O mix público-privado no Sistema de Saúde Brasileiro: financiamento, oferta e utilização de serviços de saúdeThe public-private mix in the Brazilian Health System: financing, delivery and utilization of health services

In recent years the international debate about universality in health has been marked by a polarization between ideas based on a universal system, and notions proposing universal health coverage. The concept of universal coverage has been disseminated by international organizations and has been incorporated into health system reforms in several developing countries, including some in Latin America. This article explores the assumptions and strategies related to the proposal of universal health coverage. Firstly, a comparison is provided of the models of universal health coverage and universal health systems. This is followed by a contextualization of the international debate, including examples of different health systems. Finally, the implications of the proposal of universal coverage for the right to health in Brazil are discussed. The analysis of different concepts of universality and the experiences of different countries shows that health insurance-based models, either social or private, are not as satisfactory as public, universal health systems. Greater understanding about ongoing international projects is essential in order to identify the possibilities represented by the consolidation of the Unified Health System (SUS) in Brazil, as well as the risks of dismantling the SUS.

The article analyzes the implications of the austerity policy in Brazil on the guarantee of universal social rights, focusing on the financing of the Unified Health System (SUS) and the right to health. The effects of the Brazilian austerity policy are analyzed in an international perspective, based on evidence produced in different contexts, identified from a literature review, in order to base the arguments developed in the article. Information on the fiscal austerity measures being implemented in Brazil is presented and its likely impacts on social protection in the country are analyzed in a context of significant economic recession. The austerity policy adopted in Brazil is not universal, since it does not affect all Brazilian society equally, nor does it have temporary effects, since it is not focused on reducing the momentary imbalance in public accounts. Its main objective is to promote the reduction of the size of the Brazilian State. Finally, we show alternative paths to the fiscal austerity policy that has been used to tackle the economic crisis. The authors argue by a national development project that is necessarily linked to social protection for the universe of citizens and based on values of solidarity.

Este artigo analisa, a partir de microdados de 1998 e 2003 da PNAD/IBGE, a utilização de serviços de saúde sob a perspectiva de seu financiamento ou, em outras palavras, sob o prisma do sistema de proteção à saúde pelo qual o serviço foi utilizado: se pelo Sistema Único de Saúde (SUS), ou seja, pelo sistema público financiado por meio de tributos; se por planos e seguros de saúde privados e financiados por prêmios pagos por beneficiários e/ou seus empregadores; ou, finalmente, se mediante a compra direta de serviços (pagamento direto no ato da utilização de serviços). Entre os principais resultados da análise, destacam-se os seguintes: 1) o SUS financia a maioria dos atendimentos e das internações realizados no País, participação que aumentou significativamente entre 1998 e 2003; 2) embora o número absoluto de atendimentos realizados pelos três sistemas de financiamento tenha aumentado, a expansão do SUS foi muito mais significativa e a ela correspondeu uma desaceleração do crescimento do gasto privado direto; 3) o SUS é o principal financiador dos dois níveis extremos de complexidade da atenção à saúde: o de atenção básica e o da alta complexidade.

A situação atual do mercado da saúde suplementar no Brasil e apontamentos para o futuroThe current situation of the private health plans and insurance market in Brazil and trends for the future

Evidência sobre o mix público-privado em países com cobertura duplicada: agravamento das iniquidades e da segmentação em sistemas nacionais de saúdeEvidence of the public-private mix in healthcare systems in countries with duplicated coverage: greater inequities and segmentation in National Health Systems

This article analyzes the level of progressivity in taxes financing the Brazilian Unified National Health System (SUS). Distribution of the tax burden financing the SUS was calculated using micro-data from the Household Budgets Survey, 2002-2003. The Kakwani index, which shows a tax system's level of progressivity, was calculated. The Kakwani index of public financing was -0.008, and SUS financing was nearly proportional to income. From a social justice perspective this is highly undesirable in a society like Brazil, with a Gini index of 0.57. The system should be clearly progressive in order to counterbalance the country's extreme income concentration.

Health care in Brazil is financed from many sources-taxes on income, real property, sales of goods and services, and financial transactions; private insurance purchased by households and firms; and out-of-pocket payments by households. Data on household budgets and tax revenues allow the burden of each source except firms' insurance purchases for their employees to be allocated across deciles of adjusted per capita household income, indicating the progressivity or regressivity of each kind of payment. Overall, financing is approximately neutral, with progressive public finance offsetting regressive payments. This last form of finance pushes some households into poverty. [Health Affairs 26, no. 4 (2007): 1017-1028 10.1377/hlthaff.26.4.1017 T o a s s e s s b r a z i l i an h e a lt h s ys t e m f i nan c i n g from an equity perspective, this paper analyzes the burden of health-sector financing (by source of financing) across income deciles of the population, as well as the impact of one source of health financing on income distribution and the degree of progressivity of health financing. We base our notion of equitable health-sector financing on the idea of progressivity, where the burden of financing is inversely related to individual income. 1 The Structure Of Health Financing In BrazilSince the 1970s, a large private hospital sector and substantial private health insurance have arisen in Brazil. The current Brazilian public-sector health system was introduced under the new Federal Constitution (1988), which, inspired by the idea of a national health system, created the Sistema Único de Saúde (SUS, or Unified Health System), whose principles are free and universal access to health care, comprehensiveness, and public financing. The SUS functions across Brazil's three levels of government (central, state, and municipality).Brazil's constitution allows the existence of a private sector in health, so the Brazilian health system is composed of a mix of the public system and the private sector. The function of private health insurance is called "duplicative" by the Organization for Economic Cooperation and Development (OECD) because the services covered are basically the same services that the SUS provides.2 In practice, the statutory system is the public one, and the private sector, which comprises both private voluntary health insurance and private providers, operates alongside the public system. In the private sector, people pay private providers using private health insurance or out-of-pocket payments. Because Brazilian income is concentrated, high-income populations purchase private health insurance more than do those in lower income groups.3 Exhibits 1 and 2 show the composition of financing in the Brazilian health sector. The main source of financing is taxes, which support public spending (44 percent of total health spending). One-third (34 percent) of total health spending is out of pocket; spending for private health insurance accounts for 22 percent. The central government finances most public-...