By Richard Nelson, managing editor, August 01, 2012
While the United States argues about whether health care is a privilege or a right, Brazil proves that settling the argument is not the end of the story. The country’s constitution, adopted in 1988, guarantees Brazilians the right to receive health care free of charge, and makes ensuring this a duty of the state. But, somewhat like the United States, Brazil’s health system retains a combination of public and private employment of medical professionals, and some patients choose to purchase care through private health plans.
The nation is a good match for the U.S. in other ways — with 7,000 dermatologists serving a population of 200 million, it has a similar ratio of dermatologists to patients and is one of the few countries whose system rivals the U.S. in size. With large urban centers and vast rural areas, it is ripe for the same concerns about distribution of care that challenge dermatologists in the U.S. It also features a large national dermatology society, the Brazilian Society of Dermatology, celebrating a milestone its centenary is this year, and will be celebrated at the organization’s 67th Congress Sept. 1-4 in Rio de Janeiro, while the American Academy of Dermatology will celebrate its 75th anniversary at its 2013 Annual Meeting in Miami Beach, Fla.
Public system: Universal access, long waits
“The public system, known in Brazil as Sistema nico de Sade (or SUS), has been organized to provide all levels of medical assistance in different types of health care units, from primary care (which is usually offered in simple primary care units in the community) to very specialized and advanced care (mostly offered at university hospitals),” explained Fernanda Bellodi, MD. “The public system provides medications free of charge for patients. The government pharmacies offer basic drugs for frequent diseases like hypertension and diabetes and also, for selected cases, drugs with very elevated costs, like biologics, oral retinoids, immunosuppressives, and many others.”
The system does a good job of delivering primary care, according to Tania Cestari, MD, PhD. “Basic and family health care is easily available in almost every city and in small towns,” she said. “Additionally, the health campaigns, including pre-natal care, vaccines, and treatment of prevalent infectious disorders, cover almost all of the population, even those living in difficult-to-reach regions.” Dr. Bellodi agreed that the system is showing results, including an improving infant mortality rate and a successful AIDS/HIV program that encompasses education, prevention, and treatment. Still, according to Paulo Eduardo Neves Ferreira Velho, MD, PhD, “there are areas of Brazil where we have neither doctors nor the structure to care for patients.” [pagebreak]
Even where the care structure exists, it is imperfect. Not surprisingly for a system that offers free care, “the public system is burdened by huge waiting lists and lack of sufficient resources,” according to Regina Schechtman, MD, PhD. Dr. Bellodi agreed. “Patients may wait for months or even years depending on the type of assistance they need,” she said. “This situation is worse in the poorer regions of the country, which makes millions of patients seek medical care in the larger and more developed cities, overloading even more facilities.” Indeed, she added, “It is very hard for me, as a doctor, to realize that sometimes patients miss their medical encounters because they don’t have enough money to take a bus to the hospital, for example.” And patients who barely have money to pay for food and shelter cannot be expected to adopt lifestyle or habit changes that are “sometimes fundamental for successful treatment of dermatologic conditions,” she said. “Fortunately, these extreme situations are not the general rule, but they eventually happen and the health care provider that practices in the public system has to be prepared to face them and offer viable solutions.”
While the public system is already plagued with long waits, Dr. Velho points out that even with a guarantee of health care for the population, Brazil has not yet achieved true universal access: “Just 68 percent of the Brazilian population consulted a doctor in 2008. That is low if compared with countries like Germany, France, and Canada.” She cited a 2011 Lancet article about Brazil’s system (377(9779):1778-1797) that said, “In 2008, 76 percent of individuals in Brazil’s highest income group reported visiting a doctor, compared with 59 percent of individuals in the lowest income group, which shows that socioeconomic inequity exists.” (A 2005 American Family Physician study said that 77 percent of the U.S. population consulted a physician in 2002; the Lancet article suggested the figure had dropped to 68 percent, identical to Brazil, in 2008.)
Private insurance: More cost, access, less waiting — but no Rx coverage
Patients with private insurance purchase quicker access to care, as well as more direct access to specialists. In the public system, according to Tania Cestari, MD, PhD, “patients are usually seen by the primary care physician or by the pediatricians.” Those who need to be are referred to a secondary or tertiary care center for specialized evaluation, exams, or treatment. But, she said, “in private practice they come directly.”
