INTRODUCTION – The rapid growth in health spending around the world has led health systems to a situation of increasing tension between financing needs and constraints. The Institute for Health Metrics and Evaluation (IHME) estimates a current global health spending of approximately US$ 8 trillion per year, which is projected to double by 2050.1 Growth in financing needs is expected to accelerate particularly in developing countries, where population is rapidly aging and health systems still face coverage and quality issues (SDG Collaborators, 2017). In light of the overall trends and challenges, it is therefore relevant to question whether and how developing countries will cope with increasing financing needs in healthcare over the path towards universal health coverage.

In this paper, we estimate and characterize health-financing needs in Brazil over the next four decades. We also identify potential tensions between financing needs and spending constraints in the future, in particular under different fiscal scenarios for the public sector, and discuss health system sustainability. Brazil is often considered a forerunner by the public health community and a potential model for other developing countries to follow (Harris, 2014; Atun et al., 2015). Brazil established universal and egalitarian access to health care as a constitutional right, and introduced a Unified Health System (Sistema Único de Saúde [SUS]) with the aim of achieving free universal health coverage and reducing disparities in access to healthcare services and health outcomes. SUS design therefore closely resembles social insurance models, in opposition to subsidized health insurance schemes and other models typically found in developing countries.

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