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World Report www.thelancet.com Vol 387 April 16, 2016 1603 Brazil’s health system woes worsen in economic crisis Budget cuts and political instability are exacerbating existing problems in Brazil’s public health system amid increasing patient demand. Jonathan Watts reports from Rio de Janeiro. When José da Costa Filho started struggling for breath, his family knew from experience of Brazil’s health system that they faced a gauntlet in getting the emergency care needed for the 67 year old. Given the recent deterioration of the economy and reports of funding cuts in their home state of Rio de Janeiro, they also had an inkling that securing access to a doctor and hospital bed might be more fraught than usual. But even in their worst nightmares, they never imagined the resource shortages, legal battles, and bureaucracy that ultimately resulted in what the family say was a fatal delay. Filho was ﬁ rst taken to the Santa Luiza Emergency Care Unit on Dec 3. He had a tumour and heart condition and was evidently gasping for breath, but it took 9 hours before he could see a doctor, who diagnosed pneumonia and sent Filho home with antibiotics. When he worsened on Dec 28, the family decided to go directly to a hospital, but were turned away on the grounds that staﬀ could only handle “life-threatening cases”. They returned to an emergency unit, where a doctor diagnosed severe pleural effusion and recommended immediate transfer to a hospital. But again there was no space, so he spent most of the time at the emergency unit. “There was no water at one point, so the nurses couldn’t even wash their hands. They didn’t have new sheets, so my father was on dirty sheets. And the staff there [were] working with what they have, doing the best they can in the circumstances, even without receiving their salaries”, his daughter Sheila told The Lancet. Distraught as she watched her father deteriorate, she then ran a 2-day legal gauntlet of doctors and judges to secure a court order for her father to be transferred to the hospital. Many other anxious families were doing the same thing, but eventually, at 4:30 am on Jan 8, the order was granted. Even with that, it took more than 24 hours— and another visit to the judge—to secure a place. It was too late. On Jan 13—6 weeks after he first tried to get treatment—Filho died from a stroke. “The feeling of injustice is so strong. It was those days of waiting that made him weak”, Sheila recalled. “Our outrage is because when you most need help, it’s not there.” Such complaints are increasingly common in Brazil, where long-standing problems in the country’s health-care system have been exacerbated by economic and political crises. In 1988, Brazil became one of the ﬁ rst countries in Latin America to make access to health care a constitutional right, but despite the establishment of the Uniﬁ ed Health System (widely known by its Portuguese initials SUS) to provide universal care, the government has struggled to live up to its promises. There have been important gains. Life expectancy increased by 19 years between 1960 and 2012, although at 73·7 years, it is still considerably shorter than the Organisation for Economic Co-operation and Development (OECD) average of 80·2 years and infant mortality has come down from 51·5 deaths per 1000 livebirths to 12·9, although this is still more than three times the average in wealthier nations. The Workers Party Government, which came to power in 2003, supplemented hospitals with a network of emergency treatment units and dispatched doctors (many of them Cuban) to remote regions under the Mais Médicos programme. The country has also won international kudos for its efforts to tackle HIV/AIDS, tuberculosis, and most recently the Zika virus (panel). But the safety net has gaping holes. Frustrations about waiting times, access to beds, availability of doctors, and the costs of medicine were among the many complaints raised by demonstrators in the mass protests of 2013. The problem is not purely about expenditure. Brazil’s total health-care spending (public and private) as a proportion of gross domestic product (GDP) increased from 9·2% to 9·7% between 2011 and 2015, according to the World Bank. This is higher than that of the UK and Sweden. But the overall quality of service is considerably lower because the money does not go far in such a large country that is also plagued by inefficiency and inequality. On “...long-standing problems in the country’s health-care system have been exacerbated by economic and political crises.” Panel: Responding to the Zika outbreak Despite recession and political crisis, the Brazilian Government has won plaudits from WHO for its eﬀ orts to tackle the Zika epidemic. But while the government claims no expense has been spared in the national drive to destroy the mosquitoes that carry the virus, doctors at a local level complain funding shortages make it diﬃ cult to treat infants with related diseases. This is particularly true in the northeast, where most cases of Zika—and the apparently related fetal defect of microcephaly—have been reported. In Recife—the worst aﬀ ected city—the health secretary requested emergency support of US$7 million to tackle Zika, but he was given less than a tenth of this amount. Doctors in the municipality have reported diﬃ culties procuring vigabatrin, one of the main treatments for children born with epilepsy linked to Zika-related brain damage. On a more positive note, the number of new cases of microcephaly has fallen sharply, probably as a result of cooler weather 9 months ago, which meant fewer mosquitoes to bite pregnant women. There are also hopes that the population will develop immunities over time. With so little known about the disease, forecasts remain a matter of guesswork, but oﬃ cials will be desperate for cases to stay on the low side. Given the state of government budgets, Brazil really cannot aﬀ ord a growing crisis. 