Review Article
General Science
Public Health

The pursuit of health care for all Brazilians

Eduardo Cruz1, Simone Cruz1, Edy José Pereira da Silva Filho1, Cristina Boaretto1, Maria Goreti Rosa-Freitas2

Abstract

In the pursuit to provide public, free, and universal health care for all citizens, Brazil has put many different public health policies and management models into practice for almost a century. Our objective in this paper was to carry out a historical review of the developments in public health policies in Brazil over the last century and to present recent health data, the role of current policies and management models and the directions these policies are likely to take. We reviewed facts as a historical timeline that depicts the major turning points in health policies. The results showed that, as a function of the four principles that guide the current Unified Health System in Brazil—universalization, decentralization, regionalization and social control—new management models have been implemented. Although the data are still incipient, current trends in basic health care in Brazil show evidence of innovation in public health actions, the migration of professionals and high-quality services to geographical areas where they did not previously exist, and increased access to primary health care with improved coverage of the population.

Keywords Health policies, management models, Brazil.

Author and Article Information

Author info
1 Instituto de Atenção Básica e Avançada à Saúde-IABAS
2 Laboratory of Mosquito Vectors of Haematozoans-LATHEMA, Oswaldo Cruz Institute-FIOCRUZ

ReceivedJan 30 2014  AcceptedSep 1 2014  PublishedOct 8 2014

CitationCruz E, Cruz S, da Silva Filho EJP, Boaretto C , Rosa-Freitas MG (2014) The pursuit of health care for all Brazilians. Science Postprint 1(1): e00034. doi: 10.14340/spp.2014.10R0001

Copyright©2014 The Authors. Science Postprint is published by General Healthcare Inc. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs 2.1 Japan (CC BY-NC-ND 2.1 JP) License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

FundingNo financial support of any sources.

Competing interestThere are no competing interests.

Corresponding authorMaria Goreti Rosa-Freitas
AddressLaboratory of Mosquito Vectors of Haematozoans-LATHEMA, Oswaldo Cruz Institute-FIOCRUZ, Rio de Janeiro 21045-900, Brazil
E-mailgoreti@ioc.fiocruz.br

Introduction

Health care in Brazil

Since the inception of social protection mechanisms through social insurance in the 1920s, health coverage in Brazil has aimed to be free (not requiring any charges) and universal (allowing access to medical care for all citizens). To provide free quality health care to almost 200 million people is a challenge. For nearly a century, many health policies and managerial schemes have attempted to achieve this goal. Brazil is a continental country of more than 8 million km2, and its administration is complex. Administratively, Brazil is hierarchically divided into federal, state and municipal governments. The federal administration is represented by the central government and is located in Brasília, the capital of the country. State-level administrations are represented by the 26 state governments plus the Federal District and are located in each of the 27 capitals. The municipal-level administration is carried out by the prefectures of the 5598 current Brazilian municipalities 1. The responsibilities of the different hierarchical levels—federal, state, and municipal—are distinct and have evolved over time.

The aim of this manuscript is to carry out a historical review of the developments in public health policies in Brazil over the last century and to present some recent health data that include new managerial models with the participation of public-private partnerships with third-sector social organizations and the directions these policies are likely to take.

Methods

A literature review was conducted by searching PubMed and Google for the words “health,” “system,” “policy,” and “Brazil” in English and Portuguese. Scientific papers, books, official publications and information from websites were used to construct a timeline for the previous 100 years to historically place major turning points in the development of Brazilian health policies and their attempts to achieve free and universal health coverage, as well as to situate and discuss the results found in the search.

The term “health policy” as used in this paper is defined as a set of administrative measures including decisions, management models, plans and actions chiefly carried out by governmental bodies that aim to achieve certain health care goals 2, as proposed by the 1988 Brazilian Constitution 3.

Results

The first attempts to achieve comprehensive health care coverage for the Brazilian population were established in the early 1920s and have changed over time (Figure 1).

