Sick and tired

Healthcare and education were announced as the main priorities of Fernando Henrique Cardoso's presidency. One year after coming into power, however, the new administration has made little if any progress in eradicating Third World diseases and implementing a health prevention program. It's not just a problem of lack of money. Despite efforts to clean up the system, 30% of whatever little resource there is, is being wasted through mismanagement and corruption.

Elma Lia Nascimento

In 1995 the Brazilian Health Ministry received $15.8 billion to pay its bills. Thanks to this, the Sistema Único de Saúde (Unified Health System) (SUS) was able to conduct one million doctor consultations a day, perform 4,120 heart surgeries, maintain 508.7 thousand hospital beds, and hospitalize 11,350 cancer patients. In 1989 Brazil became the first Latin American country to eradicate polio, and measles has been nearly eliminated with only around 1,500 new cases in 1995. And, Instituto Butantã, a leading research institution, has just announced that in a few months it will start producing a vaccine for hepatitis B, helping the country rid itself of this preventable disease. From the early 50s to today life expectancy has increased from 46 to 65 years. Brazil has 6,500 hospitals and proportionally, as many doctors as England (1.46 professionals for 1,000 people). Quite impressive, huh?

All of this puts Brazil just a cut above Paraguay in resources devoted to healthcare and behind countries like India and El Salvador. From the almost $16 billion spent in 95, $2.7 billion were used to pay staff, and another $2.9 billion went to cover old loans. While the US allocates 12.7% of its GNP to health, Brazil reserves only 4.2% for this purpose. Compare this with France (8.9%), India (6%), El Salvador (5.9%) and Paraguay (2.8%). This means that less than $80 per capita was allotted to healthcare in Brazil last year whereas in neighboring Argentina this number was $300 and in the US, $2,300. That's what was being spent in the sector in 1987. The situation hit bottom in 1992 when a mere $45.7 per capita from federal funds was used for healthcare. While in 1950 the number of hospital beds offered by the state was roughly the same as the private sector, the participation of the public sector has decreased to 29% of all beds available.

An analysis of the SIAFI's (Sistema Integrado de Administração Financeira do Tesouro Nacional - National Treasure's Integrated System of Financial Administration) 1995 report shows that President Cardoso gave more money to healthcare when he was Finance Minister in 1994. The government invested 28.29% less in healthcare than in the previous year. This means a shortfall of $172 million, enough to triple the Pronaica, the largest health program of the federal government which assists children. It's not even a case of cuts across the board. The total amount of federal investments from '94 to '95 fell only 1.33%.

Lack of money made 1995 a particularly hard year for the Health Ministry. Preventive medicine had several cuts when compared to the previous year. Sanitary work received less than 1/4 of what had been promised. The National Health Foundation had a cut of 50% in their vaccination program. From 1986 to 1993, the percentage of the Gross Domestic Product applied in the social has grown from 8.7% to 12.6%. That means an increase from $43,986 million to $54.938 million. The health sector, which had received $12.736 million in 1989 had this amount reduced to $9.347 million in 1993.

Women have a tougher time. Mortality for mothers in Brazil is 150 for every 100,000 births. In Japan, for example, this number is 50 times smaller, with 3 deaths for every 100,000 births. Around 5,000 women die every year due to pregnancy or postpartum complications. Experts say that 98% of these deaths could be avoided if some basic precautions were taken. Unicef (United Nations Children's Fund) estimates that between 9,000 and 15,000 children annually become orphans due to these deaths. High blood pressure is the main killer, followed by hemorrhages, infections and abortions, but cesareans also contribute to these deaths. And Brazil is the world champion of cesarean deliveries, accounting for 1/3 of all deliveries in the country. There is no recent data about infant mortality, but it is estimated that there are 5,000 deaths for every 100,000 live births. (In the US there are 828.8 deaths for 100,000). The Health Department has as one of its goals to reduce this number by half, by 1998.

