The activities for the day included a lecture from Prof.Clarice Mota from the Federal University of Bahia titled “The Brazilian National Health System: Short History, Advances, and Challenges,” and second lecture presented by Prof. Dandara Ramos from the Collective Health Institute, Federal University of Bahia titled, “Racism and Health: A Brief Overview.” After class, we visited Irmã Dulce Hospital, and ending the day with free time to check out the“African market” at Salvador Bahia’s Mercado Modelo.
Before you can begin to understand the Brazilian health system, you must first understand the history of Brazil, and the connection torace and health to better comprehend why and how the Sistema Único de Saúde (SUS), Brazil’s united health system, was born. Brazil is the largest country in Latin America. It has the largest “Black” population outside the Africancontinent with approximately 55% Black/brown & mixed/pardos, 47% White, 0.6% Indigenous, and 0.4% ‘Other’.1 With such a large territory, there are differences in size, regional differences, as well as social inequalities that plague the nation, with worse racial inequities in the Southeast and Southern regions. As a country under military dictatorship as recently as 1964-1985, there were limits to free speech as well as consequences to those who spoke critically of the economic and political system in social movements resisting the regime. As a result of this suppression, people fought for the right to healthcare being a part of democracy. In 1988 the Constitution of Federative Republic of Brazil was created, then in1990 the SUS was defined and operationalized.
As with other movements in Brazil’s culture that were initiated as a form of resistance (e.g. capoeira), the SUS was the outcome of people fighting for health to reduce inequality. It was reform driven by civil society rather than government, political parties, or international organizations. This system of healthcare is free and provided to all Brazilian permanent residents and foreigners in Brazilian territory. Its principals focus on factors such as comprehensiveness and social participation, relying on community and reinforcement from community health workers to support health, which is supported by Brazil’s principals of love as a principal and collective community.
The SUS serves as an entry point for access to primary care. It uses interdisciplinary teams, and has secondary and tertiary care available by region. Equity is another principal of the SUS, yet disparities are still present.The availability of SUS funding, ability for “private” insurance to be purchased by some for services or amenities unavailable (or those with a longer waiting period) to participants in SUS, and reliance on the Ministry of Health to fund states and municipalities and coordinate monitoring does not taking into account the chronic underfunding. This begs the question, is there truly equity in practice or only in law?
In Brazil, there are three branches of public health: epidemiology, social science, and political science. While there may be variation in their effects, all three have a distinct effect on race, history, and health in the country. Prof. Ramos explained in her talk that, “epidemiology is the study of the distribution of health diseases and their determining factors in human populations. There are unequal experiences of birth, life disease, and death, which demonstrate inequalities and make social impacts and political divides more visiblep.” While generally Brazilianshave a culture that supports immunizations and vaccines, an example ofpolitical divide was COVID-19 where there was a political conflict with scienceimpacting outcomes of vaccine rates compared to previous vaccines andvaccine success historically experienced in Brazil.
Personal tensions arose around the thought of whether the“United States” of America’s social or political state may be influencing Brazil’s typically strong culture, and the ability to combat misinformation;these two systems and cultures cannot be compared in theory nor practice. Theshift in personal perspective that required deep thought and strategicnavigation was what makes the USA “right” in thought or practice in theirapproach to health and care? There is certainly grave disparities in race anddifference in history in the USA as well; should the USA look to Brazil’ssystem for a blueprint, use their advanced technological and financial positionto build on the SUS barriers and opportunities to refine the health system inthe USA? Only time will tell.
Following our lectures, we went on a tour of Irmá Dulce Hospital which began with an introduction to Santa Dulce Dos Pobres, her life,calling, and mission up until the time of her death at the age of 77. She became a nun at an early age, making her mark as an advocate for the poor and leading by example. The legacy that she built started with a small hospital but quickly expanded to become a cornerstone of the community and a place (with100% care) that meets people where their need may be, whether old, sick, or specialty care. She was known to have met those high in religion and priesthood, and had acknowledgement, visits, and prayers from Pope John Paul II.
During this tour, we had the opportunity to walk through an oncology clinic and infusion center to understand the structure and operation.One personal assumption that required navigation was that there would belimited technology and advanced tools for managing health needs. While the tools looked different than what was expected, they were still available. One of the personal discomforts that became palpable as the sightseeing continued was the difference in how the very vulnerable (immunocompromised in the infusion center) could have potentially been exposed by visitors without a strong emphasis to mask, ensure handwashing, etc. to protect their population. This likely comes from my population health and clinician background but makes me think about policies and procedures of “established” centers/countries/ health systems compared to others with regards to how to keep patients protected.
Lastly, another tension was while the hospital is “100% free,” there are costs associated with providing certain medications, building and equipment maintenance, etc. While the government contributes a small percentage of funding to this hospital and the community, for the other portions, how sustainable is this model and for how long? What can be done in the short and long term to ensure that essential places, like this hospital, can stay viable and continue to support those populations with the greatest needs.
Shaterra Davis, PhD, MBA, BSN, ONC, NE-BC
1. Galan, S. Population by ethnicity Brazil 2023. Statista.2025. Accessed January 13, 2026. https://www.statista.com/statistics/1001058/share-population-brazil-ethnicity