Intended for healthcare professionals


Brazil’s struggle to reconstruct healthcare post-Bolsonaro

BMJ 2023; 381 doi: (Published 24 April 2023) Cite this as: BMJ 2023;381:p805
  1. Rodrigo de Oliveira Andrade, freelance journalist
  1. São Paulo
  1. rodrigo.oliandrade{at}

After years of devastation wrought by covid-19 and former president Jair Bolsonaro, Brazil is attempting to get its healthcare system back up and running. Rodrigo de Oliveira Andrade reports

On 14 January 2021, dozens of Brazilians died as authorities scrambled to get oxygen to Manaus, an isolated city in the heart of the Amazon. Over the next few days, the federal government began transporting critical patients to other states, but lines for hospital beds were still long. Without oxygen supplies, many had to be resuscitated in hallways, while others suffocated to death.

The Manaus oxygen crisis is perhaps the best example of how Brazil’s former far right president Jair Bolsonaro handled the pandemic. It is also a reflection of the precariousness to which the country’s public healthcare system—also known as Unified Health System, or SUS—has descended after years of regulatory and institutional setbacks promoted by former administrations.

Its reconstruction should now be one of the main priorities of President Luiz Inácio Lula da Silva, re-elected for his third term in October 2022. Since taking office, however, it is clear he is facing greater challenges than in his previous terms.

In addition to the more than 693 853 covid deaths in Brazil by the end of 2022—corresponding to 10% of the global death toll—the pandemic undermined SUS’s provision of non-covid-19 procedures,1 resulting in the deterioration of several health indicators in Brazil.

According to the Transition Commission’s Health Working Group—a commission created by the Lula government to evaluate the state of public administration—only 71% of the target population was vaccinated against polio in 2021, the lowest coverage since 1995. Between 2019 and 2021 maternal mortality increased from 55 deaths per 100 000 live births to 110.

The restriction of patient access to the healthcare network during the pandemic also resulted in a sharp decrease in consultations, surgeries, and other procedures carried out by SUS, which negatively affected the tracking of many diseases. As a result of social distancing measures, many people simply stopped having preventive examinations, increasing the risk of diseases like cancer being diagnosed only at an advanced stage.

“The pandemic reached Brazil at a moment when SUS was seriously weakened, exposing both its importance and problems,” Rafael Dall’Alba, a public health professor at the University of Brasília’s Faculty of Health Sciences, told The BMJ.

Chronic underfunding

Before SUS was launched in 1988, only those who made regular social security payments were covered by the public healthcare system; the poor and unemployed depended on charity hospitals.

“No other public healthcare system in the world claims to treat such a large population without imposing restrictions or co-pay mechanisms,” says Reinaldo Guimarães, a professor at the Federal University of Rio de Janeiro and vice president of the Brazilian Association of Collective Health.

Some 76.9% (159.8 million) of Brazil’s population rely on SUS for all their healthcare needs,2 but everyone in Brazil may use it, even those with private health insurance. (Technically, if such a patient is treated under SUS, their insurer must reimburse the healthcare system.)

But SUS has suffered chronic underfunding since the beginning.3 In recent years, the system has been further weakened by economic and political factors. The 2014 financial crisis was followed by political instability and long term fiscal austerity policies, such as that imposed by the 95th constitutional amendment in 2016, which froze government spending for 20 years. According to the Transition Commission’s Health Working Group, SUS lost almost R$60bn (£9.1bn; €11bn; $ in funding from 2018 to 2022 as a result.

The situation worsened further during the pandemic, mainly because of the Bolsonaro administration’s approach the health emergency. Four ministers of health held the job within two years, with specialists in public health replaced by military commanders with no relevant qualifications or experience, delays in buying vaccines, official recommendations for ineffective drugs such as chloroquine and ivermectin, boycott of public health measures already adopted by local governments, and the wide dissemination of fake news by public agencies.4

In a live broadcast, Bolsonaro said that “official reports from the UK government suggest that fully vaccinated people are developing acquired immunodeficiency syndrome much faster than anticipated.”5

“As the national health authority became weak, SUS lost the capacity for national coordination and articulation of health policies and programmes,” Marcia Castro, a statistician and demographer at the Harvard TH Chan School of Public Health, told The BMJ.

A system under reconstruction

Efforts to rebuild SUS are now being coordinated by a new minister of health, Nísia Trindade Lima, a former president of the Oswaldo Cruz Foundation (Fiocruz), one of the leading research institutions in Brazil.

