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OECD reports 2019 shares of all hospital beds by ownership, but those shares do not identify who paid for care, who used a facility or whether a private manager owns a public asset.", "tags": [], "territory": "Brazil, SUS, hospital ownership, management and private-provider context", "title": "SUS, hospital ownership and management boundary", "urls": [ { "kind": "url", "source": "not supplied", "url": "https://legis.senado.leg.br/norma/549956/publicacao/34619933" }, { "kind": "source_reference", "source": "OECD Reviews of Health Systems: Brazil 2021", "url": "https://www.oecd.org/content/dam/oecd/en/publications/reports/2021/12/oecd-reviews-of-health-systems-brazil-2021_6797af6a/146d0dea-en.pdf" }, { "kind": "source_reference", "source": "The Brazilian health system: history, advances, and challenges", "url": "https://eutils.ncbi.nlm.nih.gov/entrez/eutils/efetch.fcgi?db=pubmed&id=21561655&rettype=medline&retmode=text" } ] }, { "analytical_mapping": { "mapping_basis": "declared_from_federal_legal_sources_cross_checked_against_oecd_review", "mapping_group": "actors_and_functions", "mapping_id": "candidate-mapping:BRA:actors-functions:tripartite-sus-roles", "source_projection_ids": [ "country-improvement-source:BRA:law-8080-1990", "country-improvement-source:BRA:law-8142-1990", "country-improvement-source:BRA:oecd-primary-health-care-2021" ], "support_state": "candidate_supported", "target_slot": "federal-state-municipal-sus-roles", "target_view": "functions", "typed_fields": { "boundary": "responsibilities are legally differentiated and do not show equal local delivery capacity, transfer adequacy or a fixed division of every service", "federal_role": "Ministry of Health defines national policy; the federal framework allocates the National Health Fund and governs transfer conditions", "municipal_role": "municipal health authorities manage SUS locally, including primary care", "state_role": "state health authorities provide regional governance and specialized services not decentralized to municipalities", "transfer_channel": "Law No. 8,142 provides for regular automatic National Health Fund transfers to states, municipalities and the Federal District, subject to statutory conditions" } }, "annotation_status": "open", "authors": [], "availability": {}, "citation": "Law No. 8,080, Articles 9 and 16 to 18; Law No. 8,142, Articles 2 to 4; OECD, Primary Health Care in Brazil, 2021, pages 49 to 50.", "country_ids": [ "BRA" ], "coverage_domains": [ "actors", "authoritative_review", "decision_rights", "governance", "government_responsibilities" ], "display_status": "shown_in_full", "document_type": null, "evidence_mode": "reported", "excerpt": null, "institution": null, "locator": { "description": "Law No. 8,080, Articles 9 and 16 to 18; Law No. 8,142, Articles 2 to 4; OECD pages 49 to 50" }, "material_id": "material:c44404d3fc36309ac81d8ff4", "notes": [ "Do not infer that every municipality provides every specialized service or has the same managerial capacity. Treat National Health Fund links as formal transfer provisions, not measures of funds received, purchasing volume or provider payment." ], "origin": "candidate-analytical-mappings", "period": "Legal framework enacted 1990; OECD review published 2021", "publication_date": null, "publication_year": null, "record_kind": "candidate_analytical_mapping", "record_kind_label": "Candidate Analytical Mapping", "screening": { "previous_boundary_detected": false, "previous_visibility": "previously_not_projected" }, "source_layers": [ "official" ], "source_system": null, "source_version": { "detected_media_type": "text/html", "response_sha256": "10d09840007e0071ed896755afdabd713ce4bd046f4aca0d25b48f929538650c" }, "statement": "Brazil's SUS has differentiated federal, state and municipal functions. The formal map also includes a National Health Fund transfer channel to states and municipalities. It does not show transfer adequacy, a completed payment or equal local delivery capacity.", "tags": [], "territory": "Brazil, national, state and municipal SUS responsibilities", "title": "Tripartite SUS roles", "urls": [ { "kind": "url", "source": "not supplied", "url": "https://legis.senado.leg.br/norma/549956/publicacao/34619933" }, { "kind": "source_reference", "source": "Law No. 8,142 of 28 December 1990", "url": "https://legis.senado.leg.br/norma/550018/publicacao/15715902" }, { "kind": "source_reference", "source": "Primary Health Care in Brazil", "url": "https://www.oecd.org/content/dam/oecd/en/publications/reports/2021/12/primary-health-care-in-brazil_8ba611b2/120e170e-en.pdf" } ] }, { "analytical_mapping": {}, "annotation_status": "open", "authors": [], "availability": {}, "citation": "Concept Environmental and Social Review Summary (ESRS) - BRAZIL COVID-19 RESPONSE AND RECOVERY PROJECT - P176796. 