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back to index backGLOBALtalk December,  2011


Expat guide to Brazil: health care

Our latest country guide gives the lowdown on medical care when visiting or living in booming Brazil.

The world’s fourth-biggest democracy covers a country as wide as it is varied. Recognised as a fast-emerging economy, Brazil mixes wealth and extreme poverty to a startling degree.

This may account for the country’s patchy health system. Health care overall is adequate, but that administered by the National Insurance (Sistema Unico de Saúde), or SUS, is not always comparable to North American and European standards.

Hospitals can handle emergencies, but nursing care may be below the standards expatriates expect. This is particularly true outside the major cities, where quality of care varies greatly.

Improving picture

Unicef singled out Brazil as one of the world’s best improvers in a report in 2008. Mortality rates for children have fallen a commendable 60 per cent since 1990. Malnutrition among children under two years old in the period 2000-2008 fell by 77 per cent. Life expectancy is 74 years (in the UK it’s 80).

Infant mortality, the most used marker of a nation’s health care, is 22 per 1,000 live births. (In western Europe, it’s around five deaths per 1,000 live births.)

But as befits Brazil’s recent economic performance, matters have improved. Infant mortality was 32 per 1,000 live births relatively recently – in 2003. Each passing year has shown a decrease.

Access for all

The health care system is available for all, free at point of use, a concept enshrined in legislation since 1988. Like the NHS, it is government funded. But the system relies on private provision much more than in UK. Private hospitals, some not-for-profit, are reimbursed by the government and carry out more than half the medical procedures performed across the country.

As stipulated by the 1988 act, state funding of subsidies for health services derive from the social security budget, which in turn draws on earmarked taxes and contributions from employee payrolls and business profits.

The money is distributed to 26 regions. And while in Britain, a postcode lottery in health care remains a vexed political issue, Brazil’s health care is fully delegated to autonomous regional health boards. They set their own parameters.

Emergencies

Expats usually rely on private hospitals and clinics. Many major private hospitals have their own ambulance services. These should be called directly if you need immediate service.

However, just as with Britons in continental Europe, you can also expect to be treated for emergencies in Brazilian public hospitals. However, they do not offer treatment for existing illnesses or care after you have been stabilised – a point emphasised by the British Foreign & Commonwealth Office. Public hospitals are usually crowded, especially in big cities.

Private cover

Many Brazilians, particularly in the major cities in the south, have private medical insurance. Some become members of US-style HMOs — health care management organisations that both insure and provide care. As with other countries, the total number insured changes regularly. This correlates not so much with wealth as with perceptions of the acceptability of state medicine, just as in Britain. The proportion of GDP spent on health – by the state and by the individual – is close to the European pattern.

Private hospitals require a large deposit upon admission. Bank cheques and sometimes credit cards will be accepted, along with cash. Your health insurance plan should issue you a health card, to be carried at all times. This may help admission and should guarantee reimbursement of charges. In the primary care setting, family doctors often expect immediate cash payment for their services.

Steep rise in charges

Since 2009, private hospitals operating to American and European standards have hiked prices by 20-30 per cent, leading to strong protests from patients and health insurers alike.

The problem is the common one: few hospitals measure up to necessary standards. Those that do are in Rio and São Paulo, and they know a duopoly when they see one.

Dr Sneh Khemka, medical director of Bupa International, said: “We have major challenges on cost in Brazil. In the big conurbations there is good provision and some famous hospitals that have made themselves very good names.

“There is medical-tourism traffic going to Brazil because the surgeons are well qualified and there’s excellent inpatient provision.

“However, Brazil has become by far and away the most expensive country in Latin America to seek private health care. Its costs are 20-30 per cent above those of its country neighbours, and are even coming to level with the US. Inpatient stays, overnight stays, cost of admission, ancillary fees – they have all gone up.”

Some isolated cases were actually costing more than equivalent operations in America, added Dr Khemka. The majority of charges in Brazil were within 10 per cent of US charges.

