The professional career of SUS and the health conference

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By PAULO CAPEL NARVAI*

The debate on the State Career of the SUS is, until now, the main absentee of the 17th National Health Conference, which ends in July

1.

An important innovation has been marking the organization of the 17th National Health Conference (17th CNS), whose closure will take place at the national stage in Brasilia, from July 2 to 5, 2023. national stage,nationwide free conferences” which, in number that exceeded one hundred, took place in the period from August 5, 2022 to May 31, 2023.

Until now, since the historic 8th National Health Conference, held in 1986, which bequeathed us the Unified Health System (SUS), one of the greatest social achievements of the 1988 Constitution, national health conferences were restricted to the three stages, which began with municipal and state conferences and culminated with the national stage, which ended the process. This was also the case in this 17th CNS, with municipal conferences taking place between November 2022 and March 2023 and state conferences from April to May 2023.

But, in addition to these more than 1.500 municipal conferences and the 27 state conferences, which elect their respective delegates for the following stages, more than 100 free conferences were held nationwide. Thus, in addition to the delegates elected in the 27 state conferences to be in Brasilia, the national stage will also have delegates elected in the free conferences, in addition to observers and guests, the latter with the right to speak, but not to vote.

The first of these free conferences took place in 2022, convened by front for life, with the support of various entities and social movements. A Free, Democratic and Popular Health Conference 2022 was preceded by dozens of meetings and preparatory meetings and its final plenary was held in São Paulo, on August 5, 2022, with the presence of current President Luiz Inácio Lula da Silva.

The set of more than 100 free national conferences represents an invaluable contribution to the 17th CNS, either for the mobilization involved in its accomplishments, or for the guidelines and proposals that, forwarded to the organizing committee of the 17th CNS, are being incorporated, in a systematic way, to the Consolidated report of the conferences that precede the national stage.

In Brasilia, delegates elected by the three segments legally represented in the National Health Council (CNS), that is, SUS users, system managers and workers, will debate and decide on what stays and what does not, how decision of the 17th CNS, in the guidelines and proposals approved by the conference. They will do so, based on what is contained in this Consolidated Report, whose origin is the municipal stage of this complex process that mobilizes millions of people throughout Brazil, directly or indirectly, to assess the health situation of the population, the functioning of institutions responsible and propose the directions that the country should take in the sector.

Not without reason, given the recent history of Brazilian public health, the central theme of the 17th CNS is “Guaranteeing rights and defending the SUS, life and democracy – tomorrow will be another day".

Among the many contributions of a national health conference is the fact, according to the National Health Council, that its deliberations should be included in the Union's next planning cycle and serve as a subsidy for the preparation of the National Health Plan and Plan Multi-annual from 2024-2027. And, at the local level, provide subsidies for the review of Municipal Health Plans, to be prepared by 2025.

2.

But if the objective of the “free national conferences” was “to expand the mobilization of the population and establish direct dialogues with Brazilian society, about the guarantee of rights, life and democracy, as well as the defense of the SUS”, according to the organizing committee of the 17th CNS, it should be noted that, among the dozens of free conferences, one did not take place: the one that should have referred to the Career of the State of the SUS (Carreira-SUS). No one was interested in it to the point of organizing it. Without interested in its promotion, it did not occur.

The theme simply did not manage to enter the debate agenda, which was positively focused on the defense of social rights, democracy and popular participation. With a “deliberative nature” to guide and forward guidelines and proposals for the national stage of the 17th CNS, the free conferences covered a huge range of themes, ranging from strategic telehealth and digital health, to homeopathy in the SUS, passing through issues such as recovery high vaccination coverage, medical marijuana, oral and mental health, anti-capitalist health, among others.

Despite the relevance of these dozens of topics, which are so hot on health in Brazil, the issue of Career-SUS remained forgotten. Therefore, it is equally urgent to make labor relations in the system less precarious and promote its necessary professionalization, including social security protection, whose absence or deficiencies at the municipal level astounds those who work, directly or indirectly for the SUS, through outsourced companies, in which allegations of mismanagement thrive, including fraud and defaults labor.

O Guiding document presented at the beginning of the process of the 17th CNS, in 2022, recorded the flexibilization and attacks on the rights of workers, denounced the extinction of the National Permanent Negotiation Table of the SUS, by Decree nº 9.759/2019, but did not specifically contemplate , the Career-SUS, although there is a generic mention to the “career of the SUS”, in the block that evaluates the situation of chronic underfunding of the system. Career-SUS is, however, a claim that has been reiterated by delegates at health conferences since 1986.

Still at the 16th CNS, held in 2019, there were Several proposals were approved for this purpose, which can be summarized in the following proposition: “Guarantee a Career Plan, Positions and Salaries of the SUS for public servants in the three spheres of government, with isonomy of salaries, in the statutory regime (RJU) that contemplates: (a) functional advancement and objective criteria for filling leadership positions; (b) maximum working hours of 30 hours per week; (c) exclusive dedication; (d) policy for valuing civil servants and dignified salary adjustments; (e) strategies for securing health professionals in the interior of the country and in areas of difficult access and supply, which include a professional training policy with salary and career incentives; (f) regulation of special retirement resulting from unhealthy and dangerous activities; (g) isonomy of salaries for civil servants of all levels of complexity and spheres of government; (h) abolish all forms of precariousness and outsourcing of public services by the private sector; (i) including community health agents and endemic agents.”

