Realizing the right to health in Brazil's Unified Health System through the lens of breast and cervical cancer

Abstract

Background: Health is recognized as a fundamental right in Brazil's constitution. In the absence of a clearly defined benefit packages of healthcare services that are financed under the Unified Health System (Sistema Único de Saúde, SUS), courts have become important in adjudicating coverage decisions. Empirical assessments of equity and the right to health tend to focus on simple measures of access. However, these empirical perspectives belie the significant inequalities and rights violations that arise in the case of more complex health needs such as cancer. To shed light on these issues, this paper focuses on the care pathways for breast and cervical cancer and explores access and quality issues that arise at different points along the care pathway with implications for the realization of the right to health in Brazil.

Method: A mixed method approach is used. The analysis is primarily based on a quantitative analysis of national representative administrative data principally from the cervical and breast cancer information systems and the hospital cancer registry. To gain more insights into the organization of cancer care, qualitative data was collected from the state of Bahia, through document analysis, direct observation, roundtable discussions with health workers (HWs), and structured interviews with health care administrators.

Results: The paper reveals that the volume of completed screening exams is well below the estimated need, and a tendency toward lower breast cancer screening rates in poorer states and for women in the lowest income brackets. Only 26% of breast cancer cases and 29% of cervical cancer cases are diagnosed at an early stage (stage 0 or I), thereby reducing the survival prospects of patients. Waiting times between confirmed diagnosis and treatment are long, despite new legislation that guarantees a maximum of 60 days. The waiting times are significantly longer for patients that follow the recommended patient pathways, and who are diagnosed outside the hospital.

Conclusion: The study reveals that there are large variations between states and patients, where the poorest states and patients fare worse on key indicators. More broadly, the paper shows the importance of collecting data both on patient characteristics and health system performance and carry out detailed health system analysis for exposing, empirically, rights violations and for identifying how they can be addressed.

Keywords: Bahia; Brazil; Brazil’s Unified Health System (Sistema Único de Saúde, SUS); Breast cancer; Cancer care; Cervical cancer; Equity; Health system; Right to health.

Fig. 1

Cancer incidence in Brazil, 1997 and 2013

Fig. 2

Trends in breast and cervical cancer mortality rates/100,000 women

Fig. 3

Screening rates for women never tested by income (by minimum salary), 2003 and 2008

Fig. 4

Stage of disease at diagnosis for breast cancer, by region, 2012

Fig. 5

Days between diagnosis and treatment by location of diagnosis, by region, 2006–12 (averages)

Fig. 6

Resources for cancer care, by region, 2013

Fig. 7

Percentage increase in cancer treatment provision between 2011 and 2013, by services