Author(s): Pérez MA*, Siliansky MF, Karkow LP, Sant’Ana P, Mesquita LG, Moreira IM and Sousa RM
Thirty-one years ago (July 1990) Brazil regulated a public and universal health system (UHS) created by the new 1988 Constitution that has been progressively enhanced throughout the following years [1]. It might not be considered too naïve to forecast that in the present century, most countries in the world will engage in similar systems where from primary care to organ transplantation is assured to all citizens.
This article will describe a few of the overwhelming difficulties of this toilsome task, particularly in developing countries [2]. Great Britain (UK) for instance expended 10.3% of its Gross domestic product - GDP which is roughly the same amount of expenditure found in Brazil. However, while 83,1% of the health expenses in Great Britain was public, in Brazil, only 46% was, which means a huge inequality between social groups in the amount of money spent in health because only 25% of the population has an almost integral access to the private providers through voluntary private insurance and the UHS guarantees access for all [3]. On the other hand, the UK population was estimated in 2020 to be approximately 68 million souls, with a GDP totaling U$ 2,83 trillion while in Brazil this number is around 220 million inhabitants with a GDP of U$ 1,84 trillion, which implies a huge disadvantage for health care at the starting line [4]. In Contrast hand, Brazil has established an exemplary model for HIV/AIDS assistance, which covers all citizens with free inpatient and outpatient support as well as treatment coverage.
Quality of healthcare is another issue of paramount importance and our group has recently published a paper where skin cancer mortality was strongly correlated with variables associated with lower income, which suggests that the primary goal (decrease in health inequality) of a universal health system is still far from becoming a reality, albeit over thirty years has gone by since legal implementation of UHS [5]. Delay in diagnostic and especially treatment procedures due to an overwhelming range of problems (poor throughout clinical examination, excessive time for more sophisticated exams, etc.), is simply the landmark of poorer or better prognosis.
Quality of medical information is another important bottleneck to be addressed. Our research group is currently analyzing data on mortality for cardiovascular and cerebrovascular disease, with data retrieved from death certificates from over 5,000 counties. A very strong correlation has been found (data not yet published) between higher income and cardiovascular and cerebrovascular deaths which may suggest an important lack of precision in filling out this important document, especially when lower income is also associated with poorer health quality, which again is a major contradiction of any universal health care, which is a well-known phenomenon worldwide, where accuracy of death certificates may vary, depending on the registered pathology from 20% to 90% [6,7].
Another issue that shall be addressed is the vital importance of at least some level of independence between public health services of every state or county and any central political government. For the first time in its history, Brazil has been living in a democratic system for little over 30 years. Our current president has become worldwide famous for defending some of the most nefarious (to say the least) policies against the COVID-19 pandemic. However, most of the laws he tried to pass, regarding the pandemic, were simply discarded by congress, senate or even the supreme court. As a surplus, the strong independence of local governments (state and counties) allowed them to simply ignore most of the more damaging guidelines issued by the Ministry of Health.
Finally, it is also important to draw some concern regarding the cost of medical treatment. Although the pharmaceutical and medical industry as a whole invests billions of dollars and receives a good amount of public funds for basic research, specially of risky products to develop newer and more efficient drugs and medical equipment and therefore, are entitled to profit from that investment, the fact remains that most of the efficient new treatments and procedures will take many years until they become financially feasible to be applied in a universal public health system, including now poorer or richer countries [8]. This is particularly troublesome for many pathologies in which neoplasm disease is an excellent example. In fact, prices are initially high due to the fact that pharmaceutical industry recovers the investment made to develop that new agent, but on the other hand, hundreds of thousands of treatments are not being sold, and consequently there is no profit at all, just an overwhelming amount of deaths, due to high prices that are sometimes initially established. Although this is a very complex situation that has been many times addressed over the years, this simply can’t be an unsolvable issue in the current century [9,10].
In short the authors conclude that albeit there is all evidence of a worldwide unstoppable march towards a universal health system, its implementation will be hindered by many issues such as funding, health care quality, as well as reliable information systems, the ever growing cost of healthcare as well as some degree of independence for medical support in county or state levels in order to cope with greater shifts in central political power.
