Healthcare in Brazil “Excellence and Innovation in health care in Brazil - Private sector” Miguel Cendoroglo Neto

1. Healthcare in Brazil “Excellence and Innovation in health care in Brazil - Private sector” Miguel CendorogloNeto COO and Medical Director, Albert Einstein Jewish Hospital, Brazil

2. The healthcare sector in Brazil represents 8.9% of GDP Market size(1) Funding (1) Population Coverage (2) Contracting Service Providers Physicians US$ 213 billion Public: 45.7% 75,3% Single Health System (SUS) Self-management Pharmaceutical and healthcare industry equipment Insurers Cooperatives Private: 54.3% Hospitals Managed Care Organization (MCO) MIGRATION Medical Diagnostics 24,7% Private • 7thLargest Economy in the World - US$2.4 trillion (2012) • 5thLargest Population in the World - 201 million (July 2013) • - 84% of the population concentrated in urban areas • 5thLargest country in geographical area - 8,514,877 sq km • 1988 Constitution: - Healthcare is an universal right of every citizen and a responsibility of the State. Access is universal (Unified Health Care System – SUS), with no fees or copayments. • A Country of Contrasts: • – Some top quality institutions and • – Very poor income distribution, though improving In 2011 Source: ANS, LAFIS, IBGE, WHO, Booz Allen & Hamilton; 2011 – WHO; 2012 - ANS, IBGE

3. Health Care in Brazil • 90% of population use SUS: • 29% use exclusively SUS services • 62% uses SUS and private services • 9% of population use only private services • Hospitals: 6,756 (Private/Public) • Beds: 448,954 (2.2/1000 hab) (Private/Public) • Physicians: 388,015 (2.0/1000 hab) • 11.7 million hospital admissions/year Fortaleza Recife Brasilia Salvador Rio de Janeiro São Paulo

4. Healthcare Facts: • Good coverage of Primary Health Care: Vaccines, Basic Care, Infant Mortality Rate decreasing • Unequal access to acuity care • Brazil is the 1st country in public transplantations in the world; 2nd in total transplantations • Unequal access to high complexity procedures • Unequal access to healthcare as a whole across regions Physicians per 1,000 people Infant mortality rate (probability of dying between birth and age 1 per 1000 live births) Solid organs: heart, liver, pancreas, lung, kidney Amapá 0.95 Pará 0.84 Maranhão 0.71 -74% in 22 years +75% in 9 years Distrito Federal 4.09 RJ 3.62 São Paulo 2.64 Rio Grande do Sul 2.37 Source: WHO, National System of Transplants, Brazil Federal Council of Medicine

5. Stroke incidence is higher in less affluent areas of the city of Sao Paulo (green, yellow and red areas of the upper right graph), where the distribution of hospitals with CT-scan devices is lower than in the more affluent areas.

6. Albert Einstein is a private, non profit network, with activities in 5 main areas (hospital, diagnostics and preventive medicine, social responsibility, education and research) carried out through its units distributed around the city of São Paulo Paraisópolis Morumbi Perdizes/Higienópolis M’Boi Mirim Alphaville Jardins Ibirapuera Francisco Morato Paulista Vila Mariana C O N S U L T O R I A E G E S T Ã O

7. Albert Einstein Hospital is a reference in Latin America Joint Commission Accredited since 1999. Only Stroke Center accredited in Latin America AméricaEconomía - Best hospital in Latin America for the 5th consecutive year Planetree Designation 1460 liver transplants, 2579 solid organ transplants Leadership in Robotic Surgery Centers of Excellence with published outcomes in orthopedics, cardiology, neurology and oncology Reference Spine Center for top health insurance in Brazil First Hybrid Cardiac Operating Room in Latin America Physician-Hospital Relationship Program – Model in Brazil (meritocracy) Comprehensive Patient Flow Program - first in Brazil

8. Projects to Support the Institutional Development of Public Health System (PROADI-SUS) • Application of 100% tax exemptions for Projects to Support the Development Institutional of Public Health System (PROADI-SUS), divided into: • Projects: minimum of 70% of the resources in partnerships with the Ministry of Health • Services: maximum of 30% of the resources in partnerships with the State or Municipal Health Departments Studies of Technology Acquisition Researches of Public Interest in Health Human Resources Training Development of Technical and Operation Management in Health Services

9. The activities of the Public Sector already represent a significant share of the activities of the Institution 30% - Services

10. Einstein performed 26% of the liver transplants in the state of SP, with survival rates 18p.p. higher than the best centers in the country and similar to the US. Leader in adult liver transplant performed in the world in 2010 80% 62% +18p.p. in 3 years Cost per MELD quartile (Average cost per transplant = R$ 85,147 or USD 43,000) Total Liver Transplants Global Survival Results 70% - Projects

11. Can we do more?

12. Can we do more? X

13. Can we do better?

14. Support for ICU patients in public hospitals (PROADI-SUS) 1st opinion program (decision support) for critically ill patients at 24 hospitals - 2012-2014. Program already in operation in four hospitals > 300 pacientes already seen Videoconferencing and telepresence

15. Reduction in mortality rates after implementation of a telemedicine program (specialist telepresence) for Stroke, MI and Sepsis at Hospital Moyses Deutsch (JardimAngela, Sao Paulo) Myocardial Infarction Ischemic Stroke 75,6% 43,8% 43,8% Sepsis or septic shock 16,2% 16,2%