Brazil’s healthcare landscape is a complex, interwoven network of public-private activity that defies easy evaluation. Across the expansive country, there are almost 7,000 hospitals in operation, of which 70 percent are private and clustered in large, metropolitan areas that are not easily accessible to most of the population. And hospital accreditations, which verify facilities meet certain standards of quality and safety, are few and far in between. “Only around 1.4 percent of those 7,000 hospitals are accredited or have obtained some kind of accreditation or accredited certification,” says Heleno Costa Junior, former nurse and current safety consultant and health administrator at Samaritano Hospital in São Paulo, though a 2015 report claimed that figure to be a bit higher, closer to 8 percent.
Achieving accreditation isn’t easy, and it may mean a lot of physical changes and new, expensive additions to a hospital’s infrastructure. But still, Brazil has been severely underperforming in this quality and safety benchmark, especially when compared to two of the countries it has modeled its own National Accreditation Organization (Organização Nacional de Acreditação, or ONA) after: the U.S., which, according to the same 2015 report has over 90 percent accreditation rates, and Canada, which has over 80 percent.
“Getting accreditation requires a lot of financial support, which is incredibly hard to get,” says Costa Junior. “And even then, that support is unstable. Hospitals often lose accreditation because Brazil’s economic investment in healthcare is so inconsistent, and they fail to keep up with the protocols ONA, JCI and others require.”
Accreditation is voluntary, so hospitals operate on an incentive-basis to strive for these certifications of quality and safety. Of the hospitals that currently have accreditation, the majority are privately-run. This is no surprise when considering the disproportionately large role of private healthcare spending in Brazil’s health sector. In 2013, for instance, of the 9.1 percent of Brazil's GDP that was spent on healthcare, 5 percent was solely private expenditures. This means private hospitals often have the resources to fund pricey and long accreditation processes, as well as an incentive to build up brand reputation and market-value in an increasingly competitive space.
But public hospitals don’t have that luxury, as the country’s public system is chronically under-funded. Three-quarters of Brazil’s population receive care through the government-funded National Health System (Sistema Único de Saúde, or SUS), yet only 42 percent of healthcare spending in the country is in the public sector. When hospitals are strapped for cash, achieving accreditation is often a low priority. “For public hospitals especially, you will see a research institution or academic medical center behind their accreditation efforts,” Costa Junior says. “Without that support, they would never get it. And the rare times they do, they often lose it.”
The root of the problem, nevertheless, isn’t the economic instability, Costa Junior adds. Medical professionals and hospital staff are trained on quality and safety procedures, but until just a few years ago, there was no singular regulatory body present in hospitals that focused solely on quality and accountability. This changed in 2013, when the Ministry of Health installed patient safety programs nationwide, but hospitals are still adjusting to the new regulations. “Administrators try, but there’s a real challenge with implementing changes, reporting errors and following through,” he says. “The culture inside hospitals needs to change first, so that the issue of safety can be demystified, prioritized and taken seriously.”
Heleno Costa Junior is also the author of the 2015 book, Qualidade e Segurança em Saúde: os Caminhos da Melhoria via Acreditação Internacional. The English translation is set to be released sometime in 2017.
— Tarsilla S. Moura
Tarsilla S. Moura is the managing editor at GHCi.