Brazilian Unified Health System PHC financing Claunara Schilling

Brazilian Unified Health System PHC financing Claunara Schilling Mendonça Universidade Federal do Rio Grande do Sul Geneva, April 2016

Brazilian Federation: three distinct political entities (federal, states and municipalities), each of them with administrative autonomy (without hierarchical submission). Number of states: 26 states and a Federal District Number of municipalities: 5, 562 Area : 8, 511, 996 km² Population (2015): 205 million GNP (2015): US$ 2, 36 trillion Gini: 0, 49 (2014) 0, 54 (2008) Total expenditure per capita on health: US$ 512 Private expenditures on health (2012): 52. 5% Life expectancy at birth (2015): 75. 2 (78. 8 ♀) Infant Mortality Rate (2013): 15/1, 000 live births Matern Mortality Rate (2013): 62/100, 000 Number of physicians (per 1, 000 people, 2011): 1. 8 Brazil

Unified Health System Milestones 1980’s - Sanitary reform movement – social movement against the debt after 20 years of military dictatorship 1988 Constitution – Health as a citizen right Health legislation: general directions (19 September 1990) and social control (28 December 1990). Main purpose: universal health care provided for every citizen Access should be: • Universal • Integrated • Comprehensive

PHC and Family Health Teams Milestones Primary Care delivery model milestones 1991 Beginning of the Community Health Workers Program northeast region 1994 Launching of the Family Health Program 1998 Change of Primary Care financing Primary Care Organization Manual National data system for Primary Care PHC national indicators Capacity Building University Strategy

Six major points in PHC change 1 – Definition of a Family Health Team national standard and its essential functions, integrated to a larger health network. 2 – Changes in funding and growth of budget provisions for PHC. 3 – Definition of responsibilities for each government level in PHC management. 4 – Development of monitoring and evaluation systems. 5 – Support from municipality managers and users. 6 – Positive outcomes and growth in political importance of PHC.

FIXED PAB Financing of PHC • A per capita / year value, intended for financing of primary care activities in general. It ranges from R$20 to R$25 (~US$ 10), according to the calculation basis of the population census. VARIABLE PAB • Representing the fraction of federal funds to finance primary care organization strategies: Family Health (SF); Community Health Agents (ACS); Oral Health (SB); Compensation of Regional Specificities; Indigenous Health (SI); Health in Prisons; NASF; Health School. The maintenance of financial resources transfer regularity of the variable PAB is given by the flow of information on systems (CNES and SIAB). R$ 440. 000 per year ~ US$144, 000

Evolution of PHC $$$ resources – Brazil (Million of Reais) 18 16 14 12 10 PAB Variável PAB Fixo 8 6 4 2 0 2002 SOURCE: National Health Fund 2004 2006 2008 2010 2012 2014

PAB changed the mode of payment for production and represents an innovation in health financing. For the first time in Brazil, the transfer of federal funds is more equitably distributed in the country.

PER CAPITA DISTRIBUTION OF PRIMARY CARE FINANCIAL RESOURCES 1998 2008 Up to 20 - 40 Up to 40 - 60 Up to 60 - 80 More than 80 (R$/hab/year)

EQUITY Distribution of the Family Health Teams according to municipalities income bracket Source: Ministério da Saúde; Saúde da Família no Brasil – Análise de Indicadores Selecionados, 2008.

Mais Médicos [More Doctors] Program 18, 240 physicians in 4, 058 municipalities and 34 Indigenous Districts 72. 8% of Brazilian municipalities 63 million Brazilians covered BUDGET: R$ 2. 9 billion (2016)

FACING THE CHALLENGES • Providing more money for low HDI cities, Amazon region cities and, lately, to violent areas in the big cities to pay more to the professionals • Investing in better infrastructure • Building management capacity for the decentralized system • Stimulating regular contracts with the PHC workers • Stimulating the redirection of research production on PHC and community-based needs, developing a high level PHC research network

Mais Médicos Program and Equity Fonte: Rede Observatório do Programa Mais médicos

CHALLENGES

FACING THE CHALLENGES • Providing more money for low HDI cities, Amazon region cities and, lately, to violent areas in the big cities to pay more to the professionals • Investing in better infrastructure • Building management capacity for the decentralized system • Developing advocacy: PHC and FH International, National and Regional Conferences, Exhibitions and Meetings (2008 III National Exhibition with 7, 000 participants) • Strengthening the Family Medicine association – SBMFC • Stimulating regular contracts with the PHC workers • Implementing partnerships with universities to create attractive programs, able to keep professionals in PHC teams • Providing specific funds to the universities to support PHC • Stimulating the redirection of research production on PHC and communitybased needs, developing a high level PHC research network

Old and New Challenges for the Family Health Strategy • Lack of infrastructure - needs improvement and to be more effective • Financial issues – hospitals X PHC • Burnout of good FH professionals after 5 years • Old practices brought to the Family Health Teams • Professional qualification – few medical residencies, very few Master degrees, no Ph. D and high resistance to have Family Medicine Departments at the universities • Lack of social prestige • Difficult integration of the services network

Family Health Team • At least one physician, one nurse assistant and 4 to 12 community health workers. Most of the teams include dentists (65%) • Each team is assigned to a defined geographical area and is responsible for about 1, 000 families • User fees are not permitted and there is no evidence of informal payments. • Some municipalities are beginning to use performance payment • Employment contracts are responsibility of municipalities