Question

An examination of the financing and delegation of responsibilities in brazil/ mexico countries with healthcare systems characterized by central policy and/or fiscal control and delivery of services delegated to state, regional, or local institutions"

How well does central funding and local delivery appear to be working in those countries where it is part of the healthcare system?

How equitable does the funding stream for central policy development with local delivery of services appear?

What is the impact of rural/urban disparities on the delivery of healthcare services?

How does geography impact the delivery of healthcare services?

How is healthcare delivery impacted by transportation and communication infrastructure inadequacies?

How is the private sector incorporated into the delivery of healthcare services?

need this answer in 2 to 3 page include refenace list.

Answer 1

Brazil is a populous high/middle-income country, characterized by deep economic and social inequalities. Like most other Latin American nations, Brazil constructed a health system that included, on the one hand, public health programs and, on the other, social insurance healthcare for those working in the formal sector. This study analyzes the political struggles surrounding the implementation of a universal health system from the mid-1980s to the present, and their effects on selected health indicators, focusing on the relevant international and national contexts, political agendas, government orientations and actors.

Starting in the late 1970s and early 1980s, the international debate surrounding the crisis of the nation-state and the neoliberal agenda began to reverberate in Latin America. Some countries, like Mexico and Chile, were influenced by early neoliberal economic reforms, also with effects on their health policies [5].

While other countries in the region were moving toward a neoliberal model, Brazil took a somewhat different path. During these years, it experienced a serious economic crisis, criticisms of the model of import substitution industrialization (ISI), and a movement toward democratization after nearly two decades of military dictatorship. Brazil also experienced intense social mobilization in favor of progressive reforms.

It was in this context that the movement for healthcare reform emerged, seeking to transform a health system that was segmented, fragmented, inefficient, and oriented toward privileging the private sector while excluding most of the population. The healthcare movement brought together various groups seeking to construct an agenda for reform of this sector. Key groups involved included academics at university departments of preventive medicine or public health, administrators, and experts from the federal Ministry of Health and from the health bodies connected to the Ministry of Social Security, and health professionals, among others. These years also witnessed the formation of the Brazilian Center for Health Studies (CEBES), the Brazilian Postgraduate Association in Collective Health (ABRASCO), and national councils of state and municipal secretaries of health. These healthcare professionals joined with other social movements, including community-based movements associated with the Catholic Church and progressive politicians to construct a reform agenda [6, 7].

Successful experiences with reorganizing health care systems at the local level, along with the presence of progressive public health officials in national posts, set the stage for gradual transformations in healthcare institutions, even as a national reform agenda was created, based on the recognition of health as a right of citizenship. During a 1979 symposium in the Chamber of Deputies (the lower house of Congress), CEBES presented a paper focusing on the relationship between democracy and health [8].

After nearly two decades, gubernatorial elections were held in 1982, and elections for mayors of state capitals and cities designated as “national security” zones in 1985. Also in 1985, Congress indirectly elected the first civilian president since 1964. With the death of the President-elect before his inauguration, the Vice President-elect took office and assembled a broad coalition government.

In 1986 the Eighth National Health Conference brought together over 4000 participants from across the country—academics, administrators, health professionals, social movements, and ordinary citizens—who advocated for the strengthening of the public system and for the designation of health as a right. The conference led to the formation of the National Committee for Health Care Reform, which elaborated a reform proposal that was presented to the 1987–1988 National Constitutional Convention. Brazil already had an important private health sector, with private hospitals contracted by public social security institutions, as well as a growing sector of private health insurance plans. These groups pressured legislators to avoid proposals that could result in a radical shift toward state control and the imposition of constraints on the private sector [9].

The 1988 Constitution recognized health as a universal right that the state was required to provide, guaranteed by broad social and economic policies. It also institutionalized the concept of “social security”—comprising health, pensions, and social assistance—and the Unified Health System (SUS), a public, universal system intended to ensure comprehensive health care for the population. The Constitution affirmed the complementarity of the private sector, with priority for philanthropic and non-profit institutions. It also stated that health care would be “open for private investment,” thus retaining openings for expansion of the private system, even as it failed to address important questions regarding public financing of healthcare.

The global transformations of the 1970s and 1980s affected Brazil, with implications both economic (economic crisis, the exhaustion of ISI) and political (democratization). However, the national context better explains social changes, including in health care. The international agenda of neoliberal reforms did not have the same impact on Brazil in the 1980s as elsewhere in Latin America. The temporal sequence of two processes—democratization and economic liberalization—and the promulgation of a comprehensive Constitution served to shield Brazilian social policies from the neoliberal reforms: they would begin later, in a less aggressive and more pragmatic form [10]. The return to democracy in the 1980s created an atmosphere conducive to mobilization for universal healthcare reform, with the support of state and local governments and legislators. The inauguration of a civilian president and the calling of a National Constitutional Assembly, amidst a climate of intense debates over the future of the country, played a significant role in enabling the creation of SUS, a system inspired by the experiences of other countries, like the United Kingdom’s National Health Service (NHS) and Italy’s healthcare reform.

On the other hand, several key political actors were not on board with the SUS agenda. For example, the businesspeople who controlled the private sector sought to protect their market share. The labor movement expressed inconsistent positions regarding the conflict between weakening workers’ access to healthcare and universalizing the system; they also lobbied employers to provide private plans. For their part, although medical doctors rarely oppose SUS directly, and the organizations representing them espoused a range of positions, their responses to its agenda were motivated primarily by their collective professional interests.

Over the following decades, these conflicts of interests and projects would surface forcefully. Two aspects—restrictions on public financing, and the nature of public–private healthcare relations—emerged with the difficulties in constructing a universal public system capable of helping to overcome the fragmentation of the system and reduce healthcare inequalities.