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].
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
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.
[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.
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