementation of a defined package of benefits for the SUS).

 

(iii)    Management Reforms (establishment of integrated health care networks defined by geographic areas and improved coordination and integration between public and private sectors inside each network).

 

(iv)    Health Financing Reforms (financing flows centered in the patients’ needs and providers payment systems driven by results and performance).

 

However, given the political and ideological divide and a strong conflict of interests within the institutional environment of the Brazilian health sector, it has been difficult to get most of these reforms taken, planned, and executed without a slow and lengthy process of negotiation leading most of the problems that prevent an efficient organization of the SUS remains in place. The biggest structural problems of the Unified Health System (SUS) in the moment of the 2022 presidential elections are:

 

(a)   incomplete universal access to quality health care. High regional inequalities aggravated by a fragile culture of promotion, prevention, and primary care, which should be the backbone of the system to avoid the still prevalent hospital-centered model. This situation was worsened by the pandemic, leading to significant reductions in access to outpatient and hospital care in the SUS throughout 2020-2022.

 

(b)  insufficient emergency preparedness capacity, as demonstrated throughout the Covid-19 pandemic, leading to the need of reviewing the current pandemic preparedness guidelines (including those related to the availability of medical supplies, protective equipment individual, vaccines, and medicines) and adopting, during future pandemics, quick and accurate interventions to minimize the negative pandemic protective measures effects on the functioning of the economy and society.

 

(c)   the scarcity of health networks in the system which should be essential to integrate the levels of care (primary, secondary, tertiary), to create gatekeepers, referrals, and counter-referrals of services, and to establish a process of continuum of care between all levels and specialties, centered on the needs of patients and not just according to the convenience of the services.

 

(d)    the lack of federal public funding for the SUS, aggravated since the 2015 crisis, and associated with inefficient public spending on health policies. According to research by the World Bank, the inefficiency of the SUS funding has resulted in a yearly waste of 0.3% of GDP in public financing allocated in ineffective care.

 

(e)   the lack of tools to transform abundant information into metrics, indicators and analyzes to offer technically precise decisions on policies, targets, goals, resource allocation and effective results.

 

(f)    the lack of political will to change the mechanisms of health education, as well as instruments for contracting, training, and paying health professionals to increase their commitment with better health achievements, deep health outcomes evaluation, effective health policy implementation, and to define objectives and targets with quality, diligence, and efficiency.

 

(g)   the lack of a solid, flexible, and fluid integration of public and private services to maximize efficiency and to avoid waste of public and private funding in the health sector, using all health structure available in each geographic area and avoiding services duplication and bad investments in unnecessary infrastructure (such as small number of beds` hospitals and health units abandoned due to lack of personal).

 

(h)   the need to have an operational definition of the constitutional concept of healthcare integrality to avoid waste of public funds with unnecessary judicial complaints against the SUS.

 

(i)    the need to support an innovative and problem-solving digital health governance, as well as regulations to improve health therapies, clinical pathways and managing models, based on equipment, pharmaceuticals, electronic medical records, and artificial intelligence in health, as well as a national strategy to produce inputs and technologies for cost-effective promotion, prevention, treatment, and rehabilitation.

Along the Luiz Ignacio Lula da Silva (Lula) 2022 political campaign, its program named Brazil Hope Coalition[ii] - a document of 19 pages – has dedicated only two paragraphs to address his promises to the SUS and to the health sector, as can be seen below.

 

Health, the right to life, and the Unified Health System (SUS), have been treated with disregard by the current government. There is a lack of investments, preventive actions, health professionals, consultations, exams, and medicines. It is urgent to give the SUS conditions to resume meeting the demands that were dammed up during the pandemic, assist people with sequelae of covid-19 and resume the recognized national immunization program. Were it not for the SUS and the brave workers and health workers, the irresponsibility of the current government in the pandemic would have cost even more lives.

 

In the Lula and Dilma governments, health was treated as a central public policy, as a right of all Brazilian men and women and as a strategic investment for a sovereign Brazil. We reaffirm our commitment to strengthening the public and universal SUS, the improvement of its management, the valorization and training of health professionals, the resumption of policies such as Mais Médicos and Farmácia Popular, as well as the reconstruction and promotion of Health Economic and Industrial Complex.

