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. Electronic supplementary material The online version of this article (10.1186/s12939-019-0938-x) contains supplementary material, which is available to authorized users.

Analysis of the effects of the age-period-birth cohort on cervical cancer mortality in the Brazilian Northeast

“…In addition to the low coverage and poor quality of screening programs, the PNCC presents difficulties associated with the referral of women with cervical cancer or their precursor lesions to treatment in specialized services (surgery, chemotherapy and radiotherapy) [56][57][58][59], correlating with the large proportion of women diagnosed in advanced stages of this disease (III/ IV). In Brazil, from 2006 to 2012, only 29% of women with CC were diagnosed at the early stage of the disease (in situ or stage IA carcinoma).…”

“…In Brazil, from 2006 to 2012, only 29% of women with CC were diagnosed at the early stage of the disease (in situ or stage IA carcinoma). From 2000 to 2012, there was an increase of 1.10% per year in the proportion of women diagnosed at an advanced stage [45,59].…”

Ethical Concerns Regarding Breast Cancer Screening

“…Brazil is a developing country with a population of 209.3 million inhabitants with enormous social and economical disparities between its 5 regions [44]. Moreover, there are also inequalities in the distribution of human resources and health infrastructure with a significant variation in the number of hospital beds and physicians dedicated to oncological patients leading to significant differences in health outcomes [8]. Another source of outcome variability is the duality of access to the healthcare system.…”

“…Moreover, the late presentation at diagnosis raises the hypothesis that the current screening program is not effective or that the patients do not have proper access to it. Added to that, the mortality due to breast cancer in Brazil has been increasing in the last decades [8]. All these issues taken together generate an ethical dilemma to be explored, once the investment of public resources in an ineffective program impacts negatively the whole society.…”

Ethical issues surrounding breast cancer screening in Brazil

“…The late stage at diagnosis, on the other hand, leads to the hypothesis that the current screening program is either not effective or individuals do not have proper access to it. Additionally, BC mortality in Brazil has been increasing in the last decades (4). Together, these factors pose an ethical issue, as investing valuable resources in an ineffective program negatively impacts the whole society and, therefore, smarter resource allocation schemes should be implemented to address this issue.…”