By PAULO CAPEL NARVAI*
If hospitals in RJ remain federalized, then why not provide the same treatment to other SUS hospitals, outpatient clinics and health units throughout the country?
Democratic dialogue, said Jürgen Habermas, involves accepting the other person's truth, whatever it may be, even if one disagrees with it. What others declare about themselves and what they think cannot be distorted, falsified, or altered. This means that if your interlocutor says they are from Vasco, this needs to be accepted, whether you like it or not.
It’s not worth attributing to him the status of Flamengo fan and continuing to dialogue based on arguments like “well, since you’re Flamengo fan…”. It's not worth it. It is not democratic. It's not exactly dialogue. Doing so says more about you than your interlocutor.
I mention the German philosopher and sociologist, illustrious member of the Frankfurt School, who contributed so much to the development of critical theory, just to defend myself against what seems to me a manifestation of this falsification of the position of the other.
I published it on the website the earth is round two articles (“Federal hospitals in Rio de Janeiro – dust under the carpet?"and "Federal hospitals in Rio de Janeiro”) on the crisis in Rio’s hospitals. In the first, on 22/3/2024, I wrote in all letters that the main problem with federal hospitals in Rio de Janeiro is that they are still federal hospitals in Rio de Janeiro. In the second article, dated 11/7/2024, I wrote that the decentralization of federal hospitals in Rio de Janeiro should not be fought or welcomed, it is a necessity.
A few days after publication, the “Unified Movement in Defense of the Federal Network/MS” released a note entitled “Privatizing the SUS is bad for health!”, with a subtitle “Response to Professor Paulo Capel’s article”. The content of the document surprised me. I hoped to find arguments and proposals to overcome the crisis which, after all, is what matters – not responding to me. But I found nothing with this perspective. However, I was surprised by some of the changes in what I wrote and, above all, the attempt to place myself alongside the mentors behind the privatization of SUS hospitals in the city, something that, evidently, I reject outright. Nothing I have been doing or writing for at least four decades authorizes this distortion of what I think.
After stating that “we appreciate the criticism”, the note states that “we partially agree”, as “it is true that decentralization is part of the original SUS project, but it is necessary to consider the profound transformations that the system has undergone since then”.
It’s not that decentralization is “part of it”. She was part of it.
Currently, it is no longer a project. A decentralization It is a legal imperative, as it is included in the Constitution of the Republic, in art.198, which states that “public health actions and services are part of a regionalized and hierarchical network and constitute a single system”. When defining this network, the 1988 Federal Constitution states that it has three guidelines, one of which (article 198, paragraph I) is “decentralization, with a single direction in each sphere of government”. This is not, therefore, just the “original SUS project”, nor my opinion, but the text of the Magna Carta, to which all infra-constitutional legislation is subordinated.
It is correct that the SUS, as wrote Flávio Goulart, and Gilson Carvalho liked to say, “it is a health system carved out of ordinances”, so many ordinances have regulated it. Therefore, I am not unaware of “the profound transformations that the system has undergone since then”. My point, in this episode, is that despite so many changes, the institutional situation of SUS hospitals in Rio de Janeiro still remains in the historical period before the 1988 Constitution, whose norms continue to be violated. It is time, therefore, to overcome this delay and promote the changes required by law, as per the timely initiative of Health Minister Nísia Trindade.
The note contains conclusions, such as stating that the GM/MS Ordinance No. 4.847, of July 5, 2024, which “establishes the decentralization of services from the Hospital do Andaraí, a federal public body, to the Municipal Government of Rio de Janeiro” (PMRJ), ensuring the Hospital Federal do Andaraí (HFA) resources and personnel to that actions and services are not interrupted and provides that the management of the HFA is shared by the Union and the Municipal Government of Rio de Janeiro, for 90 days, extendable if necessary, until administrative normalization, “involves electoral interests” and “completely ignores the SUS principles of universality, completeness and equity”.
It is certainly possible to counter-argue in defense of maintaining the status quo, reducing Rio's complex institutional process to supposed “electoral interests” and using the principles of the SUS that are challenging us across the country, as elements to convince readers. But, in my opinion, the circumstances in which the problem of SUS hospitals in Rio de Janeiro became more acute are not the result of the electoral agenda, although such connections are considered.
Against this interpretation, it should be noted that the federal government's initiative comes after more than three decades of postponing decisions that should have been taken, as they were in all other Brazilian capitals, in the early 1990s, after the sanctions of laws 8.080 and 8.142, which regulate the functioning of the SUS throughout Brazil. One can, of course, consider a connection between the Ordinance and the elections. You can, but, knowing the history of this long process, you shouldn't. Hence brandishing “Fora Nísia”, and promoting the symbolic burial of Lula’s minister in a public event, goes a huge distance.
