­­­­­­The Health Sector in The First 100 Days of the Third Lula Government in Brazil — [no Diagnosis, no Strategic Plan, no Urgent reforms]

Andre Medici and Joaquim Cardoso
21 de Abril de 2023

Why the First 100 days of Government matter to the Health Policies?

The Great Depression of the 1930’s was the scenario where, at first time, a president used the phrase “first 100 days” to address early new government progress.

This was Franklin Delano Roosevelt, president of the United States, which make a sound radio speech in 1933 addressing how he was conducting his plan to combat the American crisis of the century. 

He followed through on his promises, passing major bills in the Congressional sessions along the first 100 days of his government, including taking the country economy off the gold standard and creating public-works relief programs. 

In total, Roosevelt passed 76 laws and issued 99 executive orders in his first 100 days, a record that still stands[1].

Democracy requires to governments sound demonstrations about how they are conducting their duties to achieve political campaigns’ promises. 

Since Roosevelt initiative, other elected presidents, not only in United States but everywhere, have tried to emulate this success by using their first 100 days to push through ambitious campaign promises while their approval ratings are typically at their highest.

However, how to prove progress along the first 100 days in specific sectors, such as health? 

This exercise should start before the government be launched. 

To improve health system performance, policy makers must have a clear situational diagnostic to understand what the gaps and which areas require prioritization and resource allocation. 

This can be achieved through regular monitoring and assessment of health systems, which is essential for finding data and relevant information in systematic bases. 

It also requires listening and dialogue with the key stakeholders of the health sector to understand their perspectives, strategies, and ways of collaboration. 

Both — assessment of the health systems and dialogue with stakeholders — are essential to determine what are the current strengths, weaknesses, opportunities, and threats for the implementation of the health actions to be prioritized.

To improve health system performance, policy makers must have a clear situational diagnostic to understand what the gaps and which areas require prioritization and resource allocation.

Setting health system goals along the political campaign is a critical step to promote further analysis of the past governments’ performance, as it provides a framework for assess results. 

Across various health system frameworks, there is consensus on key health goals, such as improving health outcomes, prioritizing patient needs, promoting equity, ensuring fair financing, and increasing efficiency.

By evaluating the performance of each component of the health system and identifying areas of improvement, policy makers will be able to develop strategies to strengthen the system and achieve the proposed goals. 

This underscores the policy relevance of ongoing evaluation and monitoring to ensure that health system strengthening efforts are effectively improving health outcomes.

fiocruz, 2026

The Role of Health System Performance Assessment (HSPA) in the First 100 Days

To help governments strengthen their health systems, it is crucial to conduct sound health systems performance assessments that can inform policy discussions, decision-making, and the development and implementation of health strategies. 

These assessments will also play an increasingly important role in guiding government responses and systematic problem solving to improve the performance of health policies.

There are tools available to access the ability and response of the health systems to achieve universal health coverage at distinct levels. 

In 2017, the Universal Healthcare 2030 Technical Working Group (UHC2030-TWG) was set up to address these challenges by bringing together and discussing solutions among diverse stakeholders.

The TWG searched for developing and implementing effective health system assessments that can inform and guide policymakers in their efforts to improve health outcomes for their populations. 

This initiative resulted in the creation of the Health System Performance Assessment for a UHC framework (HSPA), which provides a conceptual representation of how health systems assessments can contribute for the improvement of health systems performance.

The HSPA framework is built around four critical health system functions necessary to achieve health systems goals: (1) governance, (2) financing, (3) resource generation, and (4) service delivery, as can be shown in Figure 1.

Figure 1 — The Health System Performance Assessment (HSPA) for UHC Framework

Source: UHC2030 (https://www.uhc2030.org/fileadmin/uploads/uhc2030/Documents/About_UHC2030/UHC2030_Working_Groups/2017_Health_Systems_Assess_Working_Group/HSPA_Framework_for_UHC.pdf)

The HSPA framework bridges the gap between HSAs (Health Systems Assessment) and health system performance by taking a three-pronged approach to address fragmentation, ownership, and performance bottlenecks. 