Every 24 minutes there is a new case of breast cancer. Since there is very little preventive medicine, 60% of the women discover the disease when it is already advanced. Tests like the Pap smear used for detecting cervical cancer that could save many lives are reduced to five weekly exams in some public clinics due to the bureaucracy involved in the proceeding.

Before taking office, President Fernando Henrique Cardoso had presented his vision for healthcare in his platform book Mãos à Obra, Brasil (Set to Work, Brazil). He wrote: "The crisis in the health sector is undeniable. Its visible face scrapped hospitals, professionals on strike, patients thrown on cots in the corridors, lack of material and medicine hides the failure of a model mainly interested in the cure and treatment of diseases."

Soon after being inaugurated, Cardoso established as priority goals for the health sector to reduce child mortality and to vigorously fight dengue and malaria. The President will be satisfied if he can cut in half the mortality rate that is now 45.3 deaths for every 1,000 born children. Symptomatically enough twice in the past Brazil had announced the elimination of Aedes aegypti, the mosquito that transmits yellow fever and dengue. Close to 1,000 municipalities in 20 states now have Aedes aegypti. Dengue had disappeared at the beginning of the century, but in 1994 the number of dengue cases was 56,200, and it jumped to 96,100 cases just in the first eight months of 1995. As for malaria, spread by the Anopheles mosquito, Brazil hasn't been able to lower the incidence of the disease from an average of 540,000 cases a year in the last decade.

Other Third World diseases such as barber bug fever and schistosomiases spread by contaminated water are rampant. At least 1,069 municipalities have schistosomiases. While 90% of the population get water and sewage service in urban areas, this number falls to a mere 17% in the rural regions. Brazil is also having to deal with cholera which entered the country from Peru in 1991. In 1994 the disease attacked 51,344 people and killed 542. The year before, the number of cases was 60,340 and there were 670 deaths. As the older population increases, Brazil must also increasingly deal with First World ailments like heart disease and cancer.

Tuberculosis is another disease which is making a comeback. The disease was being fought successfully with a 2% decrease in cases annually. This trend, however, has switched direction again with the increase of AIDS cases. AIDS victims who also have tuberculosis offer a higher resistance to medication and facilitate the transmission of this infectious disease. In 1992, there were 74,000 new tuberculosis cases in the country, in 1993 it went up to 91,000 but it is believed that this number has now exceeded 100,000. Even old biblical scourges like leprosy are on the increase. While in the early '80s there were 12 cases of leprosy for every 100,000 people, in the '90s this number has jumped to 20 cases.

Brazil is going through a period that experts call epidemiological transition. The country has to deal simultaneously with underdeveloped country diseases, and ailments such as cancer and arteriosclerosis more prevalent in industrialized nations. Sophisticated treatments in São Paulo, including heart surgeries, hemodialisis and organs transplants, consume 40% of all the resources destined to health while benefiting only 3% of the population. For lack of money ($3 billion would be necessary) 1,750 new hospitals were started but were never finished.

Brazil has 160,000 dentists and every year 8,000 new ones enter the market from 90 odontological schools. But it doesn't help that the Brazilian dentist is considered one of the best only American and Sweden dentists have more prestige among its peers around the world. It is estimated that Brazil has 1.5 billion cavities. In a country where the loss of teeth seems to be considered as natural as the loss of hair more than 70% of the over-50 population have lost all its teeth. That means a nation with 25 million toothless mouths. The best Brazilian dentists are visited by clients from Europe and the US, but only 5% of the Brazilian population has access to private clinics in which this first-class treatment is available. The fluoridation of water has existed for 30 years in Brazil, however, only 30% of the population has benefited from it.