Compared to other support areas of Lula's campaign, health was one of the least expressive sectors of the entire program. No specific disease or social inequality was mentioned as a target to be tackled. The first of these two paragraphs highlighted the fragile situation of the SUS in the face of the Covid-19 pandemic, but the Program did not mention numbers or quantitative targets to reduce the high levels of disease burden that affect the poor. The health initiatives covered by the Program to be implemented after the elections were: (i) meeting the demand for health that was dammed up during the Covid-19 pandemic; (ii) assisting people with Covid-19 sequelae; (iii) the resumption of the recognized national immunization program, (iv) the return of the Mais Médicos Program[iii], (v) the return of the Popular Pharmacy Initiative[iv], and (vi) the promotion of the economic and industrial complex of health[v].

Some of these initiatives have somehow been implemented during the past Lula and Dilma governments in bold or soft colors, but most of the structural problems of the SUS were not mentioned by the Program. Thus, the health proposals of the Lula 2022 Program do not address the urgent reform needs discussed by most of health authorities and specialists in Brazil.

What are Lula’s Government achievements in the health sector along the first 100 days?

Giving these circumstances, along the first 100 days of the Lula government, the Ministry of Health announced the support to some well-known brand-named policies of the old Lula and Dilma Governments such as:

(a) The relaunch of the Mais Médicos Program with the perspective to insert by the end of 2023 around 28 thousand doctors in the Program.

(b) the creation of a national vaccination movement, intensifying campaigns to increase immunization coverage for several preventable diseases which were reduced during the last years.

(c) the reduction of the waiting list for surgeries, exams and medical visits to the SUS which were drastically delayed along the pandemic years.

(d) the intention to restore the health industrial development policy, with the expectation of producing 70% of the equipment and medical supplies demanded for the SUS and to reduce the dependence of imports to the health sector – one of the biggest struggles faced by the SUS along the Covid-19 pandemic, and.

(e) the search for extraordinaire budget funds to finance the expenditures created by the legislation approved by the Congress and sanctioned by President Jair Bolsonaro in 2022, which set the national wage floor for nurses in the public and private sectors, at BRL 4,750, and established that the minimum salary for nursing technicians, nursing assistants and midwives will be calculated based on that amount.

Most of these actions, as announced by the President Lula himself, were aimed to reintroduce programs and strengthen public policies that suffered setbacks during the Bolsonaro government. However, their implementation will require additional budgetary funds to support the SUS, which is challenging in 2023, as a year marked by a giant public deficit, lower GDP growth and higher inflation.

There are some caveats that make the intentions expressed by the government a little bit different from past initiatives in the health sector taken by Lula or Dilma governments. First, the Mais Medicos program was announced with some differences, such as a higher presence of Brazilian doctors, because they can understand better the SUS structure, principles, instruments, and regulations. Otherwise, Cuban doctors were poorly Portuguese spoken with difficulties to communicate with the Brazilian citizens, especially in the poorest regions. Last, but not least, Cuban doctors were not well prepared and are not able to pass in proficiency of medicine skills tests[vi]. On the other hand, foreign doctors only will be contracted after mandatory approval in the Revalida examination, which is a test to verify technical and practical skills for doctors that do not have their graduation in a Brazilian medical school.

Second, the government appear to be interested into destinating budgetary funds to the states and municipalities and subsidizing the private sector (mostly the philanthropic establishments) to allow them to reduce constraints on delivering better services to the SUS, such as the expenditures with the expansion of the wage floor for nurses.  

What are the gap and recommendations?

The deficiencies of the SUS are structural and only a new managerial framework with a complex reform could improve the current levels of performance of the public health system in Brazil. Several topics raised by specialists, such as the supply side, demand side and health managerial and financing reforms mentioned before were not announced during the first 100 days and constitute urgent gaps to be tackled by health reforms.

After the inauguration of the third Lula government, many questions remain without answers for now, such as: What are the government plans to complete the universal access to quality healthcare for the Brazilian population? What are the schemes to improve preparedness to face new pandemic situations? What are the plans and strategies to implement health networks models to guarantee integrate health care for all, using the public-private mix of services available in the country? What are the paths to assure sufficient financing and improved efficiency in public health spending and service delivery? What is the digital health strategy for Brazil, including specific public policies for the development and dissemination of telemedicine to increase access in the farthest areas with lower costs? How to improve data collection and services utilization performance by using electronic medical records, analytics, and artificial intelligence from the top management to the point of service?  How to improve health education, training on the job and payment mechanisms associated with value generation for patients and better performance?

The results announced during the first 100 days in the health sector by the current government flags only a return to past priorities tied to a backward agenda. Future priorities, recognized as relevant by the most important health specialists in the country, have not been discussed or planned by the new government so far. However, with optimism, it is expected that these priorities must be progressively incorporated by the government as the time goes.