2021. https://documents1.worldbank.org/curated/en/921561621927069387/pdf/Concept-Environmental-and-Social-Review-Summary-ESRS-BRAZIL-COVID-19-RESPONSE-AND-RECOVERY-PROJECT-P176796.pdf", "country_ids": [ "BRA" ], "coverage_domains": [], "display_status": "shown_in_full", "document_type": null, "evidence_mode": null, "excerpt": "lockdowns reduced access to referral services and protective support networks stressors including", "institution": null, "locator": { "physical_pdf_page": 6, "source_word_anchor": "lockdowns reduced access to referral services and protective support networks stressors including", "source_word_count": 12 }, "material_id": "material:de547ba899f13f83ae85813d", "notes": [], "origin": "global-corpus-excerpt-queue", "period": null, "publication_date": null, "publication_year": 2021, "record_kind": "corpus_page_anchor", "record_kind_label": "Corpus Page Anchor", "screening": { "previous_boundary_detected": true, "previous_visibility": "previously_not_projected" }, "source_layers": [], "source_system": null, "source_version": { "detected_media_type": "application/pdf", "file_sha256": "b4719174eef92e6c0b1773a802e235fa56a3430ef2edb6498cda2b0d380591fe", "page_count": 16, "text_sha256": "ca7a941d253f538f1c8feb01027f17e635f97db437a0312f6c3c0cd48db59c91" }, "statement": null, "tags": [ "control_knob:organization", "language:en", "source:World Bank Documents and Reports", "source_layer:global_literature" ], "territory": null, "title": "Concept Environmental and Social Review Summary (ESRS) - BRAZIL COVID-19 RESPONSE AND RECOVERY PROJECT - P176796", "urls": [ { "kind": "stable_source_url", "source": "not supplied", "url": "https://documents1.worldbank.org/curated/en/921561621927069387/pdf/Concept-Environmental-and-Social-Review-Summary-ESRS-BRAZIL-COVID-19-RESPONSE-AND-RECOVERY-PROJECT-P176796.pdf" } ] }, { "analytical_mapping": {}, "annotation_status": "open", "authors": [], "availability": {}, "citation": "Brazil. Constitution of the Federative Republic of Brazil, Articles 196 and 198. 1988. https://legis.senado.leg.br/norma/579494/publicacao/16434817", "country_ids": [ "BRA" ], "coverage_domains": [ "actors", "decision_rights", "governance", "government_responsibilities", "reform_history" ], "display_status": "shown_in_full", "document_type": null, "evidence_mode": "formal", "excerpt": "Saúde é direito de todos e dever do Estado", "institution": "Presidency of the Republic of Brazil", "locator": { "locator_type": "constitutional_articles", "source_word_anchor": "Saúde é direito de todos e dever do Estado", "source_word_count": 9 }, "material_id": "material:0b386422ce3eb87245b772fc", "notes": [ "Confirm amendments and constitutional case law before using this provision as a current operational description." ], "origin": "country-evidence-improvement-sources", "period": "Constitution promulgated 1988; current application requires separate legal confirmation", "publication_date": null, "publication_year": 1988, "record_kind": "country_improvement_source_lead", "record_kind_label": "Country Improvement Source Lead", "screening": { "previous_boundary_detected": false, "previous_visibility": "previously_not_projected" }, "source_layers": [ "official" ], "source_system": null, "source_version": { "detected_media_type": "text/html", "response_sha256": "5beff7a47d7723594a6c48b5a72a99bbe13b300c91f4befce2284ae7f3b86808" }, "statement": "Articles 196 and 198 establish health as a state duty and describe public health actions and services as a regionalized, hierarchical network with decentralized direction at each level of government.", "tags": [], "territory": "Brazil, federal constitutional framework", "title": "Constitution of the Federative Republic of Brazil, health provisions", "urls": [ { "kind": "url", "source": "not