International Journal for Quality in Health Care 1999; Volume 11, Number 5: pp. 437–441
Country report
Quality of health care – growing
awareness in Brazil
JOSÉ CARVALHO DE NORONHA AND MARIA LUIZA GARCIA ROSA
Institute of Social Medicine, State University of Rio de Janeiro, Brazil
The World Bank published in 1994 a report on the organization, delivery and financing of health care in Brazil. Its
chapter on quality was entitled ‘The forgotten component:
quality of care’ [1]. Tracing back the two decades preceding
its publication no comprehensive programme dealing with
quality issues could be identified. Regulatory norms issued
by the Ministry of Health (MOH) and by professional boards
were identified but only very localized initiatives were detected
in the fields of quality management, clinical guidelines, accreditation, consumer satisfaction or defence. Only in the
early 1990s, more specifically from 1995, did quality of
care initiatives become more and more widely disseminated
throughout the country. This report tries to trace this new
environment in Brazil where a growing awareness of quality
in health care can be detected among consumers, providers,
financial planners and government representatives.
The country
Brazil has an area of 8.5 million km2 and shares borders with
all the countries of South America except Ecuador and Chile.
Its political and administrative organization includes the three
branches of government – executive, legislative, and judicial
– as well as 26 states, 5508 municipios, and the Federal District
(the seat of government). The total population was a little
over 157 million inhabitants according to the 1996 population
census.
The country is divided into five major regions. The North,
the largest region, occupies 45% of the national territory, but
has only 7% of the population; the Southeast occupies 11%
of the territory and has 43% of the population. The South
is the smallest region, with 7% of the territory and 15% of
the population. Each of the other two regions occupies
approximately 18% of the territory, but the Northeast has
29% of the population, and the Central-West has only 6%.
Basic indicators of Brazil are given in Table 1.
The human development index (HDI) of the United
Nations Development Program applied to Brazilian regions
shows tremendous internal disparities. The HDI in the South,
Southeast, and Central-West regions places them in the
upper ranges of human development, whereas the North and
Northeast regions are at an intermediate level, with the latter
region bordering on lower levels of the index [4]. Table 2
shows the differences in life expectancy at birth and infant
mortality rates in the Brazilian regions in 1991.
The Brazilian public health care system, known as the
‘Unified Health System’, is formed by the federal, state and
municipal services working in an integrated way, but with
sole authority at each level of government.
In 1992 there were 7430 hospitals in Brazil, of which 4433
had no more than 50 beds, 2127 had 51 to 150 beds and
870 more than 151 beds. Of these hospitals 72% are private
and 28% belong to the public system. Regarding hospital
admissions in the Unified Health System, 40% are to private
hospitals, 33% are to non-profit hospitals, 27% are to public
hospitals and 10% are to university hospitals.
Ambulatory care is provided mostly by public and teaching
services, the institutional composition varying according to
the type of care being offered.
Public revenues for health care come from the federal, state
and municipal governments. In 1996, public expenditures
amounted to US$ 18.0 billion; 76% came from federal sources,
13% from state sources and 11.3% from municipal sources.
In addition to the Unified Health System, there is a
private sector, consisting mostly of voluntary complementary
insurance schemes, which covers 20% of the population,
chiefly in the larger urban centres. In 1996 these plans spent
about US$9.0 billion. These complementary schemes provide
services through their own providers, through contracted
providers or by free choice of the customer. Service provision
includes group medicine, medical co-operatives, private health
insurance and company-based health services. In 1998 these
schemes came under the regulation of the MOH.
Brazil’s extreme diversity in social, economic and health
conditions is also reflected in its health care delivery systems.
One can find high quality services and facilities side-by-side
with very poor ones. Places like Rio de Janeiro, São Paulo
Address correspondence to J. C. de Noronha, Institute of Social Medicine, State University of Rio de Janeiro, Rua Sao
Francisco Xavier 524/70, Rio de Janeiro, RJ 20559–900, Brazil. Tel:+55 21 284 8249. Fax:+55 21 264 1142.
E-mail:[email protected]
 1999 International Society for Quality in Health Care and Oxford University Press
437
J. C. de Noronha and M. L. G. Rosa
Table 1 Basic indicators of Brazil1
Area
Population (1996)
Gross domestic product (1995)2
Gross domestic product per capita (1995)2
Median age (1996)
Mortality rate (1994)
Life expectancy at birth (1995)2
Infant mortality rate (1994)
Adult literacy rate (1994)
Urban population (1996)
Physicians (1996)
Hospital beds (1992)
8 547 403 km2
157 079 573
688.1 billions US$
5400 PPP$3
23.2 years
5.77 per 1000
67 years
40.0 per 1000 live births
82.7%
78.4%
13.04 per 10 000 inhabitants
3.2 per 1000 inhabitants
1
Data from [2].