Figure 1Timeline summarizing the main hallmarks and turning points in health policies in Brazil over the last 90 years

The 1920s

An incipient form of health care was created through social insurance in Brazil dating back to 1923. This social protection policy offered social insurance, health care and medicine 4.

The 1930s

Despite the creation of the Ministry of Education and Health in 1934 5, no further developments in health policies in Brazil were recorded in the 1930s.

The 1940s

In 1942, the Special Public Health Service (Serviço Especial de Saúde Pública: SESP) was created in an agreement between Brazil and the United States that was intended to internalize medical care to distant and disadvantaged Brazilian regions that were of importance to the production of war supplies during World War II. This Special Public Health Service stood out as a result of the introduction of innovative health care management methods, such as the use of planning, evaluation of said planning, and training methods for public health personnel. The Special Public Health Service was also a pioneer in home-based primary care through the use of auxiliary staff, and it implemented hierarchical networks of integrated health care, providing preventive and curative services with the possibility of hospitalization in basic medical specialties in its health units 4.

In 1949, the Domiciliary Urgent Medical Service (Serviço de Assistência Médica Domiciliar de Urgência: SAMDU) was created, whose importance to the health care system evolved from 3 innovative features: i) home medical care provided by the public sector, which had previously existed only through private practice, ii) consortium funding among the various retirement and pension institutes, and most importantly, iii) the universal characteristics of medical care, even if they were limited to emergency and urgent cases. However, universal health care to all citizens was still some distance away from being achieved.

The 1950s

In 1953, the Ministry of Health was established as an agency separate from the Ministry of Education, without new health policies in Brazil being established.

The 1960s

Created in 1966, the National Social Security Institute (Instituto Nacional de Previdência Social: INPS) increased coverage of the population by extending it to rural areas, albeit through a different regimen. An attempt at universalization, i.e., access to medical care for all Brazilian citizens and health care integration between primary, secondary and tertiary health levels, was carried out in 1968 with the launch of the National Health Plan (Plano Nacional de Saúde: PNS); however, this plan was never implemented. Among its other goals, the National Health Plan aimed to privatize the public health network and sponsor free choice of professionals and hospitals for the citizenry. With strong resistance from various sectors, the National Health Plan was cancelled 4. A new plan, the National Health System Plan, followed, but it was also cancelled for the same reasons.

The 1970s

In the 1960s 6, domestic voices began to echo the message from leaders of international organizations that health care should be carried out with the use of simple, low-cost techniques applied without risk or difficulty by elementary-level personnel recruited in their own communities and remunerated in accordance with local standards. Pursuant to this movement, health care programs were formalized 7. Initially, these were established in Northeastern Brazil and were funded by the Ministry of Welfare and Social Assistance (Ministério da Previdência e Assistência Social: MPAS) and the Healthcare Fund (Fundo de Atendimento à Saúde: FAS); beginning in 1979, they were further extended to other regions. These assistance programs were expanded by the formalization of agreements with State health departments, which marked a paradigm shift in the manner in which welfare had been administered in Brazil. Previously, social security acted directly through its own network, having been concentrated in major centers and almost entirely indirectly through contracts with private networks.

Still, during the totalitarian political period in Brazil in the early 1970s, the universalization of emergency care and the payment by social security of services contracted and/or provided by the private medical care network took place. Before the current Unified Health System (Sistema Unificado de Saúde: SUS) could be consolidated at the end of the 1980s, the Plan of Ready Action was launched. The Plan of Ready Action consisted of a set of mechanisms whose purpose was to gradually reach the universalization of medical care. Improvements in medical care were accompanied by policies to expand social rights, such as the extension of rural worker pensions and the creation of a monthly benefit for non-taxpaying senior citizens. Nonetheless, the aspiration for universal and integrated medical care had to wait once again. In response to the continuous and deep economic crisis of the late 1970s and during the following two decades, when repercussions to the governmental financing continued to be experienced, the Brazilian health system suffered from managerial disorganization.