“The problem with Brazil is that charges have inflated so rapidly over the past 18 months to two years that the market is becoming unsustainable. Medical insurance policies have to reflect that. We’re having real difficulties in managing the costs.”

Dr Khemka explained that tying hospitals down to set prices through tight contracting brought about by a steady through-put of patients, as in the UK, was difficult in Brazil.

“There’s a relative duopoly of providers in the major cities – two hospitals, maybe three – and because they have strong reputations, they have market share and our customers represent only a certain degree of those going there. Because the hospitals have the power, they are generally able to charge what they like.”

Bupa was tackling the issue through challenging hospitals not only on cost but on quality – ensuring the best outcomes were achieved but unnecessary procedures and tests eliminated. “We have seen a number of instances where more surgery is done than should be, and there’s a big trend to cosmetic interventions in Brazil – something we’re trying to tackle as well.”

There is a bright side to costs in Brazil, according to Dr Khemka. Primary care remains reasonably priced and to a good standard.

Compulsory cover

Health insurance for expats is mandatory in Brazil. Those without international insurance bought in advance should arrange good holiday travel cover for a period of at least two months after arrival. This gives time to choose the best insurance when in Brazil.

If you work in Brazil, you can elect to participate in Sistema Unico de Saúde. Brazilians are not required to qualify or register for SUS. However, any person in Brazil can receive free medical care at any hospital with a SUS contract.

Premium tariffs

Unlike the situation in many countries, in Brazil there is no great disparity in premiums quoted by major UK insurers. For a 25 year-old, the least expensive in a list drawn up by adviser Stephen Walker, of Medical Insurance Services in Brighton, is £987 a year for comprehensive cover from InterGlobal. Budget cover, which provides for inpatient costs only, is £641.

For the same 25 year-old, AxaPPP quotes £1,094 comprehensive (budget £855). Aviva International Solutions charges £1,211 (budget £1,090), and Bupa International £1,668 for comprehensive cover under its Classic plan. Its budget plan, Essential, is £881.

As with all price comparisons, allowance should be made for differences in benefits, such as application of cash limits on claims (caps) and cover for exceptional items that might be included in one policy but not another. Ambulance transport is one example.

If you take, as an example, an expatriate couple aged 34 and 31 living in Brazil, the least expensive provider is IMG, costing £2,198 a year comprehensive (budget £1,311). Other premiums include those from AxaPPP at £2,615 a year comprehensive for the couple (budget £2,044) and InterGlobal at £2,643 (budget £1,702).

Dentistry

Brazilian dental care is considered fair, but quality and specialisation vary by location. Rio and São Paulo, in particular, have excellent dental services. Their reputation has encouraged a considerable trade in medical tourism. Patients are attracted from America and even Europe.

Language

Doctors are usually referred to by their first names. Receptionists rarely speak English, even if the doctor does.

Tourist visas not needed

For tourists, visas are not usually needed. But passports should be valid for six months after arrival and you may be asked to show a return ticket. People going to live in Brazil have to find a job with a Brazilian company before going. The company applies to the Labour Ministry on the individual’s behalf for a Temporary Residence Visa or a Work Visa.

Yellow-fever certificate

If you have recently visited a country known for outbreaks of yellow fever, you will need to show proof of vaccination.

Hazards

High temperatures in the rainy season – December to March – prompt a rise in cases of dengue fever. The high fever associated with the disease usually begins a week to 10 days after the mosquito bite. Symptoms include severe headache, aching bones, joints and muscles and enlarged lymph nodes. Anyone with these symptoms should consult a doctor. (A second stage occurs with more fever and a rash. The victim is weak and ill for weeks.)

No vaccine is available. The main avoidance advice is to use mosquito nets and insect repellents and wear long-sleeved tops and trousers.

Moving on

Brazil’s economy and, with it, health care are clearly motoring. It would be a pity if a wheel were to come off the large private sector because of overpricing – as looks likely.

Source: The Telegraph - GAI





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