Flawed but fair: Brazil's health system reaches out to the poor.

Until the 1970s, Brazilians used to joke that they had to die before the authorities paid any attention to them. Dr Hugo Coelho Barbosa Tomassini recalls how they used to have a full-time “death secretary” to administer funerals in the city of Niterói, where he was once the municipal health secretary, but only one health unit to care for the living. Much has changed since then. While long queues at hospital emergency departments, beds spilling into corridors, outdated and malfunctioning equipment and a scarcity of doctors and medicine in rural areas remain common complaints, on another level, Brazil’s national health system – Sistema Único de Saúde (SUS) – has been an outstanding success. The vision of a system providing “health for all” emerged towards the end of the military dictatorship that started in 1964 and during the years of political opposition that was to a large extent framed in terms of access to health care. This struggle culminated in the 1988 constitution, which enshrined health as a citizens’ right and which requires the state to provide universal and equal access to health services. It was a dramatic commitment to the ideals in the 1978 Alma-Ata declaration of “health for all”.