This approach offers new opportunities to analyze health systems performance more effectively in a coordinated way, supplying a basis for more cohesive and efficient action.

Overall, the HSPA framework offers a way to comprehensively evaluate health systems performance and find areas for improvement. 

By linking HSA information with health system performance, this framework can help to inform for a more effective decision-making, resulting in improved health outcomes and progress towards UHC. 

Figure 1 shows the different health system components: the health system functions, their corresponding sub-functions, the assessment areas used to evaluate the performance of the functions and sub-functions, and the intermediate aims and final goals of the health system. 

All assessment areas are shown in yellow boxes (with service delivery assessment areas in both yellow and turquoise as they overlap with intermediate health system goals). 

Finally, the framework outlines key performance linkages between the functions and sub-functions and intermediate and final goals.

The HSPA Framework is based on the premise that any whole-of-sector assessment exercise should gather information on and assess both the functions of the health system and its performance goals. 

It outlines the purpose of each health system function, the sub-functions needed to fulfil that purpose, and the areas to evaluate the function’s performance. 

This innovative framework conceptually links health system functions to intermediate and final health system goals.

By using this approach, policy makers can better find and analyze the potential causes or impact of poor performance on the specific health system outcomes.

fiocruz, 2016

What are the needs of Brazilian Health System’s Reforms?

The main problems faced by the Brazilian health system are structural but could be addressed through internationally known and approved technical solutions. 

International organizations have been foreseen problems and proposed solutions for reforming the Brazilian Unified Health System (SUS) in the last decades. 

The World Bank, for example, issue in 2019 a document proposing an agenda for reforming the Brazilian Unified Health System (SUS), based in four kinds of reforms:

(i) Supply-side reforms (rationalization of the outpatient and hospital services provision, primary care coverage expansion to entire population, health services provider’s autonomy and innovative quality improvement by a social organization (OSS) model).

(ii) Demand-side reforms (use of gatekeepers at primary healthcare level, use of clinical pathways and evidence-based health protocols; implementation of a defined package of benefits for the SUS).

(iii) Management Reforms (establishment of integrated health care networks defined by geographic areas and improved coordination and integration between public and private sectors inside each network).

(iv) Health Financing Reforms (financing flows centered in the patients’ needs and providers payment systems driven by results and performance).

However, given the political and ideological divide and a strong conflict of interests within the institutional environment of the Brazilian health sector, it has been difficult to get most of these reforms taken, planned, and executed without a slow and lengthy process of negotiation. 

The biggest structural problems of the Unified Health System (SUS) in the context of the 2022 presidential elections are:

(a) incomplete universal access to quality health care. High regional inequalities aggravated by a fragile culture of promotion, prevention, and primary care, which should be the backbone of the system to avoid the still prevalent hospital-centered model. This situation was worsened by the pandemic, where there were significant reductions in access to outpatient and hospital care of the SUS throughout 2020–2022.

(b) insufficient emergency preparedness capacity, as demonstrated throughout the Covid-19 pandemic, and the need to review current pandemic preparedness guidelines (including those related to the availability of medical supplies, protective equipment individual, vaccines, and medicines) and to adopt, during future pandemics, quick and safe solutions that minimize the negative effects on the functioning of the economy and society.

(c ) the scarcity of health networks to integrate the levels of care (primary, secondary, tertiary), to create gatekeepers, referrals, and counter-referrals of services and to establish a process of continuum of care between all levels and specialties, centered on the needs of patients and not just according to the convenience of the services.

(d) the lack of federal public funding for the SUS, aggravated since the 2015 crisis, and associated with inefficient public spending on health policies. According to research by the World Bank[2], the inefficiency of SUS funding has resulted in annually waste of 0.3% of GDP in public resources.

