Lessons from the pandemic to strengthen the Brazilian Unified Health System (SUS)

/ Online Transmission - Zoom

SUS is not a problem without a solution, but a solution with problems. Although underfunded and with management issues, the Brazilian Unified Health System has prevented a social upheaval since the COVID-19 pandemic hit Brazil. Considering the severity of the current healthcare, social, economic, and even political crisis, which will have consequences to be felt for years to come, governments, the private sector, and the third sector – each with its resources and competencies – must work together.

This was the message delivered by the guests of this webinar held by three major institutions in their areas of expertise: the Sírio Libanês Hospital, HSM, and the Fernando Henrique Cardoso Foundation.

“We know what to do. We need more resources, both public and private, but we also need to be managed more rationally. Choosing leaders, defining competencies, giving autonomy, checking results, and communicating well.”
Dr. Paulo Chapchap, director general of the Sírio Libanês Hospital and coordinator of the Todos pela Saúde (Portuguese for ‘All for Healthcare’) initiative.

“In Brazil, the novel coronavirus interacts not only with other pre-existing diseases, but also with poverty, exclusion, and social stigmatization. Without focused and efficient policies to reduce inequality, nothing else will work.”
Eugênio Villaça Mendes, consultant for Brazil's National Council of Health Secretaries (CONASS) and author of the book “As redes de atenção à saúde” (Portuguese for, “The Healthcare Networks”).

“Nothing is more important than the population's health. The private sector can and should contribute with resources and with management knowledge and experience. However, it is the specialists in the field who must determine, with total autonomy, the destination of these resources.”
Claudia Politanski, Vice President of Itaú Unibanco and one of the creators of the Todos pela Saúde program.

       ‘Syndemic and third wave'

According to Eugênio Villaça Mendes, who has a dentistry degree from UFMG and a graduate degree in healthcare planning from FIOCRUZ-RJ, Brazil is experiencing a syndemic, that is, “when two or more factors combine to cause greater effects than if they were alone.”

“In situations like the one we are experiencing, the sum of one plus one is greater than two. The country's health and social conditions are very diverse and aggravate the epidemic. For example, research shows that inhabitants of more impoverished neighborhoods in the city of São Paulo have a greater chance of becoming infected. They often also have more comorbidities, such as obesity and pre-existing uncontrolled diseases. The biomedical model of mitigation and suppression is necessary but insufficient. We need policies that reduce inequalities in the short-, medium-, and long-term,” said the speaker.

According to the consultant for CONASS, Brazil needs to prepare itself not only for a “second wave” – which, according to recent numbers of new infections and hospitalizations, is already a reality in some regions – but also for what he called the "third wave".

“The third wave is a consequence of decreasing care for other health problems and discontinuing primary care, specialized care, and hospital care due to the scarcity of resources in the healthcare networks stressed by the new coronavirus and the fear of the population. Postponing non-urgent consultations, diagnostic evaluations, and surgeries will take its toll,” he said.

The specialist presented data: in the first months of the pandemic, there was a 61% reduction in organ transplants and a 44% increase in deaths among patients on the waiting lists; in the first semester, there was a 50% drop in face-to-face consultations, 1 million fewer elective procedures in the SUS network, a 60% reduction in vaccinations, 75% in breast cancer exams and 83% in dental consultations. Prenatal consultation absenteeism jumped 30%. “It is a huge liability that continues to accumulate. How do we face it now and in the years to come? It is crucial to have a plan to face this hidden side of the pandemic,” he said.

       'Call on society'

The COVID-19 pandemic represented “a slap in the face” of Brazilian society: “The suffering of the most vulnerable strata was much greater than that of the privileged classes. It is impossible to continue living with the current levels of inequality not only in healthcare but also in education, housing, and other areas. It is time to call on society: we must all step up and help to build a better future,” said Paulo Chapchap, a pediatric surgeon and one of the greatest Brazilian specialists in liver transplants.