supplied", "url": "https://legis.senado.leg.br/norma/579494/publicacao/16434817" } ] }, { "analytical_mapping": {}, "annotation_status": "open", "authors": [], "availability": {}, "citation": "Brazil. Decree No. 7,508 of 28 June 2011, Articles 2 to 9 and 20 to 24. https://legis.senado.leg.br/norma/412353/publicacao/15760644", "country_ids": [ "BRA" ], "coverage_domains": [ "actors", "decision_rights", "facility_data", "governance", "government_responsibilities", "hospital_organization", "networks", "patient_flows", "primary_care", "referral_design", "reform_history" ], "display_status": "shown_in_full", "document_type": null, "evidence_mode": "formal", "excerpt": "rede regionalizada e hierarquizada", "institution": "Presidency of the Republic of Brazil", "locator": { "locator_type": "legal_articles", "source_word_anchor": "rede regionalizada e hierarquizada", "source_word_count": 4 }, "material_id": "material:cec43a690ad0c6dd1b98b11a", "notes": [ "Treat the entry-point and referral provisions as formal design, not evidence that a patient completed that route." ], "origin": "country-evidence-improvement-sources", "period": "Decree issued 2011", "publication_date": null, "publication_year": 2011, "record_kind": "country_improvement_source_lead", "record_kind_label": "Country Improvement Source Lead", "screening": { "previous_boundary_detected": false, "previous_visibility": "previously_not_projected" }, "source_layers": [ "official" ], "source_system": null, "source_version": { "detected_media_type": "text/html", "response_sha256": "784d3f3a77ad87e48f9c6cfaf97c03b47992a8560f6465730bd915f5bce3c4d6" }, "statement": "The decree defines health regions, care networks, entry points and intergovernmental agreements. It states that ordered access begins at SUS entry points and is completed in a regionalized, hierarchical network.", "tags": [], "territory": "Brazil, SUS regionalized network and intergovernmental arrangements", "title": "Decree No. 7,508 of 28 June 2011", "urls": [ { "kind": "url", "source": "not supplied", "url": "https://legis.senado.leg.br/norma/412353/publicacao/15760644" } ] }, { "analytical_mapping": {}, "annotation_status": "open", "authors": [], "availability": {}, "citation": "World Health Organization. Implementing the primary health care approach: a primer. Chapter 4, Brazil country illustration. 2024. https://iris.who.int/bitstream/handle/10665/376777/9789240090583-eng.pdf?sequence=1", "country_ids": [ "BRA" ], "coverage_domains": [ "authoritative_review", "governance", "networks", "primary_care", "reform_history" ], "display_status": "shown_in_full", "document_type": null, "evidence_mode": "reported", "excerpt": "Challenges include governance structures, leadership, and regional inequalities", "institution": "World Health Organization", "locator": { "locator_type": "pdf_chapter_anchor", "section": "Brazil: the Family Health Strategy was pivotal to improved health system performance", "source_word_anchor": "Challenges include governance structures, leadership, and regional inequalities", "source_word_count": 7 }, "material_id": "material:6fa25c6269f0c0545f04cffc", "notes": [ "Use this as contextual WHO synthesis; do not convert it into a current municipality, facility or patient-level finding." ], "origin": "country-evidence-improvement-sources", "period": "WHO primer published 2024; Brazil illustration summarizes the preceding two decades", "publication_date": null, "publication_year": 2024, "record_kind": "country_improvement_source_lead", "record_kind_label": "Country Improvement Source Lead", "screening": { "previous_boundary_detected": false, "previous_visibility": "previously_not_projected" }, "source_layers": [ "grey_literature" ], "source_system": null, "source_version": { "detected_media_type": "application/pdf", "response_sha256": "1fc0da53d43e539af3c4960b26d06adc402e51d0baa0a6aacfcc4d00de5fb74a" }, "statement": "The WHO Brazil illustration describes the Family Health Strategy's implementation over two decades and identifies governance, leadership, and regional inequalities in resources and access as challenges. It is contextual synthesis, not a current subnational performance measure.", "tags": [], "territory": "Brazil, national Family Health Strategy implementation context", "title": "Implementing the primary health care approach: a primer, Brazil country illustration", "urls": [ { "kind": "url", "source": "not