Overview
In theory, Brazil has one of the most structured public health systems in the world. The SUS (Sistema Único de Saúde, "United Health System") was developed in 1988. This followed the INPS (Instituto Nacional de Previdência Social, "National Institute for Social Security"), which was created first by former President Getúlio Vargas in 1933. It has changed a lot over the years. The INPS used to serve only registered workers - leaving unemployed people alone with their own luck. The SUS fully covers any person, Brazilian or not, who looks for medical care.

The health structure is based on levels. At the first level, there is basic medical attention. It is composed of health promotion, prevention, family planning and basic assistance. As the levels advance, so do the complexity of the diseases treated, until the fourth and last level, where the diseases such as cancer, organ transplants and rare conditions are treated. Emergencies could be treated in any of the levels, due to the nature of the condition. The system was designed to be the best in the world and served as a model to many other health systems around the world.

What happens if you need to see a doctor?
A person can simply walk to a public hospital and ask for a consultation. General practitioners are the first line of service and can forward patients accordingly based on their needs. In SUS, patients won't be charged for any consultation or medical procedures. If the doctor prescribes medication, it can be bought in drugstores or, in some cases, it is given for free in the public drugstores.

The free medications used to treat diabetes are things like syringe, test strips and glucose monitor. To get them, a doctor’s prescription is needed. For any other medications that are un-affordable for patients, there is an administrative request with the medical prescription and an evaluation to verify if you really need the medications. Insulin pumps, insulin analogues and any other health needs, such as transplants or chemotherapy, can be requested this way, and, in general, will be given for free.

Who decides what medicines a doctor can prescribe?
ANVISA (Agência Nacional de Vigilância Sanitária, "National Sanitary Vigilance Agency") is like the FDA in Brazil, connected with the Health Ministry and approves all the medicines available in the market. Doctors will guide themselves by the intersection of international guidelines and ANVISA approved medications, giving their generic name.

In general, doctors can prescribe any medication available in the market. Doctors prefer to prescribe those medications recommended by national and international guidelines, or these ones which can be found in generic ways - for example, instead of prescribing Glifage for people with diabetes, they prescribe the generic name, Metformin. Doctors will prescribe the medications available in the popular drugstores, in order to reduce the cost to the patients, but they can prescribe any medication recommended.

Practically, what is like to live with type 1 diabetes in Brazil?
Although the system was designed to be the best in the world, it doesn't work that way in Brazil. People in Brazil do not understand the levels, and tend to go always to the biggest hospitals - usually, the third and fourth levels - and understand all health conditions to be emergencies. This fills the emergency rooms in the hospitals and, to allow people to be seen urgently, the budget and workforce is transferred from the first levels to the higher ones.

Talking about budget, this is another problem. The budget isn't really low, but the Health Ministry doesn’t use it efficiently. In 2012-2013, there was R$ 17 billion (something like US$ 11 billion!) untouched. The wages paid to the health care professionals are very low and have not been updated since 1994. Many healthcare posts are empty because no doctor or nurse wants to go to hospital where he or she will not have medicines, technology, or even paper to write a prescription! Because the Health Ministry isn't investing enough, this creates a massive vicious circle that is leading public health care services in Brazil to continually weaken. This in turn leads the private healthcare systems to raise their prices, but many still choose to buy private health care. The private systems are inundated with patients and aren't offering the appropriate support they should.

Besides these problems, the government gives citizens medications but due to SUS design, the Health Ministry gives the money to state secretaries, and the state gives the money to municipal secretaries. There is a lot of corruption, which leads to a big lack of support with medication for people with diabetes, even in major cities. The lack of education for professionals and patients also plays a big role, because it isn't seen by government as a priority.

What about getting admitted to hospital?
Again, all treatment and medication provided by a public hospital is free of charge for all patients. Any medication prescribed during a hospital stay is exempt from prescription charges. If patients go to a private hospital, they can be charged for everything. If you have a private health plan, your plan will be charged and you may or may not be re-bill this charge.

How does diabetes care vary throughout the country?
Life with Type 1 Diabetes (T1D) in Brazil can be a simple condition or a huge problem, depending on where you live. People living in major cities, like São Paulo, Rio de Janeiro and Brasília won't have big problems, since the diabetes associations in these cities will provide information enough and will forward the patients to good endocrinologists. In smaller cities, or in areas such as the Amazon forest, the Caatinga (a region desert-like in the northeast of the country) or the Pantanal (a flooded plain, in the centre of the country), life with T1D can be a huge problem. Sometimes, the nearest city with a doctor can be something like twelve hours by boat, and the nearest doctor may not even be prepared to treat diabetes. In these cases, diabetes might not be discovered until the patient develops DKA or complications and is far away from the doctor. This leads to a higher mortality rate among people in these areas due to diabetes.

Thank you Ronaldo Wieselberg from Brazil for sharing your knowledge with us.