The 1980s—the 1986 VIII National Health Conference and the 1988 Brazilian Constitution

The disorganization of the health system was the result of falling tax revenues, low social contribution, and the absence of health policies and management models brought about by the Brazilian economic crisis that started at the end of the 1970s. The economic crisis that would last for approximately 20 years also brought a decrease in the quality of life of the population accompanied by an increase in health care needs. This event resulted in a lack of basic materials, a lack of equipment, no construction of health units and the failure to attract skilled labor. In the shadow of this deep economic crisis, the movement for health reform in Brazil began. The health reform’s main demands were the improvement of the health of the population, the establishment of health as a universal right, the responsibility of the government to provide health care, care completeness, equality in attention and the decentralization of actions and services. The complete lack of activities in the area of preventive family health, however, was noted by various specialists as the major drawback of the entire structure of basic health care programming in Brazil.

The main health care goals were revisited in the 1986 VIII Health Conference and the National Constituent Assembly, at which time some of the principles that currently govern the Brazilian SUS were put into place. Some of these principles were contained in previous documents like the Interinstitutional Planning Commission (Comissão Interinstitucional de Planejamento-CIPLAN 1980), Reorientation Planning on Health Assistance (Plano de Reorientação da Assistência à Saúde: CONASP 1982), Health Integrated Actions (Ações Integradas de Saúde: AIS 1984), Programme for the Development of Unified and Decentralized Health Systems (Programa de Desenvolvimento de Sistemas Unificados e Descentralizados de Saúde: SUDS nos Estados 1987) 4. The promulgation of the Brazilian Constitution of 1988 3 brought about the creation of the SUS 8, 9, as a milestone, which continues to exist today. For the first time in the history of Brazil, health as a social right was established as a new model for governmental action. Articles 196 10 and 198 11 of the Brazilian Constitution defined the policies to be adopted and the public health actions and services to be given within a regionalized and hierarchical network as a single system, the SUS, organized according to the following four pillars: i) universalization, ii) decentralization, iii) regionalization and full services, with priority given to preventive health activities, but non-detrimental to assistance services, and iv) social control through community participation (Figure 2).

Figure 2 A major turning point: the 1988 Brazilian Unified Health System (SUS) with its 4 pillars

The 1990s

Until the late 1990s, Brazil's health system largely consisted of ambulatory health centers funded by the public sector (the so-called first sector) and hospitals held by the private sector (the second sector) 4. In 1990, 72% of the total number of hospital beds in Brazil were provided by the private sector. In 1999, the private sector owned 87% of Brazil's 723 specialized hospitals, 67% of its general hospitals (66.5% from a total of 7806 hospitals) and 95% of its diagnosis and therapy units 4. On the other hand, 73% of Brazil's health units that addressed basic health care belonged to the public sector [4, 9, 12, 13]. The third sector, largely consisting of non-profit social organizations, entered Brazil's health scene by the end of the 1990s.

