In 1988 Brazil adopted a new constitution that defined health care as a right of all citizens and the responsibility of the state. It further established a new health care system, the Sistema Único de Saúde (SUS, Unified Health Care System), which dramatically transformed all aspects of the way health care was practiced, from the way funding was allocated to the categories of citizens to whom medical care was extended to the very way that health itself was imagined.

Brazil’s transformation of its health care system was a profoundly radical step, not just in the context of the country’s emergence...

If you take the Grande Circular 2 due west from the city’s old, baroque courthouse, now the nocturnal haunt of prostitutes, past the new Dragão do Mar cultural center and the crumbling Biblioteca Pública, over one of the city’s few overpasses, and then down along the Avenida Presidente Castelo Branco, better known simply as Leste-Oeste (East-West), you will eventually end up in Pirambu. During the morning and evening rush hours the bus is crammed full of residents from Pirambu, many of whom work in downtown Fortaleza. As the bus grinds its way toward the favela, swaying under the weight of...

With the adoption of Brazil’s 1988 constitution, universal and equitable access to health care became the guiding principle of the new health care system, the Sistema Único de Saúde. To implement this system, however, its supporters in Ceará had to navigate an already entrenched two-tiered health care structure with many private medical clinics, hospitals, and physicians as well as public medical facilities, community health centers, and state-employed health care providers. One of my goals in this chapter is to describe the historical emergence of the two-tiered health care system in Ceará and its particular, multifaceted character. What could account for...

In the years that followed the military dictatorship, political and civic leaders began an intense public discussion of Brazil’s health care needs and policies. The policies adopted during this period responded to an ongoing crisis in the country’s social security system as well as to the intensifying social and political demands for health care reform. In 1986, at the landmark 8ª Conferência Nacional de Saúde (Eighth National Health Conference), a unified and decentralized health care system was outlined that was eventually to become the Sistema Único de Saúde. The SUS imposed extensive changes on the health care sector, among them...

Many of the programs associated with the Sistema Único de Saúde, such as the health councils discussed in chapter 3, were first elaborated in federal agencies; however, because spending of health care funds was entrusted to the municipalities under the SUS, several locally developed therapeutic programs were used to support the goals of the health care reforms. Farmácia Viva, which was created to teach low-income residents in Fortaleza about the scientifically correct use of traditional medicine,¹ is an excellent example of how local programming became intertwined with state and national health goals.

In 1991 the municipal government of Fortaleza established...

In January 2003 then secretary of health for the state of Ceará Jurandi Frutuoso gave a radio interview at the Universidade Federal do Ceará about the dramatic improvements in health care that the state had realized since the implementation of the Sistema Único de Saúde. In addition to greater accessibility and higher-quality medical care, Frutuoso noted that changes had occurred in the way people thought about health care. “Before,” he said, “it [health care] was like a favor. Today people know that they have the right to good health care. If a medication is not in stock, they demand to...

As my research in Pirambu expanded, I began to observe more and more of the younger residents I knew in the favela pursuing private medical care and insurance in addition to the public care they consumed for free. Although there is broad concern about the growth of private health care in Brazil, the consumption of private care by low-income residents has received scant attention.¹ An article in the medical journalThe Lancethighlights the challenges that growth in private medical care and insurance have posed for Brazil’s public health care system (Paim et al. 2011). The authors focus attention on...

Health care reform in Northeastern Brazil, stimulated by the enactment of Brazil’s 1988 constitution, integrated local, state, and national levels of care and preventive and curative medicine. The constitution’s declaration of health as a universal right of citizens allowed the leaders of the state of Ceará to replace the old and ailing public health system with the Sistema Único de Saúde. At the time of its creation, the SUS reflected many of the leaders’ aspirations for a system that expanded the right of access to health care to impoverished communities throughout the state and that encouraged new forms of citizenship,...