By FRANCISCO BATISTA JÚNIOR*

Specialists in the SUS or for the SUS? How Public-Private Partnerships are digging the grave of the Universal Health System

1.

The Health Reform movement and the Brazilian people managed to guarantee the Unified Health System (SUS) in the 1988 Federal Constitution, the greatest achievement in our history. In a deeply unequal, slave-owning, exclusionary and unequal country, the collapse of the 1964 dictatorship and the resumption of democratic freedoms and the organization of society were decisive in overcoming the resistance of the conservative, oligopolistic and backward sectors of the country.

As we predicted and stated at the time, the established Powers, the elites, the “Market” and the hegemonic economic and political groups would not passively watch the implementation and consolidation of the SUS, which was intrinsically a serious threat to the status quo. They set out to compete, aware that this was a privileged niche to be explored by them. After all, a powerful State policy was being developed with significant financial potential and a privileged capillarity capacity with a perennial, permanent and inexhaustible demand to be explored.

Organized in Parliaments, inserted in the three spheres of management and acting strongly with managers and the media, they triggered a large movement translated into the contracting of private services, initially in tertiary and specialized care, with childish arguments such as “It is important that the SUS has private partners, alone it will not be able to cope” or “The user cannot wait for the State” or even “For the user it does not matter whether the service is public or private contracted, what he wants is to be attended to”.

With the direct participation of managers committed to and at the service of the private sector, and others who, without the necessary conceptual knowledge about the proposed health reform, really believed that this could be the path, at the end of the first decade of the SUS's existence, the population and managers faced a growing dependence on the private sector, suffering the consequences in the form of compromised financing, unavailability of services, equipment and professionals, and an ever-increasing number of people deprived of care.

History and the world have taught us that, politically and financially, it is impossible to implement a universal and comprehensive Public Health System, such as the SUS, using market logic, competing with private systems that use this logic to attract professionals and provide procedures, in a deeply unequal competition. In our country, it is even more serious: the State is its own executioner while it feeds its competitors with public resources in the form of contracts, agreements and subsidies of the most varied kinds.

Alexandre Padilha, the Minister of Health, notes that 90% of specialist doctors work in the private sector and only 10% in the SUS. Why? Simple! They prefer the private sector because they receive attractive payments for the procedures they perform, which are often paid for by the SUS. Thus, with each private service that is hired, the more difficult it becomes for the SUS to have specialists on its staff. No matter how many graduates there are (the government promises 3.500), they will always prefer the private sector, regardless of the salary that the SUS offers.

In Brazil, we have a profoundly perverse equation in which the SUS is strongly doctor-centered, focused on specialized care, with significant deficits in financing, in primary care, in multidisciplinary teams, in disease prevention, health promotion and intersectoral actions, and in the training and distribution of doctors, of whom the SUS is hostage.

2.

In a scenario like this, blatantly unsustainable politically and economically, the SUS is engulfed by supplementary and private healthcare, having become totally dependent on the contracted and agreed private network and on corporations organized in cooperatives and other commercial instruments of the workforce, such as “pejotização”.

The nefarious privatization project and consequent unfeasibility and sustainability of the SUS, which began with the contracting of private secondary and tertiary care services (medium and high complexity), specialized and high cost, very quickly extended to the management and administration of the entire SUS network, through the OSS – Social Health Organizations, OSCIP – Civil Society Organizations of Public Interest, and the so-called private partners, and soon also extended, through public instruments of private law, to legal entities that exercise privatization through clientelism, patrimonialism and political patronage, such as private law Foundations, Autonomous Social Service and EBSERH.

One of the consequences of these options is that the workforce has also been and is being mortally wounded by privatization through outsourcing, subcontracting, temporary contracts, cooperatives and contracts with legal entities, which make healthcare professionals precarious and demeaning.

It is in this extremely serious situation of virtual unviability of the SUS in its basic principles that the government launches the program called “Now we have specialists”. Yes, as we said, the lack of effective primary care, intersectoral actions, a network of specialized procedures and a multidisciplinary team with full capacity to not only meet the demand, but also to reduce its exponential growth, have produced a collapse that is affecting millions of Brazilians in all regions of the country.