Data from [3].
3
Purchasing Power Parity dollars (the number of units of a country’s currency required
to buy the same amount of goods and services in the domestic market as US$1 would
buy in the USA).
2
Table 2 Life expectancy at birth and infant mortality rates
per 1000 live births, Brazilian regions, 1991
Region
Life expectancy
Infant mortality
............................................................................................................
Central-West
63.45
32.46
Northeast
60.56
82.45
North
61.78
50.98
Southeast
64.50
32.17
South
65.67
29.04
Brazil
63.29
49.49
There are many regulatory processes related to quality of
health care in Brazil:
• norms for licensure of health facilities set by the MOH;
• hospital accreditation under the federal hospital reimbursement system;
• private payer systems for accrediting services;
• norms for infection control set by the MOH;
• licensing of schools for health professionals;
• licensing for professional practice (medicine, nursing,
pharmacy etc.);
and Porto Alegre play host to the most recent and advanced
forms of medical technology and the most qualified medical
and other health professionals; on the other hand physicians
can hardly be found in some municipalities of the Northeastern states. The same is true of quality initiatives in
this large and diverse country. One will find well-structured
programmes in hospitals such as the Heart Institute of the
State University of São Paulo, the Institute of Hematology
of Rio de Janeiro or the Hospital Mãe de Deus in Porto
Alegre. Yet one reads in the newspapers about infant deaths
in an overcrowded nursery in the public maternity hospital
of the city of Rio, or receives a report on the lack of
tuberculosis chemotherapy agents in a municipality of the
State of Pernambuco, and learns of a 100% Caesarean section
rate in a maternity hospital in the State of Parana.
The only possible approach to quality issues in places like
Brazil is the concept of Continuous Quality Improvement
(CQI). Dissemination of the idea that improvements in the
quality of care can and must be pursued whatever the setting
of care and wherever it is located is absolutely crucial. In the
same way it is crucial that educational activities be developed
based on the concept that a systematic approach to this issue
is possible.
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• norms and standards of practice set by medical societies
and councils.
However the purpose of the present report is to trace
initiatives related to quality improvement actions. As reported
previously by Malik [5] and by Noronha and Pereira [6], the
Brazilian MOH tried such an approach when it started a
national programme for quality in health care in 1995. The
programme was called the ‘Five Tracks Strategy’:
(i) moving towards the use of outcomes indicators. As
indicators of undesired outcomes can function as flags
for quality improvement efforts, indicators should be
defined both at the level of services (e.g. hospital
mortality rates) and at the community level (e.g. infant
mortality rates);
(ii) setting a national accreditation programme. The process of accreditation should be distinct from regular
legal licensing procedures and should be conducted
by independent non-governmental agencies;
(iii) emphasizing quality improvement tools. Use of tools
such as Total Quality Management or CQI should be
encouraged among health care providers;
Quality of health care in Brazil
(iv) establishing basic clinical guidelines. Basic guidelines
should be established after appropriate identification
of priority problems based on frequency, costs and
social relevance. Local professional bodies should
develop and monitor these initiatives and develop
appropriate continuing education programmes;
(v) enhancing community control. Community control is
crucial for adequate quality improvement. Consumer
satisfaction surveys may be useful but are insufficient
to promote change. New methods of evaluation such
as consumer audits may prove useful and should be
developed and tested. Community councils, consumer
protection initiatives and other forms of health advocacy would help communities to monitor adequately
and to press for good care.
resulted in decreases in the still very high rates observed in
Brazil [5].
Research in academic settings is still scarce but has begun
in some academic institutions and mainly since 1990. De
Gouvea et al. [7] studied the quality of care analysed through
the sentinel event approach, and examined the occurrence
of avoidable deaths during hospital admissions. Silva and
Russomano [8] described the development of an information
system in perinatal care designed for research into effectiveness, including analysis of the relationship between
process and outcome and for quality assurance purposes.
Bastos et al. [9] tested and confirmed the hypothesis that
availability of technology, levels of staffing and diagnostic
diversity in an intensive care unit are associated with the
ability to decrease hospital mortality.
Using outcomes indicators
Accreditation
Since the early 1990s the use of outcomes indicators in
hospital and community care has been increasing in Brazil,
however there is no overall accounting of these initiatives.