supplied", "url": "https://iris.who.int/bitstream/handle/10665/376777/9789240090583-eng.pdf?sequence=1" } ] }, { "analytical_mapping": {}, "annotation_status": "open", "authors": [], "availability": {}, "citation": "Brazil. Law No. 8,080 of 19 September 1990, Articles 7, 9 and 16 to 18. https://legis.senado.leg.br/norma/549956/publicacao/34619933", "country_ids": [ "BRA" ], "coverage_domains": [ "actors", "autonomy", "decision_rights", "governance", "government_responsibilities", "hospital_organization", "ownership", "primary_care" ], "display_status": "shown_in_full", "document_type": null, "evidence_mode": "formal", "excerpt": "A direção do Sistema Único de Saúde é única", "institution": "Presidency of the Republic of Brazil", "locator": { "locator_type": "legal_articles", "source_word_anchor": "A direção do Sistema Único de Saúde é única", "source_word_count": 9 }, "material_id": "material:b3c74a523e8ccabc0154d925", "notes": [ "Separate legal assignments from the capacity, financing and practice of any particular state or municipality." ], "origin": "country-evidence-improvement-sources", "period": "Law enacted 1990; municipal wording amended in 2023", "publication_date": null, "publication_year": 1990, "record_kind": "country_improvement_source_lead", "record_kind_label": "Country Improvement Source Lead", "screening": { "previous_boundary_detected": false, "previous_visibility": "previously_not_projected" }, "source_layers": [ "official" ], "source_system": null, "source_version": { "detected_media_type": "text/html", "response_sha256": "10d09840007e0071ed896755afdabd713ce4bd046f4aca0d25b48f929538650c" }, "statement": "The law establishes single SUS direction at federal, state and municipal levels and assigns distinct responsibilities to each level. It also permits complementary private-sector participation under SUS rules.", "tags": [], "territory": "Brazil, Unified Health System legal framework", "title": "Law No. 8,080 of 19 September 1990", "urls": [ { "kind": "url", "source": "not supplied", "url": "https://legis.senado.leg.br/norma/549956/publicacao/34619933" } ] }, { "analytical_mapping": {}, "annotation_status": "open", "authors": [], "availability": {}, "citation": "Brazil. Law No. 8,142 of 28 December 1990, Articles 1 to 4. https://legis.senado.leg.br/norma/550018/publicacao/15715902", "country_ids": [ "BRA" ], "coverage_domains": [ "actors", "autonomy", "decision_rights", "governance", "government_responsibilities", "reform_history" ], "display_status": "shown_in_full", "document_type": null, "evidence_mode": "formal", "excerpt": "a Conferência de Saúde; e o Conselho de Saúde", "institution": "Presidency of the Republic of Brazil", "locator": { "locator_type": "legal_articles", "source_word_anchor": "a Conferência de Saúde; e o Conselho de Saúde", "source_word_count": 9 }, "material_id": "material:0ff02f7c156db95296534d99", "notes": [ "Do not equate a formal council or transfer condition with effective local deliberation, financial sufficiency or provider accountability." ], "origin": "country-evidence-improvement-sources", "period": "Law enacted 1990", "publication_date": null, "publication_year": 1990, "record_kind": "country_improvement_source_lead", "record_kind_label": "Country Improvement Source Lead", "screening": { "previous_boundary_detected": false, "previous_visibility": "previously_not_projected" }, "source_layers": [ "official" ], "source_system": null, "source_version": { "detected_media_type": "text/html", "response_sha256": "f981ae043856cc309582a9807aa8681d5bbc0d5ecdb3524cf5b2098b0d57d4dd" }, "statement": "The law establishes health conferences and health councils in each government sphere, describes councils as permanent and deliberative, and sets regular automatic transfers plus conditions for subnational receipt. These are formal accountability and financing provisions, not evidence of their influence in a particular locality.", "tags": [], "territory": "Brazil, SUS community participation and intergovernmental transfers", "title": "Law No. 8,142 of 28 December 1990", "urls": [ { "kind": "url", "source": "not supplied", "url": "https://legis.senado.leg.br/norma/550018/publicacao/15715902" } ] }, { "analytical_mapping": {}, "annotation_status": "open", "authors": [], "availability": {}, "citation": "Organisation for Economic Co-operation and Development. OECD Reviews of Health Systems: Brazil 2021. 