Despite being the eighth largest economy in the world, Brazil is number 74 in expenses in healthcare. The government is also infamous for late and under-payments. Since 1987, 150 million Brazilians, through the Sistema Único de Saúde, are entitled to have their health problems taken care of by the state, even though there are still 10 million others left without assistance. Before '87, only those workers paying the extinct INPS (National Institute of Social Welfare) had the right to healthcare. At that time, close to 50 million Brazilians depended on charity when they got sick. Since then, the number of people who spend at least a night in the hospital during a year has increased from 10 million to 15 million. This explains why some health centers don't have enough beds and sometimes not even material for bandaging a wound.

For sanitarian Eduardo Levcovitz, who works as an aide for the Health Ministry, the new situation means that "health has improved 100% for 40 million people who were excluded from the system and has worsened a lot for the millions who were getting assistance." The situation is naturally better for those 32 million Brazilians who can afford a private health plan. The government indirectly subsidizes these private plans by allowing the taxpayer to deduct 100% of its medical expenses. That means $2 billion a year that the federal government doesn't collect. Private hospitals also get a tax exemption for importing sophisticated medical equipment. That can mean up to $20 billion a year. Since these machines are never used for the SUS clients, the government is studying a way to make them utilized at least 20% of the time to care for the poor population. For the rest of the population things should get better as soon as some measures, like transferring to the municipalities the responsibility of managing all health resources, are fully implemented. The idea is to do away with the state health departments or at least make them just a normative office.

The example of Natal, capital of Rio Grande do Norte, has shown that the new system, being experimented with in 53 cities, can work. Since Natal became responsible for managing the money the federal, monthly bill to pay for hospitals has fallen from $1.7 million to $1 million. The economy allowed Natal to increase by 50% its outpatient assistance. Visits to doctors and dentists also grew by 23% and 28% respectively. Recife, capital of Pernambuco, also has a success story to tell. Their newly equipped and staffed ambulance crews are able to answer a call in ten minutes or less, thereby helping to relieve hospitals for more complex procedures. Recife's favelados (shanty town dwellers) now don't need to take a bus and go downtown for their lab tests. Every morning a minivan visits the six health districts and takes all the material for tests.

Many private hospitals, even some with non-profit status, are refusing to take SUS patients. The situation is so chaotic and often so unbelievable that it borders on the absurd. Despite a 190% average increase in the fees the government pays for healthcare in 1995, a doctor receives $2 for a consultation roughly the price of a shoeshine and the hospital receives not more than $130 for each normal childbirth. The Associação Médica Brasileira's (Brazilian Medical Association) own price list determines that the consultation should cost $20. Doctors get paid an average of $400 a month by the federal government. But this amount can be $100 in some Northeastern states.

When Health Minister Adib Jatene himself operated on his fellow minister Paulo Renato of Education the procedure cost the Union $2,145. A little more than 20% ($463.61) went to the team led by Jatene. That meant that when the money was distributed, the country's most prestigious heart surgeon was left with $92.70, for five hours of work.

The situation is more than an invitation to fraud, and in recent years Brazilians have been finding how widespread deception is. According to an audit by the Health Ministry last June, 30% of all the money allocated to healthcare by the federal government ends up financing items as varied as sophisticated imported medical devices which are never used, parties, pleasure trips and reinforcing the domestic budget of all kinds of people. Fraud is a $2-billion business, representing 30% of all money used in the health sector.

Computerization of all hospitals didn't work to stop fraud. Some even believe that the new system contributes to it. Proliferation of specialized agencies to input hospitals' information coincided with an increase in the average cost of hospitalization. In some cases these bureaus' owners are former managers at the Health Ministry who know very well the department's mechanics and frailties.

The average cost of hospitalization had fallen from $179 to $156 between 1991 and 1992. In '93 it grew to $165 and then jumped to $213 in '94, coinciding with the time the consulting firms started to help. In some cases the inspectors and auditors chosen to verify the bill presented the government are themselves on the audited institution's payroll.