1604 www.thelancet.com Vol 387 April 16, 2016 World Report average, US$1109 was spent on each of the country’s 200 million residents in 2012, less than a third of the OECD average. As a result, there are fewer doctors (1·8 per 1000 people compared with the OECD average of 3·2), fewer nurses (1·5 compared with 8·8), and fewer hospital beds (2·3 compared with 4·8). They were not shared equally. Less than a quarter of the population have private health insurance. The remainder use SUS, which accounts for only 46% of health-care spending—well below the OECD average of 72%. There are also wide geographical diﬀ erences in coverage. The poorest northern state of Maranhão has less than a ﬁ fth of the doctors per person of the wealthier southeastern state of Rio de Janeiro. Austerity measures These problems are being exacer- bated by an economy that is now in its deepest recession in more than a century. GDP shrunk by 3·7% in 2015 and is expected to decline by about the same amount this year. With tax revenues down, governments at national, state, and municipal levels have tried to introduce austerity measures. Public health-care budgets are among the ﬁ rst to be curtailed. At the end of March, the planning ministry announced its latest cut—of 2·3 billion reais—to the federal health- care budget. This is barely 2% of the total, but the impact will be greater, according to Carlos Ocke-Reis, senior economist in the health ministry, because the pressure is coming from all sides. “It is not just the funding cuts, it is also the increase in demand for public services because many laid-oﬀ workers are dropping out of private health-care plans”, he said. “And the costs of treatment are going up because the weak currency pushes up the price of imported drugs and medical equipment.” Worsening the situation is political instability. The health system has become just another bargaining chip. Embattled President Dilma Rousseff, who might face impeachment, is poised to appoint her fourth health minister in 6 months as a result of reshuﬄ es aimed at buying off the support of smaller parties with the lucrative post (which controls one of the biggest budgets in the cabinet). The ﬁ rst to go was Arthur Chioro, a professor of public health and member of the Workers Party who was a strong advocate for the public health system. The next in line, Ricardo Barros, is from the more conservative Progressive Party and is in favour of welfare cuts. Cuts are also being made at lower levels, prompting crises in some cities. In Rio de Janeiro, at the end of 2015, salaries for doctors and nurses were delayed and several hospitals operated on minimal staﬀ that allowed treatment for only life-threatening cases. There were reports of inpatients having to buy their own cleaning materials and morgues where bodies had to be left in corridors because there were not enough refrigerator units. In late December, the Medical Union sued the Rio State Government for failing to commit the legally required minimum of 12% of its budget to public health. Earlier this year, it’s president Jorge Darze warned the health system was ill prepared for the influx of Olympic visitors. “What worries me is the possibility that tourists could contract diseases such as Zika and not be able to get adequate medical support”, he told a press conference. The broader problems are evident in Mesquita, a northern district of Rio State, where local doctors say a single emergency unit with about 12 doctors is the only medical facility for the 185 000 population. The staﬀ have always been overloaded with cases, but more so since the end of 2015 as other medical institutions turned people away due to funding disruptions. The facility has been unable to cope with patients it was never designed to treat, yet it is also suﬀ ering from shortages. “We have heart attack patients who have to stay here for 3 or 4 days without transfers or adequate tests”, said general practitioner Fabricio Quintanilha. He said only two of the units four respirators were working, several of the cardiac monitors were broken, salaries were being paid late, equipment was in short supply, and waiting times were growing. “We are overworked”, he said. “This situation increases mortality and morbidity.” Emergency nurse Bianca de Rossi said the unit was still able to handle life-threatening cases, but its other functions were becoming impossible. “We’ve become a substitute ambulance service for emergency services because other parts of the health system are overwhelmed”, she said. “I would say we see about 700 cases a day, sometimes more. 2 years ago, I guess the amount was half that.” Doctors prioritise the most severe cases. Other patients have no idea whether they can get treatment even if they wait all day. “It’s very worrying”, said Lucila Nascimento, who came with an elderly aunt who she fears might have pneumonia. “They did an initial check, but now we’ve been waiting 4 hours for an x-ray. I hoped she would be a priority because she is old and blind.” The tensions often result in abusive encounters and even violence. “We get threatened a lot. It’s frightening”, the nurse de Rossi said. “We can’t meet needs, so people are frustrated. The economy is bad. The state is not paying its bills. We are very vulnerable. This is the worst situation I have seen since I became a nurse 4 years ago.” With the government paralysed by political battles and the economy gripped by recession, the situation looks unlikely to improve any time soon. Jonathan Watts “At the end of March, the planning ministry announced its latest cut—of 2·3 billion reais—to the federal health-care budget.” Dilma Rousseﬀ Brazilian Presidency/Xinhua Press/Corbis f private health-care plans”, he said. “And the costs of treatment are going up because the weak currency pushes up the price of imported drugs and medical equipment.” Worsening the situation is political instability. The health system has become just another bargaining chip. Embattled President Dilma Rousseff, who might face impeachment, is poised to appoint her fourth health minister in 6 months as a result of reshuﬄ es aimed at buying off the support of smaller parties with the lucrative post (which controls one of the biggest budgets in the cabinet). The ﬁ rst to go was Arthur Chioro, a pr