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Rio de Janeiro’s public health system on verge of collapse

by Mathilde Dorcadie

Emergency services closed down or reserved for serious cases only, chronic shortages of medication, transplants delayed, salaries paid late... in Rio de Janeiro, 2015 ended very badly for many hospital patients and staff.

<p>Patients waiting outside the First Aid Centre in Botafogo, Rio de Janeiro, 11 March 2016.</p>

Patients waiting outside the First Aid Centre in Botafogo, Rio de Janeiro, 11 March 2016.

(Marion Lippmann)

Last year, Rio de Janeiro recorded the highest mortality rate in its public health care units for 30 years. Patients have spoken of spending several days waiting for a bed or a consultation.

The doctors’ union Sindicato dos Medicos (SinMed) has taken the case to court, accusing Luiz Fernando Pezão, the governor of Rio de Janeiro State of “failing to live up to his responsibilities”.

On 23 December 2015 he declared a “state of emergency”, calling for assistance from the federal government and seeking loans to finance the reopening of services in serious difficulty. A first envelope of 389 million reals (US$96 million) was granted a few days later.

But the sector is in arrears in its payments to its suppliers and subcontractors to the tune of 1.4 billion reals (US$347 million) according to the authorities.

Barely one month later, at the end of January, Brazil found itself facing an epidemic of the Zika virus: the already overloaded local health structures now have to deal with a new influx of patients.

Some 1,500 cases of infection by the mosquito-transmitted virus have been recorded in the region since the beginning of the year.

 

Sharp fall in public resources and poor management

None of Brazil’s 27 states have found themselves in such a dire financial situation in the country’s recent history - even if the public health sector has been facing multiple chronic difficulties throughout the country.

Two health systems co-exist: the free and universal public sector system called the SUS (Sistema unico de saúde, designed along the lines of the French social security system) and the private sector financed by expensive health insurance schemes that 20 per cent of the population pay into to make sure they are taken care of more quickly.

In Brazil public health funding remains relatively low: only 4 per cent of GDP as compared to 11 per cent in France. Government at all levels (the Federal State, the federalised states, districts and municipalities) contribute to the health budget.

The biggest contributors, however, are usually the governments of the federalised states.

So how did Rio de Janeiro State, which has 15 million inhabitants, become so dysfunctional? One reason, according to Governor Pezão, is the shrinking of Rio’s income from oil revenue. The fall in the price of a barrel of oil and the difficulties facing Petrobas, the Brazilian oil giant embroiled in a huge corruption scandal, have impacted on the state’s budget by way of collateral damage.

In one year alone, tax income, notably the equivalent of VAT, fell by 14 per cent. But Rio State’s chaotic financial situation is not only due to current economic conditions.

“A fall in tax income cannot explain the total collapse of the system run by the local government. Describing the situation as a ’crisis’ doesn’t help solve the problem in Rio de Janeiro, because that only leads to emergency measures which are aimed solely at putting out the fire,” notes Ligia Bahia a public health system specialist and lecturer at the Federal University of Rio de Janeiro.

The problems have been around for decades and Rio State has regularly ranked as the worst provider in terms of the quality of its health care system. Specialists also single out other factors such as poor management, tainted by corruption.

At the beginning of March, for example, the press revealed that 1000 tonnes of out of date medicines purchased by the State Health Ministry had to be or will be incinerated, while many health care centres are desperately short of drugs.

As if the cost of this wastage alone was not enough, the State also has to pay the cost of incineration, estimated at several million reals.

Public money is also regularly misappropriated. The most recent example was in February, when a court case revealed a network producing false medical bills with the proceeds going to local politicians in São Gonçalo, the State’s second biggest city after Rio.

The unions have also criticised the absence of a guarantee fund, from oil royalties, which could have prevented the paralysis of the system, like those that exist in other countries.

The ever-more frequent use of private management companies to run the public hospital networks has also been criticised for being costly and ineffective. One of the savings measures envisaged is a review of the contracts with these operators.

 

Concern for the population and for the Olympic Games

“The situation is becoming criminal,” says Jorge Darze, presdent of the Rio de Janeiro branch of the doctors’ union. “If it is already difficult to provide health care for the population of Rio, how are we going to cope when all the tourists arrive for the Games?”, he said at a press conference in January.

Some 600,000 national and international visitors are expected in August in the city hosting the 2016 Games.

Brazil has been in recession since 2015, forcing the federal government to make budget cuts.

Thirteen national bodies in the health care sector have just condemned the 2014 and 2015 cuts to the programme to combat the tiger mosquito, responsible for the transmission of the Zika virus, dengue fever and chikungunya.

At the same time, the number of cases of dengue fever and Zika infections has exploded.

As the Olympic Games approach, and despite the launch of a new awareness-raising campaign, the authorities are making a derisory attempt at reassuring the international community by insisting that the event will take place during the southern winter, and that there will naturally be fewer mosquitoes.

The state of emergency is due to last six months. The government therefore has until the end of June to try and restore order to the system and to put in place sustainable measures to avoid any further crises.

 

This article has been translated from French.

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