Despite the problems there are many who defend Heath Minister Adib Jatene' idea of instituting the

CMF (Contribuição sobre Movimentação Financeira), a .25% tax levied over every check written in the country, which would be siphoned into his department. Jatene believes that such a fee $5.6 billion a year would almost double his budget, giving him close do $20 billion to spend on health. "That would allow us to spend $200 a year with every Brazilian," he says, adding: "Even then our situation would continue precarious." The minister says he would use the money for a 40% increase in the fees paid to doctors and hospitals, for preventive medicine and campaigns to decrease child mortality.

One who agrees with the minister is Crescêncio Antunes from São Paulo's Hospital dos Servidores. "This is a socially fair tax," he says. "The poor don't pay it because they don't use checks. It's time to end this cruel pact in which the government pretends to pay and the doctor pretends to work." Naturally, there is also a group in the House of representatives who think like Jatene. They are the so-called bancada da Saúde, a group of 70 legislators very much interested in health matters and their own pockets. They are hospital owners and doctors.

After months of avoiding to tackle the issue, the legislators don't seem enthusiastic about approving such a tax. One thing many legislators are asking of Jatene is a plan to fight fraud. "If you don't change the managerial model for admissions and consultation," said former Rio's Health Secretary and current representative Sérgio Arouca, "the CMF can triplicate the health sector's resources and the money still won't be enough."

Michel Temer, the leader of PMDB (Party of the Brazilian Democratic Movement) in the House, has offered an alternative to the tax proposed by Jatene. Temer wants to see part of the Lottery and Bingo money going to help the health sector. Even the leaders of the parties friendly to the government don't think the Minister is doing a good enough cleaning-up job.

A 1995 report by the Tribunal de Contas da União (Federal Audit Office) TCU revealed that there was excessive admissions of outpatients. The money spent ($1.177 billion) on people who didn't need hospitalization, corresponded, according to the report, to the whole Brazilian population being assisted seven times in the period from December '93 to December '94. There was fraud which was very easy to detect, like women having phimosis operations and men giving birth. There was health money being used to promote festive parties or to help political parties. The audit resulted in the recall of close to 1.5 million hospitalization payments countrywide, after being discovered that 24.12% of the diagnoses for hospitalization were fake.

Among the disclosures: Piauí's state Health Secretary had embezzled $500,000 using $65,000 to buy beer and mineral water, and $9,600 to get clothes and shoes for his workers. In the state of Maranhão, around 20% of the health resources ended up in private bank accounts.

Since taking charge of the Health Ministry, Jatene has adopted measures to control fraud. The municipality of Campo Grande do Sul in the state of Paraná, for example, was able to hospitalize in one year 60% of its population establishing a record in the country. One such move was to limit hospitalization to 9% of the population of a city. Since nobody has complained about being left without a hospital bed when needed it's assumed that many of the hospitalizations were fake or unnecessary. Such a reduction in just São Paulo, where hospitalizations fell from 281,000 a month to 240,000 represented an economy of $112 million in a six-month period. Jatene has also been able to reduce to 25 days the time between a bill is presented and it's paid by the federal government.

Private institutions now get the lion's share of the SUS's finances. In the state of Paraná, for example, the private sector owns 91% of the hospital beds. Throughout the country only 30% of hospital capacity belongs to the state, although the Brazilian constitution states that the private health institution should be only "complementary" to the public health network. Jatene doesn't intend to change this situation. Says he, "It doesn't matter to us who owns the hospital, but how the patients are cared for." As for medical consultation the public institutions are already taking care of 61% of the demand.

Patients haven't being as accepting of medical errors as in the past. In São Paulo, for example, the number of malpractice cases being analyzed by the Conselho Regional de Medicina (Regional Board of Medicine) has jumped from 200 to 1200. Every month there are 200 new cases presented to CRM. In Rio, there are 1,000 lawsuits being reviewed and close to 100 new complaints being made every month.