2021. https://www.oecd.org/content/dam/oecd/en/publications/reports/2021/12/oecd-reviews-of-health-systems-brazil-2021_6797af6a/146d0dea-en.pdf", "country_ids": [ "BRA" ], "coverage_domains": [ "authoritative_review", "facility_data", "governance", "hospital_organization", "market_structure", "ownership", "utilization" ], "display_status": "shown_in_full", "document_type": null, "evidence_mode": "reported", "excerpt": "38.2% of hospital beds were public", "institution": "Organisation for Economic Co-operation and Development", "locator": { "locator_type": "pdf_page_set_anchor", "source_word_anchor": "38.2% of hospital beds were public", "source_word_count": 6 }, "material_id": "material:c49ef3a96a16f70595ce6839", "notes": [ "Keep ownership, management and SUS contracting distinct. The bed shares use all hospital beds as their 2019 denominator and do not measure admissions, payments or individual access." ], "origin": "country-evidence-improvement-sources", "period": "Review published 2021; hospital-bed observations refer to 2019", "publication_date": null, "publication_year": 2021, "record_kind": "country_improvement_source_lead", "record_kind_label": "Country Improvement Source Lead", "screening": { "previous_boundary_detected": false, "previous_visibility": "previously_not_projected" }, "source_layers": [ "review_literature" ], "source_system": null, "source_version": { "detected_media_type": "application/pdf", "file_sha256": "3d685c2646302ee01e9e5f942182b860a101d36392c2fcd9b04df845253f5461", "page_count": 207, "response_sha256": "3d685c2646302ee01e9e5f942182b860a101d36392c2fcd9b04df845253f5461" }, "statement": "The OECD describes public hospitals owned by federal, state or municipal government, direct or outsourced management including Social Organisations, and state or municipal contracting of private hospitals under SUS. For all hospital beds in 2019, it reports 38.2% public, 38.1% private non-profit and 23.6% private for-profit.", "tags": [], "territory": "Brazil, national hospital and public-private delivery context", "title": "OECD Reviews of Health Systems: Brazil 2021", "urls": [ { "kind": "url", "source": "not supplied", "url": "https://www.oecd.org/content/dam/oecd/en/publications/reports/2021/12/oecd-reviews-of-health-systems-brazil-2021_6797af6a/146d0dea-en.pdf" } ] }, { "analytical_mapping": {}, "annotation_status": "open", "authors": [], "availability": {}, "citation": "Brazil Ministry of Health. Ordinance No. 2,436 of 21 September 2017. National Primary Care Policy, Article 2(1). https://bvsms.saude.gov.br/bvs/saudelegis/gm/2017/prt2436_22_09_2017.html", "country_ids": [ "BRA" ], "coverage_domains": [ "governance", "networks", "patient_flows", "primary_care", "referral_design" ], "display_status": "shown_in_full", "document_type": null, "evidence_mode": "formal", "excerpt": "Atenção Básica será a principal porta de entrada", "institution": "Ministry of Health of Brazil", "locator": { "locator_type": "legal_article_and_policy_annex", "source_word_anchor": "Atenção Básica será a principal porta de entrada", "source_word_count": 8 }, "material_id": "material:c813a23485bd0af410f37a00", "notes": [ "Treat the principal-entry-point provision as formal policy, not evidence of universal gatekeeping or a completed counter-referral." ], "origin": "country-evidence-improvement-sources", "period": "Ordinance issued 2017", "publication_date": null, "publication_year": 2017, "record_kind": "country_improvement_source_lead", "record_kind_label": "Country Improvement Source Lead", "screening": { "previous_boundary_detected": false, "previous_visibility": "previously_not_projected" }, "source_layers": [ "official" ], "source_system": null, "source_version": { "detected_media_type": "text/html", "response_sha256": "26429d82c136c1774870765b25e1cc37852e004666bc59c719a640a6ed41adc1" }, "statement": "Article 2(1) defines primary care as the principal SUS entry point and communication centre of the Health Care Network. This policy direction does not establish a universally completed referral route.", "tags": [], "territory": "Brazil, national primary-care policy framework", "title": "Ordinance No. 2,436 of 21 September 2017, National Primary Care Policy", "urls": [ { "kind": "url", "source": "not supplied", "url": "https://bvsms.saude.gov.br/bvs/saudelegis/gm/2017/prt2436_22_09_2017.html" } ] }, { "analytical_mapping": {}, "annotation_status": "open", "authors": [], "availability": {}, "citation": "Organisation for Economic Co-operation and Development. Primary Health Care in Brazil. OECD Reviews of Health Systems. 