Brazil’s state health insurance, the SUS, is usually referred to as a “unified system”, but it is in fact made up of a network of complementary and competitive providers, and is essentially a public-private mix. Around 25% of Brazilians also take out more comprehensive private cover.

The SUS is funded out of the Social Security Budget, a total of around 8% of Brazil’s GDP, and the country’s municipalities are expected to spend around half the tax they collect on healthcare provision.

The WHO describes it as ‘an outstanding success’ in that its inception has extended healthcare to many of Brazil’s poorer residents: the 1998 constitution includes healthcare as a fundamental right. Its success is shown in the increase — of over a decade — in Brazilian life expectancy. Unicef has also singled the country out for praise, pointing out that infant mortality has decreased by 60% since 1990.

Under the SUS, the public healthcare system is make up of three tiers of medical care: family clinics and health centers which provide basic local healthcare; "second-assistance" hospitals which treat common illnesses and perform minor operations; and specialist clinics offering treatment for more serious illnesses and surgery.

Its foundation consists of primary family care: the Programa Saúde da Família (PSF) is based on Family Health Teams who look after around 4,000 people. Private hospitals, reimbursed by the government, carry out around half of surgical procedures in Brazil.

However, the basic tier of the SUS is struggling, being overstretched and underfunded, with significant resource and staff shortages. Patients who are not in the big urban centres often have to travel for miles to access treatment.

The 2013 "Mais Medicos" program, designed to provide treatment in more remote areas, has been forced to rely on Cuban medical personnel. Staff report that SUS hospitals have stopped sharing information with one another, resulting in communication breakdowns: there are in any case few computerized systems in Brazilian healthcare. For this reason, as well as to diminish waiting times, many expats prefer to take out private health insurance despite the comprehensiveness of Brazilian coverage.

All citizens and residents are covered by Brazil’s universal health insurance system. Employment-based insurance is the most common type of health insurance, representing 76.9% of medical plans and 83.1% of dental plans.

In order to register for the SUS, you will need:

• your passport
• your foreigner’s identity number (Registro National De Estrangeiro/RNE)
• your individual Tax Payer’s Number (Cadastro de Pessoa Física/CPF)
• your marriage or divorce certificate, if applicable

If you are employed, your employer should sign you up with the SUS, but check that this has been done. You will need to have a valid work permit and to make a number of national insurance contributions, which will usually be deducted from your salary.

The old SUS card (Cartão SUS) has been replaced with a National Health Identification card, which you must take with you to medical appointments along with your ID card in order to qualify for treatment. The new card is still colloquially known as a SUS card, which can be confusing.

Once you have been given your card, you will be able to access the Citizens’ Health Portal (Portal de Saúde do Cidadão) in order to check your own medical records, but bear in mind that this is currently available only in Portuguese.

Once you are registered with the SUS, you will be entitled to:

• visits to the doctor
• lab fees
• hospitalization
• surgery
• prescription drugs

and in addition, depending on your circumstances, you may be able to access:

• sickness and injury benefit
• maternity benefit
• invalidity benefit
• survivor/death benefit
• unemployment benefit

As an employee, you will be eligible for sickness or disability benefits after 12 months of making national insurance contributions. You will get 50% of your monthly salary for temporary illnesses. If your illness or injury prevents you from working for longer than 15 days, you will be entitled to 91% of your monthly salary.

If you are pregnant, you will be entitled to maternity benefit from your 8th month. You will also be eligible for 180 paid days of maternity leave. Women who adopt a child will be entitled to benefits of 120 paid days, although this will be lower if the child is older than 12 months.

Your doctor can issue you with a prescription, and pharmacies are widely available across the country: you should not have difficulty accessing medication, especially in large urban areas. Generic over-the-counter drugs are often cheap in comparison to branded medication. There are also “Popular Pharmacies” (farmácia popular) which participate in a government program aiming to increase the population’s access to medicines. The program is also linked to a number of private pharmacies and drugstore networks: discounts on medications at these pharmacies can be up to 90%.

Emergency care is free for everyone, but only if it is critical. You will have to make an out-of-pocket payment for treatment if you do not have private health insurance and suffer from a broken ankle, for example. Once you are off the critical list, you will have to pay, and the SUS will not cover complications resulting from existing conditions.

As a retiree in Brazil, you will be covered by the national system if you are a resident and have been making contributions into the system. Otherwise, you will need to take out private health insurance.

If you are an international student you will be covered by the SUS, although you may prefer to take out private insurance to cover any serious eventualities such as medical evacuation.

