Brazil's political and economic crises are diverting attention from the resumption of a neoliberal model of health care by its government. Here we briefly summarise the health reforms and their likely long-term implications. The new policies can be seen from three perspectives: austerity, privatisation, and deregulation.

1 Brasil Ministério de Desenvolvimento Social

Informações do projeto de lei orçamentária anual 2017. 2 Instituto de Pesquisa Econômica Aplicada: Ministério do Planejamento

Nota técnica: número 28. , 3 Collucci C Tamanho do SUS precisa ser revisto, diz novo ministro da Saude. 4 Angelo C Brazilian scientists reeling as federal funds slashed by nearly half. , 5 Angelo C Scientists plead with Brazilian government to restore funding. , 6 G1

MEC prevê orçamento 15% menor para universidades federais em 2017. Firstly, the country's Government introduced one of the harshest set of austerity measures in modern history. The constitutional amendment passed in December 2016, called PEC-55, freezes the federal budget, including health spending, at its 2016 level for 20 years.Furthermore, in 2017, for the first time in nearly 30 years, the government undershot the minimum health budget guaranteed by the Constitution by R$692 million (approximately US$210 million).Other health-related sectors, such as education and science, also face spending cuts: up to 45% cuts in scientific research and 15% in public universities.

7 Brasil Ministério do Desenvolvimento Social e Agrário

Base de dados do Programa Bolsa Família. 8 Rasella D

Basu S

Hone T

Paes-Sousa R

Ocké-Reis CO

Millett C Child morbidity and mortality associated with alternative policy responses to the economic crisis in Brazil: a nationwide microsimulation study. 1 Brasil Ministério de Desenvolvimento Social

Informações do projeto de lei orçamentária anual 2017. 1 Brasil Ministério de Desenvolvimento Social

Informações do projeto de lei orçamentária anual 2017. 1 Brasil Ministério de Desenvolvimento Social

Informações do projeto de lei orçamentária anual 2017. Brazil's government is gradually withdrawing from the key social protection plan, Brazil Without Extreme Poverty (Brasil Sem Miséria), which has provided financial support, access to basic goods, and services to vulnerable populations through over 70 specialised programmes. Many social assistance programmes, supplementing preventive health care and reducing inequalities, are experiencing budget cuts. In 2017 over 1 million families were excluded from the Family Allowance Programme (Bolsa Família), aimed at the eradication of poverty and famine by direct, conditional cash transfer to the poorest households.According to prognoses by Rasella and colleagues, austerity measures suffered by the programme are likely to exacerbate child morbidity and mortality within the next decade.The National Programme for the Strengthening of Family Agriculture (PRONAF), which involves functions such as rural education, water supply, and job creation, and was one of the main forces behind Brazil's removal from the World Food Programme's global hunger map, has now been seriously compromised.The Water Tanks Programme (Programa Cisternas), bringing access to safe drinking water to impoverished, rural communities, has lost over 90% of its funds.Given that one of the leading causes of violent crime in rural communities is conflicts over access to water, shutting down the programme poses a serious threat to the security of these communities. Funding for the Acquisition of Food Programme (Programa de Aquisição de Alimentos), purchasing food produced by family farms for redistribution among the poor, has been reduced by 99%.Such drastic changes in the direction of social policies will probably reverse the social progress that has been made over the past two decades, which has brought 28 million people out of poverty and 36 million into the middle class.

9 Brasil Agência Nacional de Saúde Suplementar

Portaria número 8.851. 10 Instituto de Pesquisa Econômica Aplicada

Crise econômica, austeridade fiscal esaúde: que lições podem ser aprendidas? Relatório número 26, Brasília. Secondly, the Government plans to introduce commercial health plans (Planos Populares), meant to replace functions previously performed, free of charge, by the National Health System (Sistema Único de Saúde [SUS]).Commercial plans offer a narrower scope of services than the minimum offered by SUS and are subject to less regulatory scrutiny, which generally results in poor service quality and high out-of-pocket costs.

11 Brasil Ministério da Saúde Gabinete do Ministro

Portaria número 381 de 6 de Fevereiro de 2017. 12 Brasil Ministério da Saúde Gabinete Ministerial

Portaria número 10, de 3 de Janeiro de 2017. 12 Brasil Ministério da Saúde Gabinete Ministerial

Portaria número 10, de 3 de Janeiro de 2017. 13 Estados enfrentam surto de sarampo, que volta a ameaçar o Brasil. Thirdly, states and municipalities have so far been obliged to invest federal resources, via so-called financial blocks, in strategic areas of health care, including primary health care and sanitation. New regulations free the regional administrations from adhering to such spending disciplineby investing specified amounts into strategic areas of health care, which might contribute to the deterioration of SUS and to regional health inequalities. Moreover, new regulations diminish the obligatory numbers of doctors in emergency wardsand of personnel in primary health units,including the reduction of the obligatory number of community health agents. Such reorganisation of primary care not only gives more power to the private sector than before, by diminishing the quality of public services, but also reduces SUS's capacity for effective emergency management, prevention, and health promotion. The weakening of the public sector has also taken a toll on vaccination coverage and sanitary surveillance, resulting in a recent outbreak of measles.

14 Casa Civil, Brasil

Law número 13.467. 15 Stuckler D

Basu S The body economic: why austerity kills. These actions show that Brazil's government is backing away from the core principles of universal health care, despite it being a constitutional right. Neoliberal health policies, combined with the deregulation of labour laws,amid severe economic crisis are not only working against the idea of social justice, but also are likely to exacerbate two major public health concerns of the country: socio spatial and socioeconomic inequalities in health and the high homicide rate. We hope that this letter will stimulate debate on the systemic crisis of health care in Brazil, and contribute to rigorous scrutiny of neoliberal trends in public health policies and their effects around the world.

We declare no competing interests.

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Article Info Publication History Identification DOI: https://doi.org/10.1016/S0140-6736(18)30853-5 Copyright © 2018 Elsevier Ltd. All rights reserved. ScienceDirect Access this article on ScienceDirect