Recent health management plans in Brazil—an accelerated change
Guided by its four pillars but mainly driven by the aim to decentralize health care systems and policies, the SUS began work in the 1990s to leverage financial resource disbursement tools provided by the central federal government to support municipalities directly using the so-called Basic Operating Rules (Normas Operacionais Básicas: NOBs). The Basic Operating Rules were technical operational standards that i) provided payment for health services upon the presentation of invoices not only to private health care providers but also to public health care providers and governmental agencies, ii) released financial resources solely upon the presentation of health plans, programs and projects and iii) created decision-making mechanisms of a participatory and decentralized nature 4. In early 1998, however, the financial resource transfer system was changed. Payments for health services and/or transfers of resources were no longer to be made after invoice verification but prior to them by establishing a minimum value per capita made directly to the municipal funds under the responsibility of the National Health Fund (Fundo Nacional de Saúde: FNS) through a Basic Health Assistance Minimum (BHAM) value (Piso Assistencial Básico: PAB). The BHAM value was, in fact, the instrument that culminated in the decentralization of health management in Brazil. The BHAM value guaranteed a fixed, regular and automatic monthly amount to municipalities of R$10 per inhabitant (then, approximately 5 USD, according to the Brazil Central Bank calculator) for the implementation of essential health services such as basic care, vaccinations, prenatal care and minor surgeries without hospitalization, among others. With this new minimum value mechanism, public managers had to commit and adapt governmental programs to a pre-established budget, i.e., integrate between planning and action. Responsibility for the success of the Brazilian national health policy passed to the local level, with management models being decided at the municipal level. The fixed amount of the BHAM value of approximately 5 USD was, however, inappropriate relative to the realities faced by some municipalities; this concern was readily identified during the implementation of the Family Health Program (Programa de Saúde da Família: PSF), one of the basic actions of the Unified Health System. From the BHAM value followed the Basic Health Attention (BHA) payment in 1996, featuring new concepts and goals and the inclusion of attention to primary health care, with prevention and health promotion activities added to the basic health care policy. The introduction of programs such as the Family Health Program, the Program of Communitarian Health Agents, the program to Combat Nutritional Deficiencies, the Pharmaceutical Assistance Program, the Program of Basic Health Surveillance, and the Program of Epidemiology and Disease Control were then subject to rules, forms of financing and specific membership standards regulated by various ordinances 14-17 Before the establishment of the Basic Health Values and Payments instituted at the end of the 1990s, only 33% (or 1842 out of 5598 1) of Brazilian municipalities had budgets or reimbursements for their health expenses. These 33% of Brazilian municipalities, representing a population of 40.4 million individuals, had been receiving federal resources whose values were between 0 and R$5 annual per capita after invoice control. For approximately 10% (or 582) of the 5598 Brazilian municipalities, no federal resources were used to pay for the expenses of basic health attention. In 1997, just one year after the creation of the BHA payment, the total volume of resources surpassed the mark of R$1.2 billion and reached R$1.7 billion in December 2001 4. Before the inception of BHA payments in 1996, only 114 municipalities had directly managed their resources. In 1998, 1343 municipalities were enabled as managers. These payment management tools visibly increased the basic health care coverage of the Brazilian population.

The Brazilian Family Health Program
To reorganize the health network as a gateway to primary health care, the Family Health Program was created in 1994 to pursue the goal of providing free access for the population to integral assistance by a multidisciplinary team that was close to home as a strategy for preventing disease and maintaining health 18. In 1997, the Family Health Program was redefined as the Family Health Strategy 19. The Family Health Strategy, which carries out both preventive actions and the rehabilitation of health and healing, has been since its inception the main instrument for changing the established assistance model by promoting preventive health and encouraging lower dependence on hospitals as the central focus of public health services 4. Despite all of these plans and projects in Brazil, however, public health treatment in the public sector advanced little in the 1990s and 2000s. Long lines and wait times for care continued, and the lack of hospital beds was a common scene from health centers to large hospitals.

2000s to present

In 2000, the Ministry of Health, through the National Health Foundation (Fundação Nacional de Saúde: FUNASA) initiated the process of decentralization in the areas of epidemiology and disease control 4. One of the tools used for the decentralization of epidemiology surveillance and disease control in Brazil started in June 2001 using financial resources to be transferred from the federal to the state and municipal governments. These financial resources were subdivided as follows: i) fixed and variable basic payments for primary care, ii) epidemiological surveillance and disease control, iii) medium-complexity care and iv) high-complexity care. Again, this disbursement policy heralded another major turning point in public health care in Brazil. Practically, it meant that new management models had to be implemented by the municipalities, which became the centers of decision-making for all health actions. The municipalities ceased to be health providers and became health managers, delegating health programs, actions, service supervision, and expenditures. The municipalities were given the opportunity to incorporate innovative managerial models to achieve their goals in an independent and regionalized fashion that was decentralized from federal policies. One of the innovative methods a few Brazilian municipalities adopted to manage the health programs and actions under their aegis of responsibility was to engage third-sector social organizations through public-private partnerships. By 2001, 99% (or 5516) of Brazilian municipalities had complete responsibility for the management of resources in health, covering a population of 172.1 million individuals4. At the end of the 1990s and throughout the 2000s, more and more citizens had visited primary care in health units and health centers (Figure 3).