In Brasília, there is at least one complaint a day. Part of the problem has to do with doctors being ill prepared in a country where 8,000 new physicians graduate every year from 80 medical schools. Around 65% of these new doctors don't have a chance to train in a residence program and go directly from school to hospitals. Condemnations against doctors are rare and malpractice suits can drag for four years or more. Since 1948 São Paulo's CRM has prohibited only 14 doctor from practicing medicine.

There are some bright spots in all this chaos. One such shining example is the agentes comunitários (community agents). Created in 1991, this program tries to deal with the lack of doctors in the poorest areas. The program started with 20,000 agents, but it has increased now to more than 50,000 helpers in close to 600 cities. They receive a minimum salary a month ($100) to visit the poorest families in their community bringing sanitary and health advice as well as some over-the-counter medication.

The work has been a success mainly due to the missionary spirit of the agents whose main reward has been saving lives. The program that costs 16 million could be easily doubled if there were more money.

The good minister

So high was his reputation that President Cardoso used to say that his dream was to have a cabinet of Jatenes. The honeymoon, however, seems to have ended. More than once there has been talk that his fall is imminent. Cardoso himself has denied any problem, but he hasn't been very convincing, and in an end-of-year analysis of his first year in office the sociologist-President presented the Education Ministry as an example to follow and the Health Ministry as a mistake to avoid. The accumulated problems from Jatene's department seem too big for just one person to tackle.

Jatene, who is known for this British politeness and sardonic humor, is seen by some as a chronic crying baby always asking for money. For months now, he has been insisting that the salvation of his ministry is the CMF, a .25% fee over every check that is written in the country. The tax, which has to be approved by Congress, is not popular and even Cardoso who approved it when it was first announced by Jatene, has distanced himself from the idea more recently. Others have accused Jatene of having political ambitions like the mayorship in São Paulo South America's biggest metropolis the gorvernorship of São Paulo state, or even the presidency.

Jatene, a confessed reader of lightweights Sidney Sheldon and Paulo Coelho, who appreciates romantic singers Roberto Carlos and Maria Bethânia, didn't change. As he recommends to his patients, he avoids sweets and doesn't smoke or drink. He continues to wake up at 5 in the morning for his daily jogging at Brasília's Clube do Exército. He doesn't put less than 12 hours of daily work at his office, starting as early as 6:30 in the morning and never after 7 AM. He hasn't been doing his usual 20 to 30 heart operations a week, but he continues to perform at least five of these surgeries on weekends. With friends he normally talks about medicine and his ministry. Even when he goes to Fazenda Palmeiras, his farm in Itajobi, in the interior of São Paulo, he likes to work and he frequently use his free time to castrate his cattle.

Talking last year to a group of businessmen in Rio, Jatene presented himself as the victim of a conspiracy "from the 20% richer people in Brazil". For him there is no salvation outside the CMF. Said he: "The option is either to pay this contribution or dismantle a system that takes care of the low-income population." He also said: "I prefer 1,000 times the tears of defeat than the shame of not having fought. I read this on a truck's bumper sticker. Isn't a beauty?"

He has constantly been in Congress always bringing with him an article written by Planning Minister José Serra in which his cabinet colleague defends the idea of giving more money to healthcare. That the article was authored before Serra became minister is not a problem. "I know he wrote it when he was only a candidate," says Jatene with a wry smile. "Anyway...", he concludes without finishing his sentence.

Despite all his work in 1995, Jatene and the Health Ministry are better remembered for the struggle to get the check tax approved and the Bráulio campaign to promote safe sex. Bráulio, a talking penis, who starred in a series of TV commercials, got international fame after having provoked the ire of scores of real-life Bráulios who didn't like the fact of becoming the but of jokes all over the country. Some even sued the government. The campaign was scrapped, but the damage had been made. "To use a name of somebody was a unpleasant blunder," said Jatene.

The art of
defrauding

Invented surgery -- It's common to charge for the more expensive diagnosis in a same field. A headache might become a stroke, for example.