(e) the lack of tools to transform abundant information into metrics, indicators and analyzes to offer technically precise decisions on policies, targets, goals, resource allocation and effective results.

(f) the lack of political will to change the mechanisms for education, contracting, training, and paying health professionals to be committed with and to evaluate results of the policy implementation and to define objectives and targets with quality, diligence, and efficiency.

(g) the lack of a solid, flexible, and fluid mix of public and private services to maximize efficiency and to avoid waste of public and private funding in the health sector, using all health structure available in each geographic area and avoiding building unnecessary infrastructure.

(h) the need to have an operational definition of the constitutional concept of healthcare integrality to avoid waste of public funds with unnecessary judicial complaints against the SUS.

(i) the need to support innovative and problem-solving health therapies, clinical pathways and managing models, based on equipment, pharmaceuticals, electronic records, and artificial intelligence in health, as well as a national strategy to produce inputs and technologies for cost-effective promotion, prevention, treatment and rehabilitation.

According to research by the World Bank[2], the inefficiency of SUS funding has resulted in annually waste of 0.3% of GDP in public resources.

fiocruz, 2016

Along the Luiz Inacio Lula da Silva (Lula) 2022 political campaign, its program named Brazil Hope Coalition[3] — a document of 19 pages — has dedicated only two paragraphs to address his promises to the SUS and the health sector, as can be seen below.

Health, the right to life, and the Unified Health System (SUS), have been treated with disregard by the current government. There is a lack of investments, preventive actions, health professionals, consultations, exams, and medicines. It is urgent to give the SUS conditions to resume meeting the demands that were dammed up during the pandemic, assist people with sequelae of covid-19 and resume the recognized national immunization program. Were it not for the SUS and the brave workers and health workers, the irresponsibility of the current government in the pandemic would have cost even more lives.

In the Lula and Dilma governments, health was treated as a central public policy, as a right of all Brazilian men and women and as a strategic investment for a sovereign Brazil. We reaffirm our commitment to strengthening the public and universal SUS, the improvement of its management, the valorization and training of health professionals, the resumption of policies such as Mais Médicos and Farmácia Popular, as well as the reconstruction and promotion of Health Economic and Industrial Complex.

Compared to other support areas of Lula’s campaign, health was one of the least expressive sectors of the entire program

No specific disease or social inequality was mentioned as a target to be tackled.

The first of these two paragraphs highlighted the fragile situation of the SUS in the face of the Covid-19 pandemic, but the Program did not mention numbers or quantitative targets to reduce the high levels of disease burden that affect the poor. 

The health initiatives covered by the Program to be implemented after the elections were: 

(i) meeting the demand for health that was dammed up during the Covid-19 pandemic; 

(ii) assisting people with Covid-19 sequelae; 

(iii) the resumption of the recognized national immunization program, 

(iv) the return of the Mais Médicos Program[4]

(v) the return of the Popular Pharmacy Initiative[5], and 

(vi) the promotion of the economic and industrial complex of health[6].

Some of these initiatives have somehow been implemented during the past Lula and Dilma governments in bold or soft colors, but most of the structural problems of the SUS were not mentioned by the Program. 

Thus, the health proposals of the Lula 2022 Program are not looking forward for the urgent reform needs discussed by most of health authorities and specialists in Brazil.

Thus, the health proposals of the Lula 2022 Program are not looking forward for the urgent reform needs discussed by most of health authorities and specialists in Brazil.

fiocruz, 2016

What are Lula’s Government achievements in the health sector along the first 100 days?