Starting at a meager 15% basic health coverage in 1998, the Health Family Strategy extended coverage to 60% of the total population of 200 million Brazilian citizens by 2013 (Table 1, Figure 4) 20.

Figure 3Increasing trend in the demand for primary care in health centers

Reprinted from "The Brazilian health system: history, advances and challenges (O sistema de saúde brasileiro: história, avanços e desafios),” [article in Portuguese] by Paim J et al., 2011, Saúde no Brasil. doi:10.1016/S0140-6736(11)60433-9, p. 25. Copyright (2011) by Elsevier. Reprinted with permission.

Table 1Year, model of attention, total number of individuals attended, total population covered and percentage of coverage in Brazil from 1998 to 201320

a: Program for Health Community Professionals (Programa de Agentes Comunitários de Saúde-PACS); b: Family Health Strategy (Estratégia de Saúde da Família, previously Family Health Program); c: Other-Undetermined basic health care attention. Source: Ministry of Health Brazil, DataSUS 20.

Figure 4 Primary health care attention over the last 15 years in Brazil measured as the number of individuals using basic health care services and the percentage of health care coverage from 1998 to 2013

PACS: Program for Health Community Professionals; ESF: Family Health Program (later, the Family Health Strategy).
Source: Ministry of Health Brazil, DataSUS 20.

Family health
In 2009, there were 30,328 family health teams deployed in Brazil, covering more than 50% of Brazil's population 21. For a total of 5,293 Brazilian municipalities (95% of the total of 5565 22 municipalities), there were 80,170 family health strategy teams and 488,745 community health agents 21 in 2012. Oral health teams numbered 25,162 in 4,907 municipalities 21 by September 2012. In December 2013, of an estimated population of 201 million, 120 million (or 60%) had health coverage 21. It has been recently observed that the mortality caused by cardiovascular diseases decreased 18% and heart diseases decreased by 21% in the municipalities where the Family Health Strategy was implemented 23.

Emergency units
Public-private partnerships include the management of 24-hour emergency care units (24-h UPAs). The contribution of 24-h UPAs might be low as a percentage, but the quantity of emergency attendances confirms the relevance of the 24-hour emergency units in the State of Rio de Janeiro, for instance. In 2006, before the existence of 24-hour Emergency Units in Rio de Janeiro, emergency requests in general hospitals equaled 945,000 annually or 2,500 per day. In 2013, hospitals and 24-hour emergency units equaled 5.65 million health care requests annually or an average of 15,000 per day, five times more than in 2006. The 24-hour emergency units have emergency care specialties in internal medicine, pediatrics, and dentistry, and they are responsible for distributing medications and offering infrastructure that includes the basic diagnosis, clinical pathology exams and radiography. In Rio de Janeiro, the 24-hour emergency units have a high index of resolvability, and less than 1% of health cases had to be transferred to a hospital in 2013 24.

Brazilian non-profit organizations of the third sector
In Brazil, the role of third-sector non-profit organizations in the education, science and health fields was established at the end of the 1990s. It was only in 1998 that the Brazilian government legally qualified non-profit entities of the third sector that were managed by a council integrated by representatives of public administration and whose activities were directed at teaching, scientific research, technological development, and the protection and preservation of the environment, culture and health as social organizations 25.

Public-private partnerships
At the end of the 1990s, new managerial models of public-private partnerships with the private sector, including the third sector, were introduced, giving municipalities a preponderant role in the control, evaluation and monitoring of contracts and agreements. Public-private partnerships were implemented through contracts in which specific targets were continuously followed and evaluated. These contracts passed the responsibility to the private partner to purchase materials and equipment, to hire a workforce and to choose the best managerial schemes. In this way, third-sector social organizations effectively entered into the Brazilian health care system buying at better prices and by hiring personnel in a faster and efficient manner. In addition, social organizations could also respond more rapidly to the construction and operation of health care facilities and the implementation of programs and policies. If the results were not approved and if the goals were not achieved, the social organizations were subject to partnership contract termination.

