The Brazilian Unified National Health System: proposal of a cost-effectiveness evaluation model.
| Autor | de Oliveira, Lilian Ribeiro |
| Cargo | Report |
Introduction
One of the great achievements of Brazilian people, even in the 20th century, was the promulgation of the Constitution of the Federative Republic of Brazil in 1988 that has among others subjects, the social right as citizenship factor. Citizenship is defined as an inclusion of all individuals that share culture, belief, rights and duties for a specific national policy community (Fleury & Ouverney, 2008). Aiming to guarantee the citizenship, the constitutional text brought large mechanisms of social protection, many times understood as heterogeneous, unequal and ineffective, however built from institutions, human resources and stable resources (Cardoso & Jaccoud, 2005).
From the rights achieved in the named Citizen Constitution, the health care social policy implemented in Brazil was the Brazilian Unified National Health System (Sistema Unico de Saude [SUS]) that has as main objectives universality, integrality, equal assistance, community participation and decentralization of single and centralized command. The SUS is also a policy that involves all the parts of the federation, delegating delivery of services duties, supervision and funding for the states, municipality and the Federal District.
Currently, more than 190 million people benefit from SUS and approximately 75% of that population have exclusive dependence on the public health care system (Portal Brasil, 2009). According to data from the Ministry of Health (Portal Brasil, 2009), the health care system operates with 6.1 thousand accredited hospitals, 45 thousand units for primary treatment and performs 2.8 billion ambulatory procedures per year, 19 thousand transplants, 236 thousand heart surgeries, 9.7 million of chemotherapy and radiotherapy procedures and finally 11 million cases of hospitalization.
However, the new guarantees of social protection formalized in the Constitution were not enough to make the health care system homogeneous. On this way, the politic conjuncture of redemocratization and fiscal crisis contributed for the deep stress faced by the SUS, making it difficult to achieve its directives (Pires & Demo, 2006; Tanaka, Drumond, Cristo, Spedo, & Pinto, 2015).
Even facing many issues and relevant challenges, the SUS is consolidated after 25 years as a health care social public policy in Brazil, trying to guarantee the fundamental principles committed in the Constitution of 1988 (Constituicao da Republica Federativa do Brasil, 1988/2016). Thus, evaluation of SUS becomes a fundamental need in conjunction with other public policies, with the objective to measure levels of attendance considering efficiency and effectiveness.
From evaluations made on SUS, it is possible to highlight the ones made on performance and economic evaluations on health care aspect. The performance evaluation is related to quality improvement and monitoring of actions for the health care system, aiming to attend the principles mentioned of efficiency and effectiveness, also with the population health needs (Portaria n. 399, 2006; Tanaka et al., 2015), in addition to provide control and better use of resources set for the system (Costa & Castanhar, 2003; Ferraz, 2010).
In this context is the Performance Index of the Unified Health System (Indice de Desempenho do Sistema Unico de Saude [IDSUS]), synthesis indicator that represents the directives commitment proposed during the creation of SUS and measures the distance between the real and ideal SUS (according to the international accepted standards) (Forte & Nobre, 2014; IDSUS, 2011; Reis, Oliveira, & Sellera, 2012). The index is relatively new and was announced on March 2012, as a set of 24 indicators that measure access to the health services and the effectiveness of this system, so works as a photography of the Brazilian public health care system in the previous years (triennial 2007-2010) and it is presented as a representation of health condition to the municipalities of the country.
This method offers results for all the municipalities of the country, and they were split in homogeneous groups, following the IDSUS classification. The homogeneous groups are needed duo to high heterogeneity of social, economic and population conditions of the Brazilian municipalities. For this study, the research universe chosen is the Homogenous Group 2, composed by 94 municipalities of the country. Justification for the group choice and deep analysis on the classification of the municipalities made by IDSUS will be handled soon, in the methodological aspects.
In addition to performance evaluations already completed, considering the scenario of insufficient resources and demand increase, it is also possible to see how important the economic evaluation on health care is, what consists in analysing two or more strategies or interventions on health care comparing costs and benefits achieved (Drummond, Stoddart, & Torrance, 1987; Elias & Araujo, 2014; Ferraz, 2010; Ribeiro & Polanczyk, 2005).