According to the Sírio Libanês Hospital CEO, invited by Banco Itaú to coordinate the Todos pela Saúde initiative, public-private collaboration should be structured upon four pillars: 

1. Inform the population about each person's permanent responsibility in preventing the novel coronavirus: “Take care of yourself and everyone, including those who provide care.”

2. Coordinate the actions of the three levels of government and of the public and private sectors within SUS: "The lack of coordination, primarily on the part of the federal government, has aggravated the pandemic."

3. Increase the resources allocated to SUS and improve how it is managed: “Public spending on healthcare represents just under 4% of the Brazilian GDP, a low percentage compared to other middle-income countries. The private sector can also contribute with donations, partnerships, and investments and has shown itself willing to do so, but what is the best model for structuring and coordinating these efforts?”

4. Mount a vaccination plan for the entire population and a conscious and responsible resumption of social and economic activities: "If we don't offer hope and real-life perspectives, people are unlikely to stick to the necessary measures for controlling the pandemic."

       Todos pela Saúde: A new model of cooperation 

In the early days of the pandemic, Banco Itaú made an initial donation of 150 million BRL (about US$ 30 million) to reinforce the fight against the coronavirus:  50% for medical purposes; 50% for food and hygiene product distribution. “We also wanted to invest in the purchase of equipment (such as respirators and PPE), but we soon realized that we lacked the know-how. We then invited Dr. Paulo Chapchap to set up a group of experts with reciprocal knowledge and experience to apply those and other resources that would come later precisely and effectively. Thus, the Todos pela Saúde program was born,” said Claudia Politanski.

From the second week of April onwards, this “distinguished council” started meeting every day at 7 am to evaluate proposals, make decisions, and implement them. Itaú customers, employees, and partners joined the initiative and more resources were donated, creating a positive dynamic that Todos pela Saúde intends to take forward.

“This proposal to unify the expertise of those who really understand healthcare with our management experience has been so successful that we decided to create, in partnership with Bradesco and Santander banks, another similar project to contribute to preserving the Amazon and addressing environmental issues,” Concluded the Itaú VP. 

       'Healthcare has no silver bullet'

According to Eugênio Villaça Mendes, a McKinsey & Company's recent study highlights six objectives that should steer SUS in the post-pandemic period. They are:

- Create mechanisms to reduce inequality;

- Strengthen primary care;

- Redirect the system to adapt to the rapid demographic transition underway in Brazil;

- Increasingly invest in technology;

- Integrate the system into a network;

- Work from macro-regions of healthcare.

“SUS is the way forward and there is no silver bullet to make it more efficient. It is vital to increase resources (financial and human), improve the quality of services, review the payment system to prioritize the value generated for the user, implement a plan to modernize management and make it more innovative. It is essential that the three levels of government collaborate, as should the public and private sectors,” said the expert.

       'Direct administration and private management can coexist' 

According to Paulo Chapchap, SUS has room for both direct administration by the Federal Government and private management of public hospitals: “Public service is characterized by its free accessibility to citizens. I do not see healthcare management as a model of management done through contracts between state and municipal governments and the private sector.”

According to the director-general of Sírio Libanês, philanthropic hospitals, mostly Santas Casas (charitable association units), even if underfunded, account for about 60% of SUS hospital services. Chapchap also highlighted the role of the so-called philanthropic hospitals of excellence: “Sírio alone gives approximately 200 million BRL back to society per year through the Brazilian Unified Health System's Institutional Development Support Program (PROADI-SUS). We do half of the country's pediatric transplants and have a survival rate greater than 95%,” said the surgeon. 

According to the Todos pela Saúde coordinator, SUS is the largest social program in the country and, therefore, deserves all of the private sector's support. “The pandemic has taught us a lot. To make Brazil less underprivileged, money is not enough. You also need leadership capacity, responsibility, enthusiasm, and dedication,” he concluded.


Otávio Dias is a journalist specializing in politics and international affairs. A former correspondent for Folha in London and editor of the website, he is currently the content editor at Fundação FHC.

Portuguese to English translation by Melissa Harkin & Todd Harkin (Harkin Translations).

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