Giving these circumstances, along the first 100 days of the Lula government, the Ministry of Health announced the support to some well-known brand-named policies of the old Lula and Dilma Governments such as:

(a) The relaunch of the Mais Médicos Program with the perspective to insert by the end of 2023 around 28 thousand doctors in the Program;

(b) the creation of a national vaccination movement, intensifying campaigns to increase immunization coverage for several preventable diseases which were reduced during the last years;

(c ) the reduction of the waiting list for surgeries, exams and medical visits to the SUS which were drastically contracted along the pandemic years;

(d) the intention to restore the health industrial development policy, with the expectation of producing 70% of the equipment and medical supplies demanded for the SUS and to reduce the dependence of imports to the health sector — one of the biggest struggles faced by the SUS along the Covid-19 pandemic, and;

(e) the search for budget funds to finance the expenditures created by the legislation approved by the Congress and sanctioned by President Jair Bolsonaro in 2022, which set the national wage floor for nurses in the public and private sectors, at BRL 4,750, and established that the minimum salary for nursing technicians, nursing assistants and midwives will be calculated based on that amount.

Most of these actions, as announced by the President Lula himself, were aimed to reintroduce programs and strengthen public policies that suffered setbacks during the Bolsonaro government. 

However, their implementation will require additional budgetary funds for the SUS, which is very challenging in 2023, considered as a year marked by a giant public deficit, lower GDP growth and higher inflation.

There are some caveats that make the intentions expressed by the government a little bit different from past initiatives in the health sector taken by Lula or Dilma governments. 

First, the Mais Medicos program was announced with some differences, such as a higher presence of Brazilian doctors, because they can understand better the SUS constituency, speak Portuguese, and have more technical skills than Cuban doctors, for example[7]. On the other hand, foreign doctors only will be contracted after mandatory approval in the Revalida examination, which is a test to verify technical and practical skills for doctors that do not have their graduation in a Brazilian medical school.

Second, the government appear to be interested into destinating budgetary funds to the states and municipalities and subsidizing the private sector (mostly the philanthropic establishments) to allow them to reduce constraints on delivering better services to the SUS, such as the expenditures with the expansion of the wage floor for nurses.

fiocruz, 2016

What are the gaps and recommendations?

The deficiencies of the SUS are structural and only a new managerial framework with a complex reform could improve the current levels of performance of the public health system in Brazil. 

Several topics raised by specialists, such as the supply side, demand side and health financing reforms mentioned before were not announced during the first 100 days and constitute urgent gaps to be tackled by health reforms.

  • What are the government plans to complete the universal access to quality healthcare for the Brazilian population? 

  • What are the schemes to improve preparedness to face new pandemic situations? 

  • What are the plans and strategies to implement health networks models to guarantee integrate health care for all, using the public-private mix of services available in the country? 

  • What are the paths to assure sufficient financing and improved efficiency in public health spending and service delivery

  • What is the digital health strategy for Brazil, including specific public policies for the development and dissemination of telemedicine to increase access in the farthest areas with lower costs? 

  • How to improve data collection and services utilization performance by using electronic medical records, analytics, and artificial intelligence from the top management to the point of service?

  • How to improve health education, training on the job and payment mechanisms associated with value generation for patients and better performance?

The deficiencies of the SUS are structural and only a new managerial framework with a complex reform could improve the current levels of performance of the public health system in Brazil.

These are questions without answer for now. 

The results announced during the first 100 days in the health sector flags only a return to past priorities tied to a backward agenda. 

Future priorities, recognized as relevant by the most important health specialists in the country, have not been discussed or planned by the new government so far. 

However, with optimism, it is expected that these priorities must be progressively incorporated by the government as the time goes.

To fulfill these expectations, our recommendation is the implementation, as soon as possible, of the WHO HSPA framework.

This should be the first step to allow the new government to bridge the existing gap between spending, assessment, and outcomes, by identifying in detail, the current fragmentation, management, and performance bottlenecks.

This will allow the government to better design, strategize, and effectively implement the urgent SUS reforms deserved by the Brazilian citizens.

To fulfill these expectations, our recommendation is the implementation, as soon as possible, of the WHO HSPA framework.

This will allow the government to better design, strategize, and effectively implement the urgent SUS reforms deserved by the Brazilian citizens.


[1] See The Economist (2021), Why an American president’s first 100 days matter Ed. Jan 24th 2021 (https://www.economist.com/the-economist-explains/2021/01/24/why-an-american-presidents-first-100-days-matter).

