[Private health expenditures in Brazil].

The Brazilian Federal Constitution of 1988 established that health is “a duty of the State” and “a right of the citizen”. According to the law, every citizen is entitled to use the Brazilian Unified National Health System (Sistema Único de Saúde – SUS), in line with their social needs, regardless of their ability to pay, occupational status or health conditions. To ensure universal care, the State should have targeted its efforts to improve health equity and quality over the past 25 years. Health, however, is open to the private sector, and the Health Maintenance Organizations, which are very stringent in selecting their risks, received considerable governmental incentives, whose subsidies largely favored the use of private goods and services 1. For public health specialists, it is not easy to deal with this discrepancy. The distortion of this “system” tends to segment SUS’s public character, and the increase of private expenditure and the economic power corrode the sustainability of state funding, leading to a vicious circle characterized by the relative drop in payments and direct investments by the government. In addition, the regulation of a duplicate system is more complex for the State, as the private sector also provides services covered by the public sector. Differently from the Beveridian system and similarly to the American model, once the National Institute for Medical Care of the Social Welfare system (Instituto Nacional de Assistência Médica da Previdência Social – INAMPS) ended, the Brazilian system became a travesty comprising a mix of parallel and replicated actions, with the private sector establishing a parasitic relationship with the public health system (SUS) and the public funding standard. Even worse, in the current historical framework, with no power to support a strategic project that opposes the expansion of the neoliberal hegemony, a fiscalist perspective that advocates the development of the private health-plan market as a pragmatic solution to disencumber the public finances is advocated by economicist sectors of the State and of society.