There are four types of economic analysis on health care according to Drummond, Stoddard and Torrance (1987): cost-minimization, cost-benefit, cost-effectiveness and cost- utility. The cost-minimization is the most simple among the four types because it observes only the lowest cost between two alternatives; the cost-benefit relates both costs and monetary benefits and compares two alternatives; the cost-effectiveness considers not only monetary benefits but also social benefits; finally the cost-utility is the most refined analysis compared to all the others as it compares not only costs and benefits, but also life quality perception of patients (Camelo et al., 2011; Drummond et al., 1987; Ministerio da Saude, 2008). As part of the most used methods are the cost-effectiveness and cost-utility, as they englobe both monetary and clinical benefits. It is possible to note in Brazil, even as a start, utilization of the cost-effectiveness analysis carried out by the Ministry of Health conducted by the Department of Science and Technology (Departamento de Ciencia e Tecnologia [DECIT]).
It is emphasized that this study proposes a cost-effectiveness analysis model of the current and active health care public policy in the country. Therefore, health care revenues are observed (cost) using database the System Information of the Public Budget for Health Care (Sistema de Informacoes sobre Orcamentos Publicos em Saude [SIOPS]) and the scores achieved from IDSUS (effectiveness) giving as outcome the possible impact produced by the resource on the score achieved.
The purpose of using the cost-effectiveness analysis model is justified because it differs from economic evaluations on health care adopted, which states there are two scenarios that need to be compared, computing other economic variables in the analysis. It is possible to say that this model aims to compare the relations between health care revenue and the IDSUS scores, in order to join two distinct databases and generate a consolidated evaluation.
Utilization of joined data contributes to the efficient management of already scarce resources, being it one of the pillars of public administration. Furthermore, it looks for meeting citizens expectations, who expects from the government better services, reaching the social demands with transparency and integration of all parts of the government (Motta, 2013; Pollitt, 2003).
The Unified Health System (SUS)
In Brazil, access to public health care system as factor of citizenship was established only in 1988 with the promulgation of the Constitution, and hence has been treated as a right of the Brazilian citizen (Conselho Nacional de Secretarios de Saude, 2011; Finkelman, 2002; Santos, Francisco, Faria, & Goncalves, 2011). This fact occurred through Article 196 (Constituicao da Republica Federativa do Brasil, 1988/2016, p. 118, our translation), that states:
Health is everyone's right and duty of the State, guaranteed through social and economic policies with the objective to reduce risk of disease and other injuries and the universal and equal access to actions and services for his promotion, protection and recovery. In the context of the organization and management of the Unified Health System, there are basic premises in the Constitution, decentralization of administration, as single command in each government sphere, democratic governance and participation of civil society (Conselho Nacional de Secretarios de Saude, 2011; Pessoto, Ribeiro, & Guimaraes, 2015). While SUS fundamental premise is decentralization, an important way of universally attend all population and to manage a complex conjunction of actors, its structure is developed including the three spheres of government (Paim, Travassos, Almeida, Bahia, & Macinko, 2011). The Ministry of Health is primary responsible for the national strategy through planning, control and evaluation of public policies implemented by decentralizing the system (Conselho Nacional de Secretarios de Saude, 2011; Finkelman, 2002; Noronha, Lima, & Machado, 2008). However, it is the state's duty to follow directives established at federal level, in addition to formulate their own policies and contribute in the financing, planning, control and evaluation of SUS in their regions; finally, municipalities have to follow national and state directives as a mission, plan, organize, control, evaluate and finance the system at the municipal scope (Conselho Nacional de Secretarios de Saude, 2011; Finkelman, 2002; Gonsalves, 2014; Noronha et al., 2008).
The main financier of the health care universal model in Brazil is the Union, and the management of resources is a municipality role, which allocates available resources according to the needs of the population. Investment in health care should vary according to the variation of the Gross Domestic Product (GDP) (Produto Interno Bruto [PIB]), in the same year, and the municipalities should apply from 12% to 15% of its revenue in the public health care...
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