[2] Banco Mundial (2017). Um ajuste justo: Análise da eficiência e equidade do gasto público no Brasil. Banco Mundial, Brasília, 2017, pp 109–119, Link: https://documents1.worldbank.org/curated/en/884871511196609355/pdf/121480-REVISED-PORTUGUESE-Brazil-Public-Expenditure-Review-Overview-Portuguese-Final-revised.pdf

[3] “Coligação Brasil Esperança” as expressed in Portuguese. Link: https://divulgacandcontas.tse.jus.br/candidaturas/oficial/2022/BR/BR/544/candidatos/280001607829/pje-3b1196fd-Proposta%20de%20governo.pdf

[4] The Mais Médicos (More Doctors) Program was created in July 2013, during the Dilma Rousseff government, with the aim of hiring 18,200 doctors (63% from Cuba) to serve the poorest municipalities in Brazil. The Program was poorly designed, without clear goals and objectives and without reaching the list of the poorest municipalities without doctors. From 2013 to 2016, the Program had a mix of good and bad results. A report prepared by the Federal Court of Auditors (TCU) in 2017 pointed out that, despite administrative and accountability failures, there was an increase in the number of medical services provided to municipalities benefited by the Program. However, 26% of the poorest municipalities were not attended by physicians, alongside other non-priority municipalities that received physicians from the Program. Faced with this situation, the Mais Médicos Program had little impact in reducing inequality in access to primary care compared to other existing initiatives, such as the Family Health Program (PSF), which were not sufficiently expanded. Some of the Program’s design problems were corrected during Michel Temer’s government, partially improving its performance. After the election of Jair Bolsonaro (President of Brazil from 2019 to 2022), the Program changed its name to Médicos pelo Brazil (Doctors for Brazil) Program, being restructured with the promise of hiring an additional 18,000 doctors. However, during this government, especially after the Covid-19 pandemic, the Mais Médicos Program lost strength and financial support, dismissing 8 thousand doctors. The Médicos pelo Brazil Program, on the other hand, was never implemented by the Bolsonaro government.

[5] The Popular Pharmacy program was created in 2004 (First Lula Government), with the objective of ensuring the treatment of diseases through free or discounted medicines. The Ministry of Health pays part of the drug price (up to 90% of the reference values) and the citizen pays the rest, according to the price charged by the pharmacy. However, the program has flaws and difficulties in the process of acquiring and distributing medicines. In 2022, the Popular Pharmacy program served around 20 million people, which represents 9 million fewer visits than registered in 2015. According to specialists, the Program’s budget for 2023 is three times less than the need for medicines by the population in the free and subsidized modalities.

[6] The Health Industrial Complex is configured as a system constituted by the industrial sectors of chemical and biotechnology base (biological, synthetic, and semi-synthetic medicines, vaccines, active pharmaceutical inputs, and diagnostic reagents), of mechanical base, electronics, and materials (medical devices) and health services that establish institutional, economic, and political relationships aimed at innovation and production in health. Since the first government Lula there is practical measures to strengthen the health industrial complex. However, the Bolsonaro government pushed the relevance of this sector by creating in July 2022 (Decree number 11,098) the Department of the Industrial Complex and Innovation in Health of the Secretariat of Science, Technology, Innovation and Strategic Inputs in Health (DECIIS/SCTIE/MS) aimed to propose, implement, and evaluate policies, programs and actions defined by the national strategy of promotion, strengthening, development and innovation within the Health Industrial Complex.

[7] During the past years the rate of approval of Cuban medical doctors who were submitted to the Revalida was only 24%. For this reason, the Mais Medicos Program was obliged to contract Cuban doctors working in the program as a internship and were not allowed formally to perform many of the traditional primary care procedures regularly performed by a national primary doctor.

Crédito da Imagem: Fiocruz, 2016 (https://cee.fiocruz.br/?q=node/481)

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