The role of social organizations in numbers
Data collection on the contribution and significance of social organizations working in the health sector in Brazil is still ongoing. The number of approved health procedures requested by third-sector social organizations working in the State of Rio de Janeiro 26 and São Paulo 27 was used as a proxy for the contribution of third-sector social organizations working on health in these two highly populated States in Brazil (Table 2) 20. A share of 36.9% of these health-approved procedures was observed in the city of Rio de Janeiro, with 17.1% in the city of São Paulo in 2013 (Table 2). This share is lower when third-sector social organizations working in the health sector are compared to other administrative tasks carried out by public and private health organizations, decreasing to 0.6% for the city of Rio de Janeiro and 0.5% for the city of São Paulo in 2013 20.

Table 2Number of approved medical procedures by type of health provider in the States of Rio de Janeiro and São Paulo, Brazil, in 2013

The types of health providers are health units under federal, state and municipal management, private, and social organizations.

a: Including all forms of management; excluding the capital of the state and state management (as types of health providers)

Discussion

In Brazil, health care has been pursued as a basic citizenship right for almost a century. Nevertheless, deploying this right in the primary, secondary and tertiary health levels to approximately 200 million Brazilian citizens is a difficult task and has been sought to be achieved through the application of many health policies and managerial models for decades. Nonetheless, the universalization of health care was a rather recent accomplishment, only having been cemented by the 1988 Constitution and put into practice at the end of the 1990s with the creation of the SUS and its four pillars of universalization, decentralization, regionalization and social control. From the beginning of the 2000s (upon decentralization), more than 5 thousand Brazilian municipalities were given the power to administer the financial resources earmarked for health actions through the transfer of payments from the central federal government. One of the administrative mechanisms municipalities found to effectively manage health disbursements and provide quality health care and access to health care was to engage third parties. This required that municipalities depart from health service provision and be left only with health services management and supervision. The engagement of third parties in health attention in Brazil was largely performed through partnership contracts with third-sector social organizations. Public-private partnership contracts with third-sector social organizations have been implemented with success and have proved to be putative players in metropolises such as Rio de Janeiro 28, 29, and São Paulo 27. In our view, public-private partnership contracts with third-sector social organizations might be chosen as an important managerial model tools for the delivery of an inclusive, universal health care system, as required by the SUS.

The third sector, in fact, has an important role in primary health care in developed countries as well as in developing countries where, for example, universal access to health systems was sufficient for all and in countries without universal coverage where vulnerable populations had no access 30. The role played by the third sector in basic attention to health has developed largely in the context of political and social inequality to varying degrees in the United States, a few states in Canada, Australia, New Zealand and Brazil, but at a much smaller scale what has been witnessed in the United Kingdom 30. Canada and Australia, for example, in spite of the existence of universal health system coverage, the dominant private sector and the way in which primary health services are performed, where consultations and other medical services are paid, has deterred entire vulnerable populations from receiving primary health care, as in the case of low-income populations in Canada and the Aboriginal population in Australia 30. The favorable political environment and the visible deficiencies of the State and the private sector in providing primary health care services that are accessible to low-income populations, rural communities and excluded populations led to the development of third-sector social organizations that provide primary and secondary health care in various parts of the world during the 1980s and 1990s 30. For European countries, despite a long tradition of voluntary and charitable organizations dating back centuries, contracts of public-private partnerships with social non-profit organizations have blossomed only in recent years 31. Regarding the amount of funds invested, Europe leads with the most public-private partnership contracts in the world (Figure 5) 32.