Trindade is a social scientist with extensive experience in health management. She played a decisive role in the 2020 negotiations with AstraZeneca for the production of its covid-19 vaccine in Brazil. She will be the first woman to run the ministry of health.

Jesem Orellana, an epidemiologist at Fiocruz in Amazonas, says she will have her hands full just getting the ministry back on its feet. “Her first months in office will be busy reorganising the ministry of health so it will be able to work properly, and resuming SUS’s successful policies and programmes.”

Trindade revoked a series of Bolsonaro’s normative acts (presidential orders that become law) as soon as she took office, including one that required doctors to call the police when asked to perform an abortion after rape.

She also changed the ministerial structure, with the creation of a new secretariat of digital health, departments for immunisation and mental health, and the re-establishment of the department for HIV/Aids scrapped by Bolsonaro.

Among her priorities, she plans to increase vaccination coverage and reduce waiting times for specialist care—she released an extra R$200m in February to help states and municipalities reduce the backlog of surgeries, exams, and consultations in the SUS.6 The idea is to encourage the organisation of “mutirões” across the country—where physicians from a city gather together in large public spaces to carry out mass consultations, exams, and low complexity surgeries over several days.

Orellana says it’s important Trindade restarts the working relationships with other ministries too. “There are problems that the health ministry cannot tackle alone. Water contamination from mercury used in illegal mining in the Yanomami territory in northern Brazil, for instance, has many impacts on health, but its cause is environmental.”

Expanding and strengthening primary care is another challenge. One example is the family health programme—now called the family health strategy—which has produced remarkable results since its launch in 1994, reducing malnutrition and infant mortality and improving vaccination coverage and prenatal checkups.7 There is evidence that the strategy contributed to the reduction of hospital admissions for ambulatory care sensitive conditions and cardiovascular mortality. “It has proved to be the best way to tackle Brazil’s health challenges,” Castro says.

It is not without problems, however. The programme is currently plagued by a shortage of primary care specialists—Brazil had 7149 in 20208—poorly distributed throughout the country. Many regions face difficulties in recruiting and, especially, retaining medical professionals, leaving many residents without access to quality care.9

Trindade has already sprung to action. In March, she re-launched the Mais Médicos programme,10 an initiative originally created in 2013 to increase the number of physicians practising in underserved and remote areas of Brazil, but abandoned during the Bolsonaro years.11

This should open up as many as 15 000 new jobs, many of which will be deployed to ease the humanitarian crisis plaguing the Yanomami people.12

The government is hoping to recruit 28 000 health professionals throughout the country by the end of 2023,13 but this may be a tall order, since most physicians do not want to work as family doctors in small towns. The government hopes to recruit only Brazilian doctors, but may be forced to reconsider recruiting from abroad, despite recent controversies with Cuban doctors.14

Lula’s administration has also brought back its Bolsa Família programme.15 Created in 2003 during Lula’s first term as president, it provided financial aid to improve the living conditions of families living in poverty and extreme poverty. The programme became a hallmark of Lula’s previous eight years as president (2003-2010), with evidence that it has a positive impact on the treatment outcomes of many diseases, such as tuberculosis.16

Bolsonaro, however, rebranded it as Auxílio Brasil (Brazil Aid) and the programme was so poorly managed that 694 000 people who should have received benefits did not, while 1.5 million families who were over the income threshold required to qualify did.

Lula wants to rebuild the programme, bringing back those 694 000 people to Bolsa Família. Families will receive R$670, plus an additional of R$160 for each child under 6 years old.

There are plenty of plans and hopes. But Castro says the success and sustainability of these programmes depend on the country’s capacity and willingness to invest more in public health. “The approval by Congress of an extra budget of R$22.7bn for the ministry of health for 2023 will help to support these efforts,” she says.

Dall’Alba points out that the restoration of the ministry of health’s long term capacity will also depend on the review of the 95th constitutional amendment—in 2018 and 2019 the health budget was merely adjusted for inflation, which left it underprepared for the pandemic of 2020. Although funds were freed up on an emergency basis, the 2021 spending bill again reinforced the budget ceiling of R$134bn—approximately R$30bn less than the previous year.

The harsh lessons of the pandemic and Bolsonaro years should serve as a lesson, Castro says. “A warning to the world to show how it is possible in a short period of time to deconstruct a universal healthcare system.”


  • Commissioned, not externally peer reviewed.

  • Competing interests: I have read and understood The BMJ policy on declaration of interests and have no relevant interests to declare.