The development of the Brazilian Unified Health System over the last 25 years has occurred amid distinct, and at times contradictory, notions of the Social State. On the one hand, the SUS was born under the auspices of the far-reaching proposal of social protection established in the 1988 Constitution, based on an integrated and universal design of social policies and supported by an intense engagement of political actors in the health care sector. On the other hand, the system has been implemented in contexts of great difficulty: prevalence of a negative view of the state in the 1990s, and the adoption of a development model based on social policies focused on reducing poverty in the 2000s, such as conditional cash transfer programs.
Despite the adverse setting, some important advances have been achieved. Firstly, a decentralized health care structure was built, rooted in the Federalist design, which favored the creation of an important base of support, including politicians, health professionals, users and scholars. Secondly, there was a significant expansion of primary health care services in Brazil, with positive implications for the access to health care and improvement of health conditions. Thirdly, decentralization and regionalization processes have advanced greatly in several aspects – funding mechanisms, forms of organization and delivery of health care, ways of integrating activities and services in the territory, and forms of relationship and division of roles and responsibilities among national, regional and local governments. Lastly, many programs and initiatives have been implemented regarding science and innovation in health.
In the current stage of development of the SUS, the federal government is the main actor in the Brazilian health science and innovation scenario because it sets priorities, provides funding for research, fosters collaborations between public laboratories and private companies for technology transfer and manufacturing of strategic products, and purchases a wide range of health technologies.
How have we gotten so far?
In 2004, a national conference was held by the Brazilian Ministry of Health with the aim to produce and apply knowledge in the pursuit of universality, equity and quality of health care for the population. This conference produced two important outcomes: the approval of the National Policy on Science, Technology and Innovation in Health,
Government procurement came to be used to strengthen the innovation and manufacture of strategic technologies for the SUS. Partnerships for Productive Development (PPDs) are one example of this kind of policy. They are partnerships between public organizations and private companies in order to ensure people’s access to priority health technologies, reduce the vulnerability of the SUS in the long term and reduce the prices of strategic products, with a commitment to internalize and develop new technologies. The first PPDs were signed in 2009. Until June 2013, the federal government had promoted 88 partnerships, comprising 17 public laboratories and 53 private companies engaged in manufacturing 78 different technologies (medicines, vaccines and medical devices). It is estimated that the manufacture of such technologies in the country will mobilize about US$ 4 billion a year in government procurement, resulting in annual savings of US$ 3 billion.
As regards the health technology management, two articulated processes were adopted in Brazil: 1) the production, systematization and dissemination of health technology assessment (HTA) studies, and 2) the adoption of a flow to analyze requests for inclusion and exclusion of health technologies in the SUS. These processes are part of the National Policy for Health Technology Management, approved in 2009. Several advances have been made so far, including standardization of HTA methods, professional training, institutional development and international cooperation in the field of HTA, definition of the necessary requirements for the presentation of proposals, definition of deadlines, and expansion of the segments that compose the committee that is responsible for the analysis and recommendation.
Despite the identified advances, some challenges remain – research findings are poorly translated into practice; Brazilian companies are heavily dependent on government incentives to invest in research and development; high degree of dependence on foreign supply of more advanced technologies; limited tradition in the use of evidence for decision-making in health care; lack of mechanisms for engaging patients and the public in HTA activities; and low level of integration between the private health care system, which serves 25% of the population, and the SUS in relation to the management of health technologies.
In summary, Brazil is an emerging economy that succeeded in adopting, in a short period of time, a broad set of initiatives to meet the constitutional challenge of consolidating a universal health care system in a context of limited resources and decentralized decision-making processes by articulating the health policy agenda with scientific and business activities.