1. Data 14/10/08 Research Department National Accounts Coordination Health and education volume output in Brazil

2. The Brazilian health system Since 1988, Brazilian government provides tax-financed universal healthcare coverage to its citizens, with no eligibility restrictions – on principles inspired in the British National Health Service´s. Although there are no eligibility restrictions in the public health system, private health services may have increased their market share in health services value final consumption since the 80s.

3. The Brazilian health system This is due to the growing importance of private health insurance, through which private health may offer higher-quality services and lower waiting times than the public system. In 2005, final consumption of health-related goods and services amounted to 8,0% of Brazilian GDP. This includes expenditure on prescription drugs, private health insurance and medical devices and consumables.

4. The Brazilian health system Government expenditure on these goods and services amounted to 3,1% of Brazilian GDP. Part of the private health production is offered free of charge to the population – and paid for by the government. In 2005, public administrations expenditure on private health services amounted to R$ 10,0 billion, 14,9% of the overall expenditure on private health services.

5. The Brazilian education system In 2005, final consumption of private education services amounted to 1,7% of the countrys GDP. Consumption of public education amounted to 3,2%. In the public sector, municipalities are responsible for providing basic education, states for the intermediate level and the federal government for the superior one (although there are state universities as well).

6. Volume indexes: public health Volume: Weighted averages of changes in inpatient days and outpatient procedures. Source: SUS Informatics Department (DATASUS). Value: State and municipal government balance sheets and other administrative databases.

7. Volume indexes: private health Volume: Up to now, the main indexes used for private health are the total number of inpatient days and outpatient procedures bought by SUS from private health service providers, released by DATASUS. In 2008, the Brazilian Institute of Geography and Statistics (IBGE) started receiving data from the National Supplementary Health Agency (ANS), the agency that regulates market activity of private health insurance providers in Brazil.

8. Volume indexes: private health Created in 2000, ANS generates reports on health plans expenditures on health services – inpatient and outpatient care. Health insurance providers are responsible for more than half of all expenses on private health services consumption in Brazil. IBGE is currently studying the best ways to organize these data and solve scope change problems. After this, it might be possible to deflate and use these data as volume indicators.

9. Brazilian National Accounts divides private health into three activities: Inpatient care (hospital services) Other health services (ambulatory services) Private social services For the first two items, volume is given by inpatient days and number of outpatient procedures. Volume indexes: private health

10. For the third one, which includes asylums, rehabilitation clinics etc., volume is obtained through deflation, using a price index that reflects the activities costs (intermediate consumption). This third item represents less than 4% of the private health services production. Volume indexes: private health

11. Value: Value data for the three private health items come from the enterprises Income Tax information. Volume indexes: private health

12. Problems and perspectives In January 2008, SUS revised and unified its standard health procedures list, which establishes prospective payment rates for payment to health service providers and now comprises 2.311 procedures. The new standard health procedures list introduced some refinements related to disease reporting and their relation to specific procedures.

13. Problems and perspectives Procedures can eventually be aggregated by large diagnoses groups (according to the International Classification of Diseases - ICD) and then weighted by their average costs in a single volume index. It will be necessary to analyze each groups data variance throughout time before adopting this more elaborate volume index.

14. Problems and perspectives The recent change in the procedures list led to significant discontinuities in data reports. But, in the future, it may allow for better quality in output volume indexes.

15. Volume: Change in the number of students enrolled at public schools and universities, weighted by the average cost per student in each educational level. The levels used are: preschool, primary and secondary school, high school, complementary (supletivo), college and special education school. Source: Annual School Census, Education Ministry. Volume indexes: public education

16. Value: The administrative records used are similar to those used in public health. Federal government is working on an information system that might - in the future - centralize data on education public expenditure, allowing for refinements in the measurement of public educations output value. Volume indexes: public education

17. Volume: Change in the number of students enrolled at private schools according to the Annual School Census. Value: Enterprises income declarations. Volume indexes: private education

18. Brazil shares with other countries the usual difficulties in devising quality adjusted output indexes. Health and education volume indexes still do not capture the effects of quality changes in the output of these services, relying on quantitative information on inpatient days, number of outpatient health procedures and number of enrolled students. Conclusions

19. Present refinements in information systems for private and public health and for public education, however, offer hopes of change in the future. Conclusions

20. Ricardo Montes de Moraes National Accounts Coordination Brazilian Institute of Geography and Statistics (IBGE). e-mail: ricardo.moraes@ibge.gov.br.