Rio de Janeiro (AFP)

The Brazilian health system, well designed at the start, lacks funding and is poorly managed, flaws tragically highlighted by the coronavirus crisis which has claimed the lives of nearly 100,000 people.

The Unique Health System, better known in Brazil by the acronym SUS, is a universal coverage system, inspired by the British NHS. It is one of the few in Latin America to operate on this model, which in theory gives access to free health care to the entire population.

It was born with the Constitution of 1988, in which it is written that "Health is a right of all and a duty of the State".

"On paper, it's a perfect system, but on the ground, we have plenty of problems", told AFP Fred Nicacio, an emergency doctor in Bauro, in the state of Sao Paulo (south-east). "There is a lack of hospital beds, staff, and also a more complete range of drugs," he laments.

Since the start of the pandemic, several of his colleagues have had to stop for a fortnight after being infected, without necessarily being replaced.

"The health professionals who are on the front line are demotivated, the salaries are low and they do not feel valued," he adds.

Another major problem, according to him: "corruption, at all levels". "It goes to politicians who divert funds intended for the purchase of equipment to patients who pretend to be sick and clutter our services to obtain sick leave," said Mr. Nicacio.

In recent weeks, corruption scandals have erupted in many states, notably around overbilling of respirators or the installation of field hospitals.

- "Chronic problem" -

For Guilherme Werneck, doctor and vice-president of the Brazilian Association for Collective Health, corruption is "a serious problem, which must absolutely be fought", but it does not alone explain the cruel lack of resources.

"The Constitution says that ensuring access to healthcare is a state duty, but the funding of the SUS is largely insufficient. It is a chronic problem that does not date from yesterday," he adds.

According to an OECD report from the end of 2019, Brazil is at the back of the pack of developed or emerging countries in terms of public investment in health, with per capita spending 30% below average.

Brazil's spending represents barely 4% of its GDP, less than half of the percentage France spends on public health.

"Since the establishment of the SUS, 30 years ago, health has never occupied a strategic place in national policies", denounces Luciana Dias Lima, researcher at the National School of Public Health of the Fiocruz Institute.

She accuses the government of far-right President Jair Bolsonaro "of not being sufficiently involved" in the coordination of public health services.

For the SUS to function, the states and municipalities depend on financial support from the federal government, which specialists consider insufficient.

- Social inequalities -

Another paradox of this system: since the creation of the SUS, the Brazilian state has indirectly funded private clinics, through tax deductions granted to privileged people who can afford private health insurance.

"No other country with a universal health system finances the private sector in this way," explains Luciana Dias Lima.

These funds returned to wealthy taxpayers "could be used to finance the SUS", adds Guilherme Werneck.

In Brazil, more than 70% of the population depends exclusively on the SUS for access to care, while the recovery rate from Covid-19 is 50% higher for patients hospitalized in the private sector.

"Social inequalities have been widened by the pandemic: the poorest, who often live in deplorable sanitary conditions, generally have more co-morbidities and find it more difficult to obtain a hospital bed", continues Mr. Werneck.

"If the SUS were better funded, the response to Covid-19 would be much better, but if it did not exist, the tragedy would have taken on even more serious proportions," he concludes.

© 2020 AFP