Though Brazilians don't always take their grievances to the streets, making last year's demonstrations a surprise, they are known to be vocal about identifying the country's problems. Health is a case in point, whether it's complaining about the difficulty of getting a doctor's appointment or sharing videos on health care horror stories. (See: woman giving birth right outside a hospital due to lack of doctors or a doctor lamenting the state of health care.) During this election year, when you'll likely see a lot of analysis on how the economy will impact the vote, other top voter issues to pay attention to are the same ones brought up during the 2013 protests, particularly health care, corruption, and education.
Health care is something of a low-hanging fruit as far as voter issues go. With the growth of the new middle class and rising standards of living, more people are turning to private health care and many are demanding higher quality care. To put this issue in perspective, I've broken down some of the numbers involved in Brazilian health.
A row of ambulances in Bahia. (Image: Government of Bahia)
Public Opinion: A Growing Priority
Surveys show that health care is increasingly identified as a problem in the country and an issue that should be prioritized. Released this month, a Datafolha poll contracted by the National Council of Medicine found that:
- 93 percent of Brazilians say that both public and private health care are okay, bad, or terrible. Of those who use the public health care system, 87 percent expressed dissatisfaction.
- In the last two years, 92 percent of Brazilians used the public health care system, and 89 percent received assistance through this system. Most of those who had to wait to receive care (ranging from weeks to months) were women between 25 and 55 years old and of low income.
- Around 57 percent said that health should be the federal government's priority, compared to 18 percent for education and 8 percent for fighting corruption.
A March Datafolha poll contracted by a pharmaceutical group found similar results.
- 45 percent identified health care as the country's biggest problem, compared to 18 percent for security, 10 percent for corruption, and 9 percent for education. In 2006, only 6 percent identified health as the country's biggest problem.
- Of those surveyed, 62 percent said health care overall was bad or terrible. Those who identified health care as such tended to live in larger cities, have more education, and higher salaries.
- But it's not just the public system. Around 70 percent of those with private health care plans said their care was bad or terrible.
- Around 47 percent said they would rather pay less taxes and buy private health care, and 43 percent said they'd rather pay high taxes and keep public care.
Access to Doctors
Though the Brazilian government has increased its health budget, the country still has an insufficient number of doctors. Brazil has 1.8 doctors per 1,000 people, above WHO's 1.4 minimum but below its neighbors (Argentina has 3.2, Uruguay has 3.7). This, despite the fact that the Ministry of Health tripled its public health system budget over the past 11 years, rising from $27.2 billion in 2003 to $91.6 billion this year.
For example, the state of Rio de Janeiro has around 16.2 million people, but only 58,000 doctors. At 3.6 doctors per 1,000, that's more than São Paulo, with only 2.6 doctors per 1,000. Amazonas, the country's largest state by geographic size, has only 4,000 doctors for 3.5 million people, or 1.1 per 1,000.
To tackle this problem, last year President Dilma Rousseff launched the "More Doctors" program, which imports medical professionals from abroad, with a large contigent from Cuba. There are now over 13,000 foreign doctors working throughout Brazil. While the program faced controversy, around three-quarters of Brazilians approve of More Doctors, according to an April poll.
In 2013, when the More Doctors program began, the country had about 374,000 practicising doctors, around 53,000 short. The program aims to have 2.7 doctors per 1,000 by 2017, and 600,000 total physicians by 2026.
Private Health Care on the Rise
Recent estimates show that around a quarter of Brazilians have private health care plans. (Datafolha put this number at 27 percent earlier this year.) At the end of 2012, there were around 48 million beneficiaries of private health care plans, a 17 percent increase from 2011, says a PricewaterhouseCoopers report. Plus, an estimated 8 out of 10 new private health care users come from the C class, or new middle class.
Edson de Godoy, CEO of AMILpar, one of Brazil's largest private health care providers, told Fortune: "Our competitive advantage is the deep knowledge of the three pillars that compose our market: hospital, laboratory, and the health-care plans. Brazil has been changing a lot in the last 10 to 15 years, and we have been open to these changes, especially to the market ones. If the society develops, we develop with it." Specifically, he explained, private health-care has become more available to lower income families, and as the government seeks to focus on health, the private sector can provide solutions.
The PwC report adds that the health insurance market is very fragmented, and that no hospital group has national coverage; all private hospitals operate only regionally. The greatest proof of the fragmentation of this market is that no Brazilian private hospital owns 1 percent of market share based on beds.
And though more people are turning to private care, it doesn't mean they're satisfied. Health insurance companies are the most complained about businesses, according to the Brazilian Consumer Defense Institute. Last year, health insurance companies made up nearly 27 percent of consumer complaints.
With plenty of new plans popping up, the government's regulator, the National Supplementary Health Agency, has penalized companies that don't provide care within a timely manner. For example, this month it temporarily suspended sales of 123 plans from 28 companies for failing to adhere to these time limits.
Health Care Expenses
Families spend around 7.2 percent of overall expenses on health, as of 2009, according to the Brazilian Institute of Geography and Statistics (IBGE). Around half of those expenses go to medications, and nearly a third to health insurance.
And while Brazil has a large public health care system, IBGE found that over 56 percent of health expenses come from consumers, with another 44 percent from public sector spending.
Though medical debt doesn't compare to the United States, some of the country's private hospitals, particularly in São Paulo, can charge astronomical prices for patients with serious and long-term illnesses. "Medicine must be treated as a social model. This current mercantilist model has a perverse logic and only ends in cruel results," Brazilian neurologist Rogério Adas told the BBC.in April.
Time is another issue. Along with shortages of doctors in ERs, patients sometimes end up waiting for physician care. As of February, there were over 300,000 pending cases demanding health services from the public system, Fernando Aith, a preventive medicine scholar at USP, told GlobalPost.