PUBLIC AND PRIVATE IN A HIGH COMPLEXITY MEDICAL PROCEDURE

Abstract

The care to highly complex services in Brazil is carried out by federal funding. Today, there is a link between the public and private sectors in order to provide, from the private sector part, the necessary equipment for performing high complexity services, being the public sector responsible for funding it. This article aims to understand the relations between the public and private sectors when carrying out a procedure of high complexity and, thus, a case report of a patient who underwent lung transplantation will be used.

Introduction

Some of the high complexity health procedures, as lung transplantation for instance, are funded for the population and this subside comes typically from the Public Health Care System. In Brazil, the transplantation program, considered the biggest in the world, exists due to public funding. In Espírito Santo, the transplantation activities were promoted through public-private agreements. Most of its funding comes from the public sector, carried out through the Health Ministry, so, it does not affect the spending cap of the states and municipalities. The State is responsible for the management of the system, regulated by the National Transplantation System.

Nowadays it is common to see articulations between the public and private sectors, in order to provide (from the private sector part) the equipment required for the realization of high complexity procedures. The public sector is responsible for the funding of the services; a true public-private mix, regarding the providing of health services in the country¹.

The government has sought strategies for reducing the obstacles to the progress of the organ transplantation program. It offers to people living in places not covered by the program the possibility of using resources from the Out-of-home Treatment program (TFD) for the transport of patients to a transplantation center. The transplantation center must have a qualified staff, specialized in the pre, intra and post-operatory handling, and formed by several different professionals who work in an interdisciplinary approach, aiming to optimize of the biological, psychological and social conditions of the patients.² It has been partially executed in Espírito Santo, since the patients have been taken to the Lung Transplantation Group of the Hospital Meridional Transplantation Center.

This research aims at understanding the interrelation between the public and private sectors regarding the realization of a high complexity procedure (lung transplantation). In order to do so, it presents the case of a patient with pulmonary fibrosis, here named Cachoeiro, who presented shortness of breath on mild exertion, with partial limitation of the everyday life activities, and was admitted at his city hospital almost every month. He had a private health insurance and received the TFD for undergoing the lung transplantation in Porto Alegre.

Case Report

The patient was evaluated by the multidisciplinary team of Espírito Santo and referred to the Hospital Santa Casa in Porto Alegre, where he underwent the transplant procedure. The service flow, in this case, was made in the following way: 1) social worker to evaluation of housing, social support, family and income; 2) nutritionist to evaluation of the nutritional status; 3) nurse care to evaluation and orientation of the hospital proceedings; 4) physical therapist to evaluation of the physical condition and orientation about the pulmonary rehabilitation; 5) psychiatric assessment; 6) transplantation clinical staff.

Cachoeiro is a 60-year-old man, dwelling in Cachoeiro de Itapemirim, Espírito Santo, married and living with his wife, working as a jeweller. He had completed high school. It is known that education is directly related to access to health care services, especially the private services, and, maybe because of this, to the high complexity services of the Unified Health System – SUS. According to Noronha and Andrade³, the educational level of the family head has significant impact in the decision on looking for health care. The individuals who are attended exclusively by SUS have lower educational levels and use mostly the public health system, typically looking for medical appointments or other professionals, predominantly ambulatory service⁴.

The household income of Cachoeiro was around 8-10 minimum wages and he had private health insurance. According to Ribeiro et al.,⁴ only 9.2% of the patients who are attended exclusively by SUS had a per capita income higher than two minimum wages, while – among the population covered by private health insurances – this numbers was 51.8%. It is important to emphasize that individuals who have private health insurance have 56% more chances of being admitted to a hospital, and, therefore, undergoing certain procedures than SUS patients.³

Discussion

It is a paradox to think that, despite the majority of the transplants carried out in Brazil are funded by the public health care system, those who have private assistance manage to be evaluated more quickly and, most likely, get transplanted, whereas SUS patients cannot undertake all the exams in the proper time, being invariably doomed to die. According to Souza (2011)⁵, “in the health care sector, the imposition of the market logic has legitimated inequality in access to health care and formed an illusory share of health care service customers”.

After being evaluated by the social work team, Cachoeiro has received the TFD subside in Espírito Santo. He was included in the waiting list, underwent the transplant in December, 2011 and three months late was allowed to go back home. In spite of having a private health insurance, Cachoeiro looked for public assistance when it came to a high complexity procedure, such as lung transplantation. According to Souza (2011)⁵, “the private sector takes on the most profitable pathologies, associated with the most profitable therapeutic resources”. The lung transplant cost is high, and about 95% of it is funded by SUS, differently from the USA, where the transplant is funded by private health insurances or direct payment made by the patient.⁶

In Brazil, the high complexity procedures are responsible for an input of federal funding for health care at great cost to the federal budget. Although there is no official data on the number of outpatient appointments for the patients who were transplanted, one may extend the analysis and gather data from other services, such as chemo, radio, hemotherapy and hemodialysis. The southeast region is responsible for 57.4% of the appointments in Brazil and 11.6% of all appointments in SUS related to these treatments, are made for people who own a private health insurance.

Thus, some high complexity procedures, such as transplants, are promoted by public-private agreements, being the federal public sector responsible for the funding, while the private sector offers the equipment and the human resources management. As it was made clear in this case report, it is unacceptable that only the part of the population who owns a private health insurance is able to get the proper agility when undertaking the required examinations for a transplant.

References

1. Santos IS, Ugá MAD, Porto SM. O mix público-privado no Sistema de Saúde Brasileiro: financiamento, oferta e utilização de serviços de saúde. Ciênc. saúde coletiva. 2008;13(5):1431-40.
2. Orens JB, Estenne M, Arcasoy S, Conte JV, Corris P, Egan JJ, et al. International guidelines for the selection of lung transplant candidates: 2006 update – a consensus report from the Pulmonary Scientific Council of the International Society for Heart and Lung Transplantation. J Heart Lung transplant. 2006;25(7):745-55.
3. Noronha KVMS, Andrade MV. Desigualdade social no acesso aos serviços de saúde na região sudeste do Brasil. X Seminário sobre a Economia Mineira. Disponível em: http://cedeplar.ufmg.br/diamantina2002/textos/D40.PDF [Acesso em 16 junho 2016].
4. Ribeiro MCSA, Barata RB, Almeida, MFde, Silva ZPda. Perfil sociodemográfico e padrão de utilização de serviços de saúde para usuários e não-usuários do SUS-PNAD 2003. Ciênc. saúde coletiva. 2006;11(4):1011-22.
5. Souza MASL de. Trabalho em saúde: as (re)configurações do processo de desregulação do trabalho. In: Davi J, Martiniano C, Patriota LM (orgs). Seguridade Social e Saúde: tendências e desafios. 2 ª Ed. Eduepb; 2011. p.147-174.
6. Marinho A. Um estudo sobre as filas para transplantes no Sistema Único de Saúde brasileiro. Cad. Saúde Pública. 2006;22(10):2229-39.

Authors

Luziélio Alves Sidney Filho¹; Raquel de Matos Lopes Gentilli²; Luciana Carrupt Machado Sogame³

¹ Master of Public Policy and Local Development, Medical Doctor.

² PhD from the Catholic University of São Paulo – PUC/SP, EMESCAM, Professor of the Escola Superior de Ciências da Santa Casa de Misericórdia de Vitória –  EMESCAM.

³ PhD from the Federal University of São Paulo – UNIFESP, Physical Therapist, Professor of the Escola Superior de Ciências da Santa Casa de Misericórdia de Vitória –  EMESCAM.