Despite the clarity of this general orientation of a Career-SUS, the proposal has not prospered, either in the National Congress or in the initiatives of the Ministry of Health. And, it is worth reiterating, it did not even fit in the aforementioned free conference agenda. It is unlikely, however, that the theme is not included in the Consolidated Report to be debated by the delegates in July, since at least two free conferences dealt with the themes of the workforce and its qualification in the SUS. The two conferences were entitled “Valuing the SUS is valuing the SUS workforce” and “Education in the qualification of work in health and the development of the SUS”. Although they do not refer specifically to Career-SUS, the connections with the theme contribute to, in some way, give it some prominence.

3.

In sectors linked to the defense of the SUS, there are many proponents of a Career-SUS that is cross-federal, multidisciplinary, unique and national. This means that the Career-SUS that is sought must have the participation of all federative entities, Union, states and municipalities; be composed of as many positions as necessary for the SUS, to cover the multiplicity of functions performed by the great professional diversity that characterizes contemporary work in health.

Single, but flexible and plural, so as to be compatible with different service needs and public administrative modalities; and national, as it is necessary to ensure mobility at the national level for those who are part of it and to define rules for entry and promotion, working hours, guarantees of rights and setting of duties, as well as the conditions for effective public control by mandatory management councils in all SUS health units, with rules for exoneration/dismissal and administered under a co-management regime by regional management collegiates of Carreira-SUS, composed of representatives of the municipalities of each SUS Health Region, workers, through unions , and users of the SUS public health services, through the municipal health councils of the respective region.

However, there is no lack of warnings that this would not be possible because it is “illegal”, “violates the federative pact”, does not have “political viability in Brazilian federalism”, is not “feasible, given the characteristics of public administration”, among other things. sensible weights. It is argued that it is not that we still do not have a Career-SUS just because we do not want to have it or because of a lack of “political will”. The claim is fair, but not enforceable – argue the authors of these alerts.

The problem, they say, is much more complex, as a result of being a federative republic, with a large territorial extension, with autonomous federative entities, marked cultural contrasts and public administration organization. In addition, because the SUS is a health system and not a “national service”, that is, a mega-organization of national scope and administered only by the federal government. The governance of the SUS, they ponder, is incompatible with this conception of a megaorganization centralized in Brasília.

These are all consistent arguments that must be taken into account in any debate about a Career in the State of the SUS. The problem, however, is that these findings are seen as a kind of “arrival point”. This is how it is and there would be nothing to be done, except to try to improve what we have today.

But Carreira-SUS supporters say that the current scenario should be seen as a “starting point” and not the end of the road. They propose that, in view of this scenario, then what to do? Where to go?

I make these considerations because the environment of a national health conference, due to its inherent democracy and, therefore, openness to propositions of any nature, including illegal ones, is the adequate space to produce answers to these questions about what to do and where to go. go to conquer a SUS State Career. The assumption is that everything can be changed, including the laws, and obstacles overcome, if there is creativity, effort and determination in overcoming the difficulties along the way. It is enough to create alternatives and act to make what is unfeasible today possible tomorrow.

In this regard, I recover a statement that I like very much, that Sérgio Arouca valued in the process of organizing the 12th CNS, led by him preliminarily, and which was held from December 7 to 11, 2003: “dreaming is allowed here”. Sérgio Arouca conceived the process and environment of that health conference as this space: that of dreaming and trying to make dreams come true. The conference was not, for him, a former federal deputy and former secretary of Participatory Management of the Ministry of Health, a bureaucratic and formal space, plastered and tied to the current institutional framework. Having died shortly before the event, the National Health Council paid him a just tribute by naming the 12th CNS the “Sérgio Arouca Conference”.

This creative and propositional perspective, denying the pragmatism of spreadsheet managers, that “here you are allowed to dream”, should be the reference for the debate on a State Career in the SUS, as there is no reason to ban this topic, of strategic importance and the most urgent for the SUS – above all, for the future of the SUS, because without health workers there is no SUS. And without a career that values ​​them, there are not exactly workers, but an amorphous, diffuse and confused set of semi-professionals, amateurs, day laborers, hourly workers, Uber workers, entrepreneurs, precarious workers.

The SUS, therefore, needs professionals, that is to say, health workers in the best sense of the term. The Brazilian State should not deny them the exercise of this right, because according to the motto defended by FENTAS, the Forum of National Entities of Workers in the Health Area, “valuing the SUS is valuing the workforce of the SUS”.

*Paulo Capel Narvai is senior professor of Public Health at USP. Author, among other books, of SUS: a revolutionary reform (authentic).


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