Overbilling -- Hospital charges astronomical prices for services rendered.

Intensive Care Unit -- Small surgeries end up taking people to the ICU, but only on paper.

Ghost patients -- Sometimes the same patient is admitted more than once for the same procedure. Some dead patients have been readmitted on paper. Other times the services listed were never provided.

Unnecessary surgery -- Some operations are schedule only to reinforce the bank account of the hospital.

Excessive tests -- According to a report made by Rio's representative Alexandre Cardoso, 80% of all lab tests come back negative and 40% of them are never even picked up.

Embezzlement -- Money received from SUS is used for everything but health purposes by municipalities or states.

Labs
Mafia

But this is just the beginning of the laundry list of misbehaviors of pharmaceutical labs. Many are accused of using less of the medication's active substance than is declared on the medicine box and sometimes selling placebos in place of medicament. And since getting a license to manufacture a product can take years some labs just get on line, get the license and sell it for a good price to some laboratory really interested in producing the medicine.

Medicine in Brazil is a $4-billion-a-year industry which has a stock of 20,000 to 30,000 different brand names. While the World Health Organization recommends a list of 400 basic drugs, the Brazilian market has 10,000 to 12,000. It's believed that if the useless products were taken off the market there will be a 40% reduction in the number of products offered.

All numbers are imprecise in this area. How many pharmacies are there? From 40,000 to 60,000. And how many pharmacists? From 30,000 to 40,000. The legislation requires a pharmacist for each pharmacy, but there is no way to enforce the law.

AIDS

Around 90% of those with AIDS depend on the government to get assistance and medicine. This year the federal government has budgeted $162 million to spend on the treatment of the disease and on campaigns to prevent it from spreading. The situation is far from ideal. While in Europe and the US an HIV positive can expect to live 40 months after the onset of the disease, in Brazil this period is only 11 months. Even though Brazil already has anti-AIDS medicines such as AZT and DDI, these products are very expensive and they fast disappear from the market.

A recent Folha de São Paulo special report revealed that two in every 10 undocumented immigrants being treated for AIDS at New York's Saint Vincent Hospital are Brazilians. The institution is the main center for the treatment of the disease in the Big Apple. At the Gay Men's and Health Crisis, the situation is similar. From 300 foreigners receiving assistance, 50 are Brazilian. Again, at Queen's Emmerick Hospital, Brazilian lead the pack. Most Brazilians seem to be able to stay in the US through the so-called "voluntary departure", a procedure that prevents the AIDS patient from leaving the country and then coming back. Since treatment costs around $10,000 a month, many people just give up going back to Brazil. But others prefer buying a green card through a fake marriage after a fake blood test.

The Folha article also cites Berkeley University professor João Guilherme Biel, who has been studying AIDS in Brazil since 1992. He has interviewed dozens of HIV-positive Brazilians, people who, according to him, see the US as a utopia. Biels accuses the government of having "abandoned" those with AIDS and tells stories of Brazilian scared doctors who wake up AIDS patients throwing objects at them.

And for Eduardo T., a former ballet dancer, "it's more secure to be soropositive in the United States than healthy in Brazil.." He has no intention of returning to his country. "I went back to Rio for two months," he says in disbelief, "got mugged and didn't know anyone anymore." <

Some numbers

North: 491

Northeast: 1996

Center-West 674

Southeast 1977

South 1234

Total of hospital beds: 509,270

Public: 30%

Private: 45.5%

Philanthropic 22%

College 2.5%

Hospitalization: 14,698,988

North: 883,494

Northeast 4,395,416

Center-West 1,014,187

Southeast 6,090,186

South 2,315,705

Doctors per 10,000 people: 14,69

North 7.26

Northeast 8.18

Center-West 13.99

Southeast 20.81

South 13.65

Hospital beds per 1,000 people: 3.35

North: 2.14

Northeast 2.90

Center-West 3.88

Southeast 3.60

South 3.82