To fulfill these expectations, our recommendation is the implementation, as soon as possible, of the WHO HSPA framework. This should be the first step to allow the new government to bridge the existing gap between spending, assessment, and outcomes, by identifying in detail, the current fragmentation, management, and performance bottlenecks. This will allow the government to better design, strategize, and effectively implement the urgent SUS reforms deserved by the Brazilian citizens.

 

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[i] Banco Mundial (2017). Um ajuste justo: Análise da eficiência e equidade do gasto público no Brasil. Banco Mundial, Brasília, 2017, pp 109-119, Link: https://documents1.worldbank.org/curated/en/884871511196609355/pdf/121480-REVISED-PORTUGUESE-Brazil-Public-Expenditure-Review-Overview-Portuguese-Final-revised.pdf

[ii] Named in Portuguese as “Coligação Brasil Esperança” Link: https://divulgacandcontas.tse.jus.br/candidaturas/oficial/2022/BR/BR/544/candidatos/280001607829/pje-3b1196fd-Proposta%20de%20governo.pdf

[iii] The Mais Médicos (More Doctors) Program was created in July 2013, during the Dilma Rousseff government, with the aim of hiring 18,200 doctors (63% from Cuba) to serve the poorest municipalities in Brazil. The Program was poorly designed, without clear goals and objectives and without reaching the list of the poorest municipalities without doctors. From 2013 to 2016, the Program had a mix of good and bad results. After the impeachment of Dilma Rousseff by criminal administrative misconduct and disregard for the federal budget in violation of article 85 of the Brazilian Constitution in 2016, the budgetary transfers for contracting Cuban doctors were reduced and the Cuban government abandoned the Program in 2018. A report prepared by the Federal Court of Auditors (TCU) in 2017 pointed out that, despite administrative and accountability failures, there was an increase in the number of medical services provided to municipalities benefited by the Program. However, 26% of the poorest municipalities were not attended by physicians, alongside other non-priority municipalities that received physicians from the Program. Faced with this situation, the Mais Médicos Program had little impact in reducing inequality to access primary care health services, compared to other existing initiatives, such as the Family Health Program (PSF), which were not sufficiently expanded. Some of the Program's design problems were corrected during Michel Temer's government, partially improving its performance. After the election of Jair Bolsonaro (President of Brazil from 2019 to 2022), the Program changed its name to Médicos pelo Brasil (Doctors for Brazil) Program, being restructured with the promise of hiring an additional 18,000 doctors. However, during this government, especially after the Covid-19 pandemic, the Mais Médicos Program lost strength and financial support, dismissing 8 thousand doctors. The Médicos pelo Brazil Program, on the other hand, never was implemented by the Bolsonaro government.

[iv] The Popular Pharmacy program was created in 2004 (First Lula Government), with the objective of ensuring the treatment of diseases through free or discounted medicines. The Ministry of Health pays part of the drug price (up to 90% of the reference values) and the citizen pays the rest, according to the price charged by the pharmacy. However, the program has flaws and difficulties in the process of acquiring and distributing medicines. In 2022, the Popular Pharmacy program served around 20 million people, which represents 9 million fewer visits than registered in 2015. According to specialists, the Program's budget for 2023 is three times less than the need for medicines by the population in the free and subsidized modalities.

[v] The Health Industrial Complex is configured as a system constituted by the industrial sectors of chemical and biotechnology base (biological, synthetic, and semi-synthetic medicines, vaccines, active pharmaceutical inputs, and diagnostic reagents), of mechanical base, electronics, and materials (medical devices) and health services that establish institutional, economic, and political relationships aimed at innovation and production in health. Since the first government Lula there is practical measures to strengthen the health industrial complex. However, the Bolsonaro government pushed the relevance of this sector by creating in July 2022 (Decree number 11,098) the Department of the Industrial Complex and Innovation in Health of the Secretariat of Science, Technology, Innovation and Strategic Inputs in Health (DECIIS/SCTIE/MS) aimed to propose, implement, and evaluate policies, programs and actions defined by the national strategy of promotion, strengthening, development and innovation within the Health Industrial Complex.

[vi] At the beginning of the Mais Médicos Program, the approval rate of Cuban doctors submitted to the Revalida - a set of exams used to approve and certify foreign professionals who applied to practice as doctors in Brazil - was only 24%. So, to maintain the commitment with the Cuban government, the Program amended the original contracts with Cuban doctors to admit them, not as doctors, but as interns. With this type of agreement, they were not allowed (formally) to perform many of the traditional primary care procedures regularly performed by a primary care physician.