The private system, Brazilian dermatologists agreed, also offers access to the latest treatments and technologies. What it does not do, however, is pay for medications. As Dr. Schechtman put it, “Patients in the public hospital sometimes must wait a long time for exams and novel, usually expensive, drugs are often not available for dispensation. In private practice, patients have access to sophisticated exams through medical insurance. However, medications can be very expensive.” To deal with the latter issue, Dr. Schechtman said, “I give samples for [patients] to try out the prescription before buying them and I have a list of some pharmacies and sites that sell the medications at a better price.” [pagebreak]
There is some disagreement about the private system’s other merits. According to Marcia Ramos-e-Silva, MD, PhD, “in the private system and with the health plans the patient has a free choice of doctors and hospitals, so the doctor-patient relationship can be then, in the majority of cases, very good and the doctors can request laboratory tests and imaging studies when they feel they are needed. The patient has the right to change his doctor as he pleases.”
Dr. Bellodi suggested the private system has darker aspects, though: “Health care providers that work for private insurance companies in general are not well remunerated, although these companies charge patients a very expensive monthly payment.” And Dr. Schechtman expressed concern about the level of control doctors have over treatment. “Due to the particularity that medical care is paid for directly by the insurance companies in the private system, the doctor-patient relationship, as well as the right choice of treatment, are jeopardized,” she said. Dr. Velho, meanwhile, noted that even patients who choose the private system may use the public system for their vaccinations as well as high-cost services and procedures, including transplants.
Brazil sees some dermatoses more frequently due to its tropical location, according to Dr. Ramos-e-Silva. “We have a great diversity of systemic mycoses, such as sporotrichosis, tegumentar leishmaniasis, chromoblastomycosis, paracocciodioidomycosis, chromomycosis, lobomycosis and other tropical diseases,” she said. “We also see more cases of leprosy, among other diseases.”
Common diseases often seen late
University hospitals and public health units, Dr. Ramos-e-Silva said, also tend to see common diseases in very advanced stages due to a lack of prevention and early and adequate care — a simple basal-cell carcinoma may lead to death, or a case of genital HPV may reach “incredible proportions.” Dr. Bellodi agreed, and noted that “skin cancers related to excessive and unprotected sun exposure are also common. Frequently the patients are people who work in agricultural activities.” [pagebreak]
Most of the treatments used in Brazil would be familiar to the typical American dermatologist, but there are differences. According to Dr. Ramos-e-Silva, “We still use old and inexpensive drugs, such as potassium iodine for sporotrichosis, rather than itraconazole in some cases.” Another drug used more frequently in Brazil than the U.S., according to Dr. Velho, is thalidomide; the drug is under strict controls but is used to treat leprosy and other conditions, off-label, including, according to Dr. Bellodi, aphthous stomatitis, prurigo nodularis, and lichen planus. Dr. Bellodi also said that “we prescribe personalized formulations more often, especially topical drugs, and compounding pharmacies are very popular and prices are generally reasonable.”
Dr. Ramos-e-Silva said phytotherapy also plays a role in treatment; the drug Viticromin, developed from the Brazilian flora, is used to treat vitiligo. Dr. Schechtman added that dermatologists sometimes “take advantage of the climate” and recommend heliotherapy — sunlight — for psoriasis patients.
Dr. Ramos-e-Silva also noted that some fillers have been approved in Brazil but are not yet available in the United States. Indeed, dermatologic patients in Brazil, like those in the U.S., have started coming to their dermatologists for aesthetic enhancements as well as treatment of skin diseases. Like in the U.S., private insurance does not cover these treatments and procedures are not covered by insurance, Dr. Velho said; some dermatologists supplement their income by providing them to patients who choose to pay for them directly. This has given rise to a new challenge, Dr. Bellodi said. “Dermatologists who see this profile of patients have to very careful dealing with problems like false expectations concerning aesthetic procedures and patients with body dysmorphic disorders,” she said. “Although common, I am sure this is not a problem restricted to my country.”
About the contributors
Fernanda Bellodi, MD, recently completed her residency training and practices at a private hospital and in the public system. Tania Cestari, MD, PhD, is a professor of dermatology at the Federal University of Rio Grande do Sul and has a private practice. Marcia Ramos-e-Silva, MD, PhD, is also a professor and head of a dermatology department of a university hospital and has her own private practice. Regina Schechtman, MD, PhD, is academic coordinator and head of medical mycology at a public hospital and has a private practice. Paulo Eduardo Neves Ferreira Velho, MD, PhD, is full-time faculty in the division of dermatology at the University of Campinas Medical School.