The Rio de Janeiro-based Fundacao Oswaldo Cruz – Fiocruz – is Brazil’s leading medical and scientific research centre, its work forming a fundamental part of the national immunisation programme, the country’s fight against AIDS and the changing face of Brazil’s disease burden and an ageing population. More recently, the foundation is positioning itself as an international agency to promote and pursue cooperation via research projects and innovation. Its president, Paulo Gadelha, now in his second term in office, spoke to The Report Company about the pursuit of overseas funds and partnerships to help convert Brazil’s traditionally strong knowledge pool into tangible innovation.
The Report Company: What is the best way to approach the changes in public services that Brazil’s population are demanding?
Paulo Gadelha: The country has huge challenges that demand we critique, update and review policy at all times. Health is an especially complex challenge in Brazil because we have a very large population that is still very socially unequal and we have a universal public health system. A continental country with 200 million people and a universal health system is unique. Another challenge is our epidemiological profile - the disease burden - which mirrors the transition we are currently going through. We still have significant poverty-related deaths but an increasing percentage of non-communicable, developed-world chronic diseases.
Fiocruz has been continuously prospecting the horizon, and we see that, in 2038, the population will stop growing and become proportionately older, which is another major challenge. One of our most important problems right now is the production base that is necessary to produce the medications, vaccines, equipment and services the country needs at an adequate cost for the development stage of the country and the demands that a system like ours has.
TRC: With regard to resources and costs, there is a school of thought that the problem in Brazil isn’t a lack of funds but instead how they are managed. Is that fair?
PG: On the contrary. Of course we need more resources. In fact, there is an increasingly significant consensus that the health sector is under-financed when you compare Brazil with developed countries and even with those elsewhere in Latin America. It is impossible for the country to make this system sustainable with the current per-capita level of expenditure that we have.
Both issues are part of the problem, and it is clear that without an increase in expenditure, the level of services will not improve. The current floor, that is, last year’s expenditure plus the growth of GDP, has been turned into a ceiling. When we consider that the GDP will grow very little – and below inflation – that there is a new strata of the population that has become more vocal in demanding better services, that there is an increasing need for doctors and that diseases demanding large investments in technology such as cancer, neurodegenerative diseases are increasingly more relevant in the country, more resources are definitely necessary.
“Health is an especially complex challenge in Brazil because we have a very large population that is still very socially unequal.”Tweet This
TRC: When faced with a resource shortage, the education sector looked abroad. Is foreign investment in the health sector a realistic possibility?
PG: There is very strong participation of international funds in the field of healthcare today in Brazil and there have been several mergers and acquisitions in the sector recently. The issue –which is why a more autonomous financial base for the sector is necessary – is that our universal health perspective is antagonised by the rationale of private investments. Taking patients from a basic healthcare context to a more specialised one lacks coordination. For instance, in the field of organ transplants, HIV/AIDS policies, vaccines and so on, Brazil is considered exemplary. The public sector is responsible for these areas, but the problem is that the public and private sectors need to be coordinated, and they are not.
Fiscal incentives can be a handicap for the public sector, because private health expenditure can be deducted from income tax and taxes for health funds are lower in the case of civil servants. Exemptions like this are not followed by strong regulation of the state over these sectors, and this makes the system less efficient and less sustainable.
In the past, there was the idea of promotion and primary, secondary and tertiary healthcare, but today there needs to be a continuum from primary to specialised care. Today, if someone has a stroke they are more likely to survive, but they also need to come back for ongoing treatment, so you need a social assistance programme. What happens now is that this person may start at the public sector, then go for a more specialised service with the private sector, then go back to the public sector, but none of this is organised.
TRC: What is the role of Fiocruz in this context?
PG: Fiocruz occupies a very special place between science and technology and health, with a strong role in education and the environment, and the fact that we are part of the ministry of health makes it possible for us to do things differently. We are dedicated to generating knowledge, but we are also focussed on solving problems with this knowledge, something that sets us apart from universities. We never get tired of saying that we need to reform the state, changing the legal and institutional nature of the management of the public sector. We think this is absolutely crucial, especially regarding our international actions. Our country is very prominent geopolitically, but its legislation is archaic.
For example, the Pasteur Institute wants to create a mixed institution between themselves and Fiocruz here in Brazil, within our institute but with a shared governance. We have been trying to find ways to carry that out, because it would represent a great leap forward for us. We could use resources and researchers from both institutions to consider global health more organically, and even develop technology together. The two institutions are very interested in the plan, but we will have to find mechanisms to make it happen because the legislation in Brazil makes it extremely difficult. We are waiting on changes in the legal framework that the electoral year did not allow for, but there is a series of bills ready to help us begin to move forward once more.
TRC: What form is internationalisation it taking at Fiocruz?
PG: We pursued this with Yale where we wanted a mixed institution, but we went halfway and created the Fiocruz-Yale Alliance for Global Health. Institutions have been seeking us bilaterally and it has been stimulating the organic development of the internationalisation of Fiocruz, of Brazil, its universities and its companies. The climate is very receptive but we still need the right tools.
Fiocruz was born in an international context, built on the model of the Pasteur Institute and other German institutions and since the beginning it has promoted exchanges, international commissions, and so on. We have always worked for the country, but we have always been part of the international context, in both science and health.
Particularly in the last 10 years, our process of internationalisation has been very significant. We are part of the Pasteur Network, we are one of the founders of the Drugs for Neglected Diseases Initiative (DNDi), and we helped create what became the International Association of Public Health Institutes (IANPHI) whose goal is to consolidate or create institutions throughout the world dedicated to what Fiocruz does: research, human resource training, epidemiological surveillance, and so on.
On top of that, we consider that global health is crucial for local issues. For instance, Brazil is discussing with the WHO the possibility of setting up a WHO Collaborating Centre for Influenza, one of the most important challenges today in the field of health, whose main institution in the country would be Fiocruz. We have also been participating in the fight against Ebola, so you can say that it is impossible to think about scientific and technological development, health and the production base to support our unified system without being open to the world and working in conjunction with other countries. No one ever considers innovating in isolation.
“Fiocruz occupies a very special place between science and technology and health, with a strong role in education and the environment, and the fact that we are part of the ministry of health makes it possible for us to do things differently.”Tweet This
TRC: How do you want Fiocruz to be perceived?
PG: The search for excellence in the interface between science, technology and health is at the core of what we do, and at an international level, Fiocruz needs to be associated with what’s new in Brazil. Brazil produces a significant level of knowledge today, but we are well aware of how hard it is to convert this knowledge into innovation. Fiocruz behaves like a strategic institution of the Brazilian state, like a think-tank for the health field.
TRC: To what extent do you feel a closer relationship with the private sector is necessary?
PG: No doubt about it. And we have that in place already, in both the national and international spheres. However, this relationship has a very clear strategic goal: to reduce the Brazilian dependence on input products, to improve the balance of payments, and to be more autonomous so we are not as exposed to oscillations in investments, which led to serious problems with some neglected diseases.
We want to be an important think-tank for the health sector. We are doing prospecting work and developed a centre for strategic studies because we know that there can be huge gaps between evidence, knowledge and the use of them by those responsible for the governance. Fiocruz wants to fill that gap for the health field.
“The search for excellence in the interface between science, technology and health is at the core of what we do.”Tweet This