Costs of elderly health care in Brazil: challenges and strategies

Abstract

As with many other developing countries, Brazil faces the rapid aging of its population over few decades. Unlike what happened in developed northern hemisphere countries, Brazilians are getting older before the country in general, and elders in particular become richer. With an area of 8.5 million km 2 (world 5 th largest), Brazil has a population of 190 million inhabitants (2010 census) with 20.6 million above 60 years, nearly three million above 80 years. 1 By 2025 the senior population is expected to top 32 million, as illustrated in Figure 1. The life expectancy at birth is now 67.3 years for men and 75.2 years for women. 2 At the age of 60, people can expect to live another 20 years. 3,4 The health expenditure is a little over US$300 year/per capita, 5 or 8% of the GDP. 6 Despite accelerated progress in many fields, Brazil is still a poor country with great natural resources but with a big gap between rich and poor. It is the 8 th largest economy in the world, but still has 16.2 million people, (8.5% of its population) living in extreme poverty (less than US $1.25 per day). As in the whole world, chronic diseases are highly prevalent among the elderly. Recent studies 1 indicate that 77.4% of Brazilians over 60 reported some disease, and this proportion rises to 81.3% among those over 75 years. When analyzing the number of illnesses, 48.9% of the population over 60 report more than one chronic disease, rising to 54% in those over 75 years. Among the most prevalent diseases, hypertension occurs in 50% of the elderly; back pain and osteoarthritis occur in 31.5% and 24.2%, respectively. 1 In terms of functionality, the percentage of seniors who had great difficulty or who could not walk 100 meters grew from 12.2% (2003) to 13.6% (2008). This increase can be explained by the increase in life expectancy. Among those aged 75 or older, the percentage of those who reported difficulty or disability was 27.2%. Since women are the majority in this group, 15.9% of women (vs. 10.9% of men) reported having difficulty walking 100 meters. 1 Challenges here include finding solutions for a community where health perception does not match the actual morbid condition. Consequently, adherence to prevention and treatment of potentially severe diseases such as hypertension or diabetes is a serious problem. It should be noted that the variables related to health and their perception in the elderly include not only diseases per se but also physical/social frailty and lack of family support. Additionally, Brazil has problems related to its size. Great distances, the marked cultural and racial heterogeneity among the various regions of the country, 22% of its population under the poverty line and a fast decrease both in family size and in the dependence ratio 7 require decisions to guarantee a minimum social support to a growing elderly population. The Brazilian health system has three subsectors: (i) the public (SUS), where services are financed and provided by the government, at federal, state, and municipal levels, according to a decentralized policy; (ii) the private (for-profit and non-profit), in which services are financed with public or private funds (charitable institutions, foundations, etc.); (iii) the private health insurance subsector, with different forms of health plans, varying insurance premiums, and differentiated tax subsidies. 8 It is interesting to note that the right to use government health resources is universal, and extends to people with private health plans. Among Brazilians over 60, only 27% are affiliated with health plans, and, among those over 80 years, this proportion falls to 20%. Thus, SUS is nominally responsible for 73% of health care among the elderly, and 80% among the very old population in Brazil. 9 SUS has a structured system available through the internet (www.datasus.gov.br) that allows access to information and current data related to health care, in particular to, but not only, hospital admissions. In this perspective, the data that will be addressed correspond to this database and reflect health services available to 70 to 80% of the elderly people in Brazil. The annual budget of the Ministry of Health is approximately US$ 49 billion, of which approximately US$ 37.5 billion is earmarked for the financing of SUS. Brazil has few geriatricians: at the time of writing, slightly more than 1,000 Brazilian doctors have geriatric certification (one geriatrician for over 22,000 elderly Brazilians). Thus the problem of the elderly in Brazil requires solutions applicable to a rapidly growing population, with multiple illnesses, very limited financial resources and scant family support. Solutions must be simple, easily applicable, with a good cost-benefit relationship. We accessed data relating to general health and to the health of elderly people in Brazil; we initially identified the most relevant issues regarding the public care costs for the elderly: hospital costs, outpatient costs, long stay institutions, home care, vaccinations, training of caregivers and providing medication.