The program launched “Authorizes the accreditation of private clinics and hospitals for the SUS”. The right thing to do would be for the government to start a major project to expand and structure the public network in order to gradually reduce its dependence on the private network. Since there is urgency and the population, we agree, cannot wait any longer, it is reasonable to understand the need to contract some private services as long as, at the same time, a project for the public sector is launched. The problem is that, judging by the presentation made by Alexandre Padilha, the government is not thinking about expanding, strengthening and structuring the public network. On the other hand, the absolute priority, as his statements prove, is the private network.

In a way of flattering the owners and managers of private services, Padilha proudly says that “We are beginning to bury the infamous SUS table once and for all”, without mentioning, however, overcoming the table’s commercialized logic, through financing according to the needs and socio-epidemiological profile of each referenced location. On the contrary, it deepens and worsens the commercialization of procedures and services.

3.

The program proposes to accredit “Any private clinic, any private hospital, any private outpatient clinic”. Furthermore, says Alexandre Padilha, “We are going to create a program where this reimbursement (from health plans and hospitals that have debts with the government) will be exchanged for more surgeries, more diagnostic tests, more consultations with specialists”.

“(This is) the situation of several private and philanthropic hospitals in this country that have accumulated debts, debts that have accumulated over the years, tax, social security, fiscal debts. Thanks to the partnership with the Ministry of Finance, we will create a program that is reminiscent of Prouni, which took the debt and transformed it into a place for care for those who could not pay. Now this debt will be transformed into more care for people.”

Prouni played an important role, yes, in the inclusion of a significant portion of society in higher education. However, in addition to not having been accompanied by an adequate strengthening of basic education, which continues to have the same problems, it had deleterious effects such as the recovery of private institutions that were literally bankrupt, as well as drastically increasing the number of institutions (2.274, corresponding to 87,75%) and places (23.681.916 corresponding to 95,9%) in private higher education, according to data from 2023.

FIES, in turn, currently has a debt balance of R$116 billion, a default rate of 61,5%. Everything indicates that the same will inevitably happen in the country's health system and in the SUS.

Hospitals that do not have debts will also benefit “by receiving credits that can be used to reduce taxes or other payments that they have to make in the future, that is, by opening the hospital's door to the SUS, they will have the helping hand of the Union, of the Ministry of Finance to alleviate their debt, their taxes and payments in the future”.

Alexandre Padilha concludes his argument with a flourish: “Imagine, right? People being able to go to a private hospital and receive care there through the Unified Health System without having to pay any additional amount.” A perfect speech for those who are less informed. In addition, the AC Camargo Hospital, located in São Paulo, was enthusiastically announced as the largest and main partner in the area of ​​oncology.

The brief references to basic or primary care were, let's say, merely cosmetic, and the participation of the public sector, centralized in the Conceição Hospital Group (GHC) and EBSERH, were clearly and obviously – clientelism, patronage and patrimonialism – the absolute priorities of Alexandre Padilha's administration. Furthermore, there was no mention of the specialties that, inherent to practically all other categories of health, also afflict daily and greatly, with less visibility, it is true, the population that uses the SUS.

We are moving inexorably towards the end of the dream of a universal, equitable and comprehensive SUS. This seriously ill patient will have a temporary improvement in fever and pain, but the indelible cancer of privatization and the mistaken model of care that devastates him will continue to corrode him from within and will soon return in an even more violent and merciless form.

Operating according to the logic of the market and profit, the private sector will demand more and more; they were, are and will always be insatiable, and we will reach a point where there will inevitably not be enough resources to finance the party. It is impressive how important political actors do not see the obvious!

Technically, politically and financially unfeasible, the SUS will become a system that will provide a basic food basket for the poor while specialized procedures, all provided by “private partners,” will be offered, as long as the user pays their counterpart. This is the backdrop, this is the plan. And the revisionists will finally be able to say that they succeeded, that they defeated us, that they defeated the SUS and the Health Reform.

*Francisco Batista Júnior He is a hospital pharmacist at SUS in Rio Grande do Norte. Former president of the National Health Council (2006-2011).

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