Over the past 30 years, Brazil has pursued policies to achieve universal health coverage. The Constitutional Reform of 1988 gave rise to the current Unified Health System (Sistema Único de Saúde, or SUS) and since the inception of SUS, virtually the entire population is formally covered by the public health sector, with equal benefits and equal financial protection. As a result, Brazil has significantly improved most general population health indicators, increased access to health care and reduced health inequalities. Life expectancy at birth increased by 5.7 years, from 70.2 years in 2000 to 75.9 years in 2019. Infant mortality rate has decreased by 60%, from 30.3 deaths per 1 000 live births in 2000 to 12.4 deaths per 1 000 live births in 2019. The same is true for maternal mortality rate which has decreased by 13 percentage points over the same period.

However, mobilising sufficient financing for the universal health coverage mandate of SUS has been a constant challenge, not helped by persistent inefficiencies in the use of resources in the Brazilian health system. While Brazil spends a lot on health (9.6% of GDP in 2019 – higher that the OECD average of 8.8%), 60% of this expenditure is private, leaving the Unified Health System underfinanced. Furthermore, OECD projections indicate that health spending is expected to increase to 12.5% of GDP by 2040, based on demographic and technological trends, rising incomes and productivity in the health sector.

Given the challenging economic and fiscal situation, a serious reflexion is needed to secure more funding for the Brazilian Unified Health System. Critically, Brazil will need to spend more and better on its public health system to make health spending effective to achieve the goals of the system, sustainable for the future, and better able to face major health emergencies like COVID-19. This encompasses modernising the primary health care sector, still characterised by persistent problems in co-ordinating care across service levels and with too many patients bypassing primary health care to seek care directly in outpatient specialty clinics and hospitals. There are also widespread inefficiencies in the provision of hospital services in Brazil that could be tackled, such as excess capacity in normal times, outside of the context of health emergencies. In 2019, only around 52% of hospital beds were used on average for treatment, far below the OECD average of 76%. At the same time, Brazil will also face a challenge to cope with future long-term needs in the context of an ageing population. The share of the population being 65 years or older is projected to rise to from 8.8% in 2017 to 21.9% in 2050. It will be vital to transition towards more formal long-term care provision, which is currently not – or only timidly – in place. Several worrying indicators lastly point to an urgent need for better prevention and an improved public health strategy, notably to address growing risk factors for health such as harmful alcohol consumption and especially overweight, which is a known risk factor not only for chronic non-communicable diseases but also for severe COVID-19 infection.

Looking forward, building an efficient and sustainable health system is an objective that is attainable for Brazil only through the intelligent use of data and digital technologies, requiring proper policy actions and oversight. Better and larger collection, linkage, and analysis of health data will lead to significant gains and insight for service delivery planning and management in SUS. This would allow developing a more digitalised health system, and reaching a better understanding of the cost and effectiveness of medical treatments, and health care services.

This review was prepared by the OECD Secretariat to draw on evidence and best practices from across OECD health care systems to support Brazil in strengthening the performance of its health system. It uses internationally recognised indicators and policy frameworks to examine the performance of Brazilian health system, and points to key actions that Brazil should consider to improving efficiency and sustainability of financing, upgrading its health data infrastructure to leverage a digital transformation, and addressing major population risk factors such as overweight and harmful alcohol consumption.

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