The statement that “our fight is precisely for the preservation of the pillars of the system, as approved in 1988 and regulated in 1990” is not just a misinterpretation of the principles and guidelines of the SUS, but a gross alteration of what they mean, from any perspective .
The statement that “the professor himself recognizes that the natural consequence of the municipalization of Andaraí will be the privatization of the hospital by the current mayor” is a distortion of what I stated and which, obviously, I reject. “Natural” is a term that I did not use in my article, which has four sections, 33 paragraphs and 2.762 words, for an elementary reason: nothing in this process is natural. Everything about it is social and political.
What I said and repeat is that “the bad thing about this scenario of propositional emptiness is that its main consequence ends up being the strengthening of theses that advocate solutions that aim to privatize hospitals. For this reason, it is crucial, urgent, to create alternatives considering that nothing is given, that it is possible to fight and win, blocking the privatization of the SUS in Rio de Janeiro”.
In other words, I said exactly the opposite of what was attributed to me, highlighting the imperative need to create alternatives to privatization and reiterating that sticking to the single alternative of “federalizing or federalizing” does help those who have a plan to privatize the SUS in the city. However, instead of creating the politically required alternatives, the movement preferred to misrepresent my position on the case. It's the old tactic of breaking the thermometer instead of facing the fever.
Regarding the harm that privatization imposes on universal health systems, such as the SUS in Brazil and the NHS in England, to name just two well-known examples, I agree with the movement. But I also reject this argument to justify the status quo. And I fully agree that, as far as I am informed, the conduct of the process “violated the principles of the SUS (…), as the ordinance that created the working group to study the situation of federal hospitals did not respect the obligation to involve health workers”.
Unfortunately, the law does not determine this alleged obligation, but the principle of participatory management, which I advocate, does. The federal government failed in this, although there was no impediment to the representation of SUS employees formally forwarding their proposals to overcome the crisis to the Ministry of Health.
It is clear, however, that if all that was proposed to the body is what has been announced, to “federalize or federalize”, then having participated would not help much, as in addition to having a voice, you also need to have something to propose. From what I have read, and from information I have received from colleagues in Rio de Janeiro, the movement continues to face enormous difficulties in moving forward purposefully, in the direction of what SUS workers want, in Rio de Janeiro and throughout the country. There are simply no proposals to put on the negotiating table.
With the statement that “we cannot look at the history of the SUS in a simplistic way, ignoring the profound transformations that the system has been going through”, the movement insinuates that the considerations I presented in the two articles I referred to would be simplistic. Could it be. But I leave that judgment to the readers.
I disagree with the accusatory tone coming from the movement, as I think the opposite: to me, what seems too simplistic are the arguments used to try to justify an illegality that seeks, for Rio de Janeiro, privileged treatment in relation to other capitals. and Brazilian municipalities. If hospitals in Rio de Janeiro remain federalized, then why not provide the same treatment to other SUS hospitals, outpatient clinics and health units throughout the country?
But members of the movement accuse me of promoting “a deception” by saying that “the federal government cannot manage federal hospitals”. I reiterate: the federal government does not have to manage SUS hospitals. It's not up to you. This is not what the Federal Constitution establishes. This is not what laws 8.080 and 8.142 determine. When asking “who are the managers of the National Cancer Institute and Fiocruz hospitals, like Fernandes Figueira?” the movement reveals its difficulty in distinguishing what are SUS hospitals, whose mission is to provide hospital care for the population, according to the status of each institution, and what are research hospitals and teaching hospitals. Yes, they are all hospitals. But they are units with different missions and characteristics.
Ignoring this elementary distinction between the different types of hospitals, according to their institutional purposes, leads to errors, such as those that are being made, and which cannot be resolved with reiterations of commitments, as stated in the note that “the fight is for defense of the original SUS project, not the creation of two antagonistic groups. We know which side we are on: in defense of the universal and equitable public health system.”
These reiterations, although important and necessary, do not hide the absence of propositions that contribute to overcoming the crisis. But, above all, they do not serve to oppose the considerations I made, as I am also in the “fight in defense of the original SUS project” and I know which side I am on: in defense of the SUS, as a health system, state, public , producer of comprehensive health care, with universal and equal access to actions and services for its promotion, protection and recovery, decentralized, regionalized, and with community participation.
It is useless, therefore, to try to place myself on another side. And I reiterate: the answer should not be to me, but to the federal government.
*Paulo Capel Narvai is senior professor of Public Health at USP. Author, among other books, of SUS: a revolutionary reform (authentic). [https://amzn.to/46jNCjR]
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