With rumblings of support for universal health care picking up in the United States, a Drexel professor just released a study looking at how Brazil’s most vulnerable citizens feel about the state of their national health system.
Unfortunately, Gina Lovasi, PhD, professor in the Dornsife School of Public Health and co-director of its Urban Health Collaborative, found out that there are definite areas for improvement for the system.
A past study by Lovasi’s collaborators from the Oswaldo Cruz Foundation in Brazil — Débora Castiglione and Marilia Carvalho — found that those who lived before the Unified National Health System (SUS) was created in 1988 felt that it was an improvement. But this latest study study discovered that access to this public care has not been even for everyone.
Residents of favelas — which are marginalized, low-income residential areas inside Brazilian cities — seem to have a particularly dimmer view of the SUS. Lovasi, Castiglione and Carvalho teamed to interview 14 residents from the Rio da Pedras favela in Rio de Janeiro about their experiences and feelings regarding their health care.
Those who were interviewed felt the public health system was often unreliable due to long waits, absent doctors and difficulty even getting to clinics.
Moreover, the Rio de Pedras residents also often felt extremely disrespected by doctors once they were seen. A recurring theme was that doctors’ “inability to deal with the population from favelas,” as they were rude or incommunicative.
Unexpectedly, the researchers discovered that the residents were using a mixture of the public services and private health services at times. For example, someone who was pregnant might use private healthcare for prenatal check-ups, but actually do her delivery in a public healthcare setting because it would be unaffordable in private care. Even then, concerns about doctors’ attitudes clouded the experience.
Improvements do appear to be coming to the system, as the favela that was studied got its second clinic after the study concluded. So change is happening, however slowly, and more political capital and resources are necessary to continue to improve the system.
With all of this in mind, Lovasi explained three lessons she learned from this study on the Brazilian system that should be heeded if the United States ever makes an attempt at universal health care.
- Universal Health Care Means Nothing if the People Can’t Use It
Officially being included in a universal health care system is not sufficient to ensure access to timely care. Although making health a right for everyone means that people who would have gotten no care at all can finally access it, we did hear about delays that resulted in worse health for some. These delays also reduced confidence in the system from the broader community we talked to. This highlights a need to drive resources to reduce such delays.
Expanded health care access in the U.S. could have delays as well. Systems that could offset that might be market-driven (people who pay more get priority) or through some kind of wait list that decides who gets what care and when.
- Shifting Away from Reliance on Doctors Is Met with Resistance
Expectations within the community that each patient would be seen by a doctor, and resistance to being seen by a nurse instead, suggest that options to shift tasks within the clinical team may meet with resistance.
I think this applies both in Brazil and in the U.S., where limited resources and personnel availability have led professional organizations to rethink roles within clinical practice.
Recognizing the elevated stature of doctors — and perhaps the need for additional patient engagement in planning for a system change — may help to avoid resistance and dissatisfaction when care is provided by other team members.
- History Weighs Heavily, Particularly Upon the Disenfranchised
Perhaps most importantly, the participants we interviewed in an informal community in Brazil perceived public health care as being offered as a hand-out, with clinic personnel acting accordingly. In a community like a favela where people were hands-on in cultivating economic opportunities — and often in building or adding to their own homes — being treated as inferior or pitied was abhorrent.
The history in Brazil of alternating between providing state assistance toward informal communities and informal communities being treated as a blight to be removed provided a context within which public health care was felt as dehumanizing rather than deserved.
In the U.S., historical treatment of communities (particularly communities of color experiencing legacy effects of Jim Crow laws and red-lining) can likewise undermine trust in the universal systems (not only health care, but also education) that at first glance might be seen as facilitating upward social mobility. Unequal access to and unequal quality of experience within such systems may be felt as especially painful because of the historically unfair forces that have played a role in shaping current inequality.
Any media interested in speaking with Lovasi should contact Frank Otto at 215.571.4244 or fmo26@drexel.edu.