Check with the INSS (the Social Security Administration) or your employer to see if your family will be covered. In theory they will automatically be covered by the SUS if they have residency in the country, even if not specifically under your insurance. However, cover under your policy may depend on the stipulations of a group plan arranged by your employer.

The percentage of Brazilian citizens who have private cover for dental treatment is low but increasing.

Public oral health care consists mainly of the legacy of the 2004 Oral Health Policy — “Smiling Brazil” — which is intended to increase federal funds to states and municipalities in order to provide comprehensive and universal access to oral health care, including both prevention and treatment of oral concerns. The policy includes:

• examination
• diagnosis
• preventive care
• sealants
• scale and polish
• fillings
• extractions
• urgent care

It also covers some specialized procedures, such as:

• periodontal surgery
• endodontic treatment
• minor oral surgeries
• diagnosis and treatment of oral lesions
• dentures and treatment for disabled patients

Crowns and bridges are not covered. Dental care in Brazil varies: it is of a high standard in the cities, but you may wish to take out a policy which includes dental treatment, as out-of-pocket costs can be expensive.

Note that the contribution rates are currently in review by the Bolsanaro administration and it is likely that the minimum contribution rates will decrease slightly from 2019.

Your overall social security contribution will be evaluated according to your income levels, and part of this will go towards your national health insurance. If you are employed, according to Brazil’s Social Security Administration, you will pay:

• 8% of your monthly earnings if you earn up to R1,659.38
• 9% of your monthly earnings if you earn between R1,659.38 and R2,765.67
• 11% of your monthly earnings if you earn above R2,765.67

Voluntarily insured people may contribute 20% of their declared earnings, or 11% of the legal monthly minimum wage (5% for small businesses with annual incomes up to R81,000/$44,694, or for housewives) if they forego the right to the ‘length of contribution’ pension.

The minimum monthly earnings used to calculate contributions are the legal monthly minimum wage: R937/$234. The maximum monthly earnings used to calculate contributions are R5,531.31/$1384.

If you are self-employed, you will need to contribute 20% of your monthly declared covered earnings, or 11% of the legal monthly minimum wage if you forego the right to the ‘length of contribution’ pension.

Brazil has a large number of private providers, who offer four main types of insurance policies:

• private health insurance
• prepaid group practice
• medical cooperatives
• company health plans

Check with your employer to see if health insurance is part of your employment package or if group plans are available.

A number of Brazilians take out policies with HMOs: healthcare management organisations providing both insurance and care.

The main reasons for taking out private health insurance include accessing shorter waiting times than in the public system, and access to better care in rural areas. Seeing a particular specialist at a well-equipped hospital might require you to pay out of pocket, and many expats opt to take out private insurance to cover these eventualities.

70% of Brazilian hospitals are in the private sector. After the US, Brazil has the largest private health insurance provision in the world. The SUS contracts to some private services, for example in diagnostics, but otherwise the private and public systems are completely separate: there is very little or no private primary care, with private institutions being hospitals only.

Health insurance will cover facilities such as private rooms, speed of access to treatment, and medical care such as more advanced dental treatment and elective cosmetic surgery, as well as the full range of healthcare that is found in the public sector.

Depending on the type of policy you have, your private cover may operate on a reimbursement principle or pay for your treatment directly.

Premiums for someone with no pre-existing conditions are likely to be around $1K – 2K per annum. Some local providers charge around $66 per month (R268); a premium that will decrease if you make no claims. The medical provider UniMed has quoted R600 ($148) for full coverage for a family of three. You will need to pay more for services such as medical evacuation.

Private insurance in Brazil has been described as the most expensive in South America, costing 20-30% more than neighbouring countries. Hospitals will want to see your private health insurance card when you arrive, and they may also ask for a deposit to guarantee that you will be able to pay for your treatment.

In general, the cost of treatment is within 10% of fees charged in the US. A minority of hospitals in big urban areas, such as São Paulo and Rio de Janeiro, have excellent reputations and are destination choices for health tourism, but are correspondingly expensive as they have the market share.

Note that most hospitals, including private clinics, do not have English-speaking staff.

The big international providers cover Brazil, including:

• AETNA
• AXA
• Cigna Global
• Foyer Global Health
• Integra Global
• Pacific Prime

There are also some local providers.

Cadastro de Pessoa Física/CPF - individual Tax Payer’s Number

Farmácia popular - Popular Pharmacy (a government programme to increase public access to medication)

Portal de Saúde do Cidadão - Citizens’ Health Portal

Registro National De Estrangeiro/RNE - foreigner’s identity number

Sistema Único de Saúde/SUS - Unified Health System