A very good example of the use of outcome indicators is
provided by the Program of Community Health Workers
sponsored by the MOH and conducted by local governments
and communities in the poorest parts of the country, particularly in the Northeastern states. The programme prioritizes
maternal and child care and employs a number of outcomes
indicators. Examples of these are the number of mothers
exclusively breast feeding 4 months after delivery, the proportion of undernourished children < 1 year of age, the
proportion of low weight births, neonatal mortality rates and
infant mortality rates and the proportion of deaths among
women aged 10–49 years. Approximately 3700 families are
followed by the community health workers and data are
collected regularly. The data allow corrective actions to be
taken in due time, and so far the families covered achieved
an average yearly decrease of about 10% in their infant
mortality rates.
Other localized initiatives have been reported. In the City
of Rio de Janeiro a programme ‘Right to be born right’ was
introduced in 1995 by the City’s Department of Health. This
programme regularly monitors maternal and perinatal deaths
in municipal maternity centres. After 3 years a regular yearly
decrease of about 10% in perinatal deaths was achieved when
corrective measures were adopted by the outlier centres. In
the harbour city of Santos (state of São Paulo), a High-Risk
Newborn Surveillance System was set up by the Municipal
Secretariat of Health seeking to provide special care to highrisk pregnancies. Perinatal mortality rates are thoroughly
measured to evaluate the successes of the programme. Since
1997, the State of Pernambuco in the Northeastern Region has
been developing a special training programme for physicians,
nurses and midwives that includes techniques of monitoring
outcomes to evaluate the impact of their actions on mother
and child care. Follow-ups of Caesarean section rates have
been conducted by some Departments of Health and have
The basic accreditation proposal was for the establishment
of a voluntary programme distinct from the existing licensing
requirements set by the MOH and other governmental agencies. The first initiatives in this field go back to 1986 when
the Brazilian College of Surgeons, considering the training
and certification of new surgeons and the quality of the
hospitals, created the Special and Permanent Committee for
Qualification of Hospitals.
In 1990, the State of São Paulo Medical Association and
the Regional Council of Medicine of the State of São Paulo
commenced a programme called ‘Controle da Qualidade
Hospitalar – CQH (Control of Quality of Hospitals) [10].
About 120 hospitals in the State of São Paulo participated
in the programme in 1997. About 20 were awarded a ‘Seal
of Quality’.
Other initiatives in this field were the result of a programme
of the Pan-American Health Organization (PAHO) on the
Accreditation of Hospitals established by an agreement with
the Latin-American Federation of Hospitals. At the end of
1995 a manual became available for testing. Up to now it
has been applied to about 40 hospitals and a new application
manual has recently been developed. The State Secretariat of
Health of the State of Paraná also developed a programme
utilizing the standards proposed by the PAHO [11].
In 1997 the MOH started a process to establish a national
agency for accreditation. A technical group was set up to
review the manual on standards for hospitals. A final version
of this manual was published by the end of 1998 and is
available on the Internet [12]. It is structure oriented as can
be deduced from its list of chapters:
• Organization of medical care, including inpatient unit, ambulatory care, etc.;
• Diagnoses and therapy, including clinical laboratory, blood
transfusion services, rehabilitation services etc.;
• Technical support, pharmacy, food and nutritional services
etc.;
• Processing and supplies, linen and laundry services, materials
processing and sterilization;
439
J. C. de Noronha and M. L. G. Rosa
• Administrative support, building documentation, electrical
systems, general maintenance, etc.
In August 1994 the National Academy of Medicine, the
Brazilian College of Surgeons and the State University decided
to create the Programa de Avaliao e Certifição de Qualidade
em Saúde or PACQS (Programme for the Evaluation and
Quality Certification of Health Services) as the first step
towards the organization of an accrediting agency. More
recently, as further development of this programme, the
Brazilian College of Surgeons created a Permanent Commission for the Accreditation of Hospitals. In July 1997
the Cesgranrio Foundation, a foundation established by the
universities of the State of Rio de Janeiro for evaluation of
educational processes, joined this programme.
In 1998, the four organizations mentioned above formed
the Brazilian Consortium for Accreditation of Health Care
Systems and Services, the CBA. Assistance was sought from
the Joint Commission International Accreditation and a set
of standards was established based on the Joint Commission
for Accreditation of Healthcare Organizations’ standards for
hospitals and on the effort of the Joint Commission Task
Force for the Development of International Standards. A
manual was finished by March 1999. This set of standards
has been in use since August 1998 to evaluate seven federal
hospitals in the City of Rio de Janeiro. The two main teaching
hospitals in Rio and the five hospitals administered by the
State Department of Health are due to apply the same
methodology.
