Brazil’s general election will decide the future of world’s largest public health system
BMJ 2022; 379 doi: https://doi.org/10.1136/bmj.o2601 (Published 28 October 2022) Cite this as: BMJ 2022;379:o2601
The future of the world’s largest government run public healthcare system, the Amazon rainforest, and Latin America’s fourth largest democracy will be decided in Brazil’s general election on 30 October when the public will vote to either re-elect current right wing president, Jair Bolsonaro, or the leftist former president, Luiz Inácio Lula de Silva.
Polls suggest that Lula, president from 2003 to 2010, will remove the incumbent from office, but the margins are tight in what analysts say is one of the most crucial Brazilian elections in decades. “This is one of the most important elections to define the future of Brazil’s democracy, public health, education, environment, scientific development, and human rights,” said Marcia Castro, chair of the Department of Global Health and Population at the Harvard TH Chan School of Public Health.
At stake is the future state of Brazil’s national health system, the Sistema Único de Saúde (SUS), which since 1990 has delivered free healthcare to more than 200 million Brazilians. Despite the SUS’s innovative community led approaches and the dedication of its staff, budget cuts have made the system fragile, experts say. The re-election of Bolsonaro could be the death knell for the SUS, just as the poorest—hit hard by soaring inflation—need it most.
“This presidential election will determine if Brazil will start along a path of recovery or continue to face successive budget cuts in health that are weathering the SUS and the health of the population,” Castro said. “I am terrified to even think about it.”
According to João Nunes, global health expert at the University of York, the two candidates’ past terms as president are indicative of the stances they will likely take on health. “Both of them said that they would uphold the public health system, but obviously they have a very different track record,” he said.
Although Lula made serious mistakes—he was removed from office on corruption charges, although these were later overturned allowing him to run for the presidency—the improvement of health in Brazil under his watch is undeniable, Nunes said. During the former metalworker’s years in office child mortality reduced, vaccination rates increased, and redistributive programmes such as Bolsa Familia, which offered financial aid to the poorest families, led to greater food security and in turn better health outcomes. Lula’s specific policies are vague, although he has pledged to restore funding cut from Farmacia Popular, which was created in 2004 to subsidise medication for the poorest.
For Bolsonaro, critics say there is a simple metric with which to measure his management of health: 687 000—the number of Brazilians who have died from covid-19 as Bolsonaro downplayed the threat of the virus.
Calls for more funding
Brazil’s health system was weak long before Bolsonaro was elected in 2018. Mired in a series of economic crises, successive Brazilian governments have slashed funding while private healthcare has grown.1
“Brazil’s public health system is expected to deliver health to a very diverse population under very difficult circumstances. It is only due to the resilience of the people working on the frontlines of the health delivery system that you didn’t see a greater calamity in Brazil,” Nunes said.
The degradation of the SUS has accelerated under Bolsonaro, as the former military general appointed allies without a medical background who share his scepticism of science to key posts.2 The importance of the SUS will likely grow as the cost of living crisis bites, experts say. The current rate of hospital admission of babies in public clinics is at its highest level in 13 years, the Oswaldo Cruz Foundation (Fiocruz), a public health research institute, says.3 In an open letter to the candidates, Fiocruz invited them to commit to the preservation of the public health system and increase funding.4 Public investment in health should rise to 7% of GDP over the next eight years, the institute said.
Carlos Grabois Gadelha, a coordinator of the Center for Strategic Studies, a Fiocruz think tank, said, “Brazil is the largest universal system in the world in terms of population coverage, yet it’s also the universal system with the lowest public funding in the world.” Brazil currently spends around 4% of its gross domestic product on health versus around 9.5% for the Organisation for Economic Co-operation and Development average.56 Gadelha said that 7% is the minimum needed to realise the health rights enshrined in the Brazilian Constitution.
Gabriela Lotta, professor and researcher of public administration and government at Getulio Vargas Foundation, said that Bolsonaro’s distrust of science and the state suggest that he is far more likely to dismantle the SUS than rebuild it. In the height of the covid-19 pandemic he dismissed covid-19 as “a little flu,” promoted unproven medication, and said that vaccines would turn people into crocodiles.
“For those who believe in a universal and free health system, Bolsonaro is a threat as he could destroy what we have and implement an agenda of privatisation and private health insurance as we had before in the 1990s,” Lotta said.