2021. https://www.oecd.org/content/dam/oecd/en/publications/reports/2021/12/primary-health-care-in-brazil_8ba611b2/120e170e-en.pdf", "country_ids": [ "BRA" ], "coverage_domains": [ "actors", "authoritative_review", "autonomy", "decision_rights", "facility_data", "governance", "government_responsibilities", "hospital_organization", "market_structure", "networks", "observed_referral", "patient_flows", "primary_care", "referral_design", "reform_history", "utilization" ], "display_status": "shown_in_full", "document_type": null, "evidence_mode": "observed", "excerpt": "it does not work as a gatekeeper", "institution": "Organisation for Economic Co-operation and Development", "locator": { "locator_type": "pdf_page_set_anchor", "source_word_anchor": "it does not work as a gatekeeper", "source_word_count": 7 }, "material_id": "material:7279610cab366a7268676e63", "notes": [ "Keep national review findings separate from any inferred patient-level route, and preserve the report's stated regional and municipal variation." ], "origin": "country-evidence-improvement-sources", "period": "Review published 2021, using cited data through 2020", "publication_date": null, "publication_year": 2021, "record_kind": "country_improvement_source_lead", "record_kind_label": "Country Improvement Source Lead", "screening": { "previous_boundary_detected": false, "previous_visibility": "previously_not_projected" }, "source_layers": [ "review_literature" ], "source_system": null, "source_version": { "detected_media_type": "application/pdf", "file_sha256": "ad1fb483a2ef0aa5eca72a51aa9d35e037ca444cc7ea0a064ab85acb9cf49385", "page_count": 204, "response_sha256": "ad1fb483a2ef0aa5eca72a51aa9d35e037ca444cc7ea0a064ab85acb9cf49385" }, "statement": "The OECD review reports that municipalities organize, manage and deliver primary care, states provide regional governance and specialized services not decentralized to municipalities, and primary care is not a gatekeeper because many people directly access outpatient specialties and hospitals.", "tags": [], "territory": "Brazil, with reported state, regional and municipal variation", "title": "Primary Health Care in Brazil", "urls": [ { "kind": "url", "source": "not supplied", "url": "https://www.oecd.org/content/dam/oecd/en/publications/reports/2021/12/primary-health-care-in-brazil_8ba611b2/120e170e-en.pdf" } ] }, { "analytical_mapping": {}, "annotation_status": "open", "authors": [], "availability": {}, "citation": "Primary Health Care in Brazil and the Mais Médicos Program: an analysis of production indicators. Ciência & Saúde Coletiva. 2016;21(9):2685-2696. 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It does not measure a current national referral route or individual patient outcomes.", "tags": [], "territory": "Brazil, primary-care physicians and municipalities in the 2014 study dataset", "title": "Primary Health Care in Brazil and the Mais Médicos Program: an analysis of production indicators", "urls": [ { "kind": "url", "source": "not supplied", "url": "https://eutils.ncbi.nlm.nih.gov/entrez/eutils/efetch.fcgi?db=pubmed&id=27653054&rettype=medline&retmode=text" } ] }, { "analytical_mapping": {}, "annotation_status": "open", "authors": [], "availability": {}, "citation": "Massuda A, Hone T, Leles FAG, de Castro MC, Atun R. The Brazilian health system at crossroads: progress, crisis and resilience. BMJ Global Health. 2018;3:e000829. 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It is not a current measure of any one state or municipality.", "tags": [], "territory": "Brazil, national system with regional and socioeconomic disparities", "title": "The Brazilian health system at crossroads: progress, crisis and resilience", "urls": [ { "kind": "url", "source": "not supplied", "url": "https://eutils.ncbi.nlm.nih.gov/entrez/eutils/efetch.fcgi?db=pubmed&id=29997906&rettype=medline&retmode=text" } ] }, { "analytical_mapping": {}, "annotation_status": "open", "authors": [], "availability": {}, "citation": "Paim J, Travassos C, Almeida C, Bahia L, Macinko J, et al. The Brazilian health system: history, advances, and challenges. Lancet. 2011;377(9779):1778-1797. 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