The standards are organized as two groups of functions:
those focused on the patients and those focused on the
organization. Patient-focused functions are: patients’ rights,
organizational ethics and education; access and continuum
of care; assessment of patients; care of patients. Organizationfocused functions are: quality improvement; leadership; environment of care; medical staff, nursing and human resources
management; management of information; surveillance, prevention and control of infection.
This functional approach seems best suited to places like
Brazil where a very significant diversity of health care settings
exists.
Hospital Albert Einstein, in the State of São Paulo is
preparing itself for accreditation by the Joint Commission
International Accreditation.
Quality improvement tools
In Brazil, quality management issues began to be discussed
in industry in a systematic way around the 1970s. In 1990
the Federal Government created the Brazilian Programme
of Quality and Productivity oriented mainly to quality processes in industrial settings. In 1996 greater amplitude was
given to the programme enlarging the concept and scope
of quality initiatives. Four macro-priorities were defined,
including ‘quality of life’ and within this, a special project on
quality of blood was launched.
There are also quality prizes that are now attracting health
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care providers. The most important is the National Quality
Prize [13], but there are two important prizes in the state of
Rio Grande do Sul and Rio de Janeiro. Since 1994 hospitals
have begun to be awarded mentions and medals although
no health care organization has won a prize so far.
Another example of these quality initiatives is the case of the
National Institute of Metrology and Industrial Normalization
[14]. Until very recently it used to have activities only with
industries. In 1996, the Institute established a norm for ‘good
practices of laboratories’. In an effort to stimulate consumer
awareness, it developed a project of verification of sphygmomanometers that showed important problems of calibration.
In 1997 a survey was conducted by the MOH among
consultant firms and State Secretariats of Health in order to
identify hospitals that have engaged some sort of quality
management initiatives. Eighty-two hospitals in 13 states were
identified. Since 1994 a number of hospitals and other
health services have been seeking International Standards
Organization certification and by 1998 more than 20 had
achieved it.
Clinical guidelines
Basic guidelines for dealing with endemic diseases in the
country had been written for many years by the MOH. From
1994 some medical societies began to publish guidelines in
an effort to diminish practice variation and improve care.
The cardiology, paediatrics and pulmonary diseases societies
have been the leaders in this field with guidelines already
produced on the management of common childhood disorders, hypertension, post-myocardial infarction, asthma and
many others.
Consumer protection
In 1990, the Brazilian Congress passed a law on consumer
rights and protection. At the State levels offices of consumer
rights solicitors were set up. Many cases relating to health
care began to be presented to these offices, most of them
consisting of complaints against private health plans [15].
However, Brazil has nothing similar to the malpractice litigation observed in the USA. Activities in the field of consumer protection are not yet well developed. In 1997 the
government proposed a law to regulate private health plans
in the country.
In 1988 the Instituto Brasileiro de Defesa do Consumidor
(IDEC; Brazilian Institute for Consumer Protection), a voluntary organization, was created in São Paulo. In 1990 IDEC
conducted a survey on quality compliance of contraceptives.
Since 1995 it has been conducting many surveys on products
and services more directly related to health care, such as
pregnancy tests (July 1996), baby pacifiers (August 1996),
male contraceptives (November 1996), clinical laboratories
(April 1997), and ampicillins (November 1997). IDEC sponsors a monthly journal where it publishes articles on consumer
Quality of health care in Brazil
protection and the results of its product evaluations. It also
has a series of books on the subject and a site on the Internet
[16].
As a requisite of the decentralization process, health councils are being organized at state and municipal levels. By
1997, almost every state had its council and over 1000
municipalities also had their health councils. Consumers’
voices are very active in many of these councils.
Since 1995, the MOH has made available on the Internet
data concerning all activities financed by the Ministry [17].
Consumers, members of legislative branches, advocacy and
professional groups are making growing use of these data.
Conclusions
There is a growing awareness concerning quality of health
care in Brazil. The size and diversity of the country does not
allow the establishment of a single strategy for improving
health care quality. The ‘five tracks’ approach gives room to
find what combination of initiatives is best suited to the
particular local facilities or organizations. The strict regulatory
activities have proved insufficient to produce improvements
in the quality of care. Mobilization of the community, health
care providers and financiers and different levels of government in a continuous effort for improvement is crucial.
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Accepted for publication 5 March 1999
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