Figure 5Amount of funds invested in public-private partnerships in the world in million dollars by 2011

Reprinted from: Brookings, Project on State and Metropolitan Innovation, "Moving forward on Public Private Partnerships: U.S. and international experience with PPP units," by Istrate E, Puentes R, 2011, Copyright (2011) by The Brookings Institution. Reprinted with permission.Link

Countries such as France, the United Kingdom, the Netherlands, Spain, Germany, Belgium and Portugal have been active markets, with a total of almost 3 billion euros in public-private partnership contracts in just the first 6-month period of 2012. These partnership agreements included the health sector but are primarily concentrated in the area of transport and education 33. In the Americas, contracts for public-private partnerships in health are newer, having been carried out lately in the United States 34, Chile, Argentina, and Brazil. In Asia and Africa, except for a few countries such as South Korea, Japan and South Africa, contracts for public-private partnerships in health remain uncommon 35-37.

The complementary roles of social organizations in many public policies, such as in health, education, social assistance, sports, childhood and youth support—providing public services as well as cooperating to implement and monitor public policies—was established by the Brazilian Constitution of 1988 10. The Solidarity Community Program linked directly to the Brazilian Presidency’s Office began in 1995, a process of political talks with social organizations and Government representatives to restructure the third sector under the Brazilian legal system. One of the most notable results of this process was the 1998 law 38 that qualified social organizations to act as civil society organizations of public interest (Organizações da Sociedade Civil de Interesse Público-OSCIP); the law also created the partnership contract, thereby establishing agreements between third-sector organizations with the public sector tracking criteria of effectiveness, efficiency and responsibility 38. In 2005, 338 thousand private non-profit associations, as social organizations are called in Brazil, employed a record 1.7 million individuals with average monthly wages of R$1,094.44. The average time of existence for these social organizations was 12.3 years, and many of them (42.4%) were established in the Southeastern Region of Brazil. These social organizations were generally small, with 80% (269 thousand) of them without formal employees, 35% acting on citizens’ rights issues, 25% acting as religious institutions and 7% developing actions in health, education and research 39. In 2010, out of a total of 5 million Brazilian companies (5,128,568), 10% (509, 603) were classified as non-profits 40. These non-profit organizations hired nearly 7% of the employed workforce in the country (2,896,250 individuals) with average salaries of R$1,534.48 and expenditures of 58 billion Brazilian reais only in wages and other remunerations 40.

Public-private partnership contracts with social organizations have been carried out with success for more than 10 years in many sectors in Brazil. In the sector of science and technology, for example, social organizations have been managing programs and institutions such as the Institute of Pure and Applied Mathematics 41, the Synchrotron Light Laboratory 42 and the National Education and Research Network 43. The Institute of Pure and Applied Mathematics is the most prestigious mathematics institute in Latin America. The Synchrotron Light Laboratory, today called the National Centre for Research in Energy and Materials, is home to the only source of synchrotron light in Latin America, which carries out analyses of organic and inorganic materials. The National Education and Research Network, created in 1989, was the first Internet access network in Brazil and today encompasses more than 800 teaching and research institutions in the country. From these examples, public-private partnerships with third-sector social organizations can be presumed to have been working well in Brazil.

Currently, health care in Brazil is carried out by the SUS and is defined as the set of actions and health services provided by public bodies and federal, state and municipal institutions that belong to the direct and indirect administration and foundations maintained by the public sector 9, 12. The private sector can participate in the SUS by public law contracts, of which charities and nonprofit organizations are a part 9, 12, 13.

Political, administrative and social developments in the last century in search of health services for all citizens led 60% of 200 million Brazilians to be covered by basic primary health attention by 2013 and sparked innovative managerial models, such as the ones that take public-private partnerships into account. These managerial models can be closely followed by municipal managers, and they are applied to the local reality, are prone to social control and might be used with increasingly greater frequency by municipalities in the future, thereby fulfilling the targets of universal quality coverage through the Brazilian health system.

Acknowledgments

We thank two anonymous referees and the Editor for their invaluable comments.

Author contribution

Cruz E, Cruz S, da Silva Filho EJP, Boaretto C and Rosa-Freitas MG: Equally participated in the writing of the manuscript.

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Evaluation
  • General
  • Innovation
  • Advancement
  • Industry