By FRANCISCO BATISTA JÚNIOR*
The forms of organization that have been proposed for the SUS, such as system management methods and the case of federal hospitals in Rio de Janeiro
In Part 1 of this series, I addressed aspects related to the care model and financing of our universal health system, as well as public-private relations in health and labor relations in the SUS. In Part 2, I analyze the forms of organization that have been proposed for the SUS, as modalities of system management, namely: the “state” foundation under private law, the autonomous social service and the public company, such as the Brazilian Hospital Services Company (EBSERH). I conclude this Part 2 with considerations on the case of federal hospitals in the city of Rio de Janeiro.
Private law “state” foundation, autonomous social service or EBSERH at the MEC
The proposals for a “state” foundation, Autonomous Social Service and EBSERH are very courageous, to say the least, when we recall the disastrous history of cronyism, political-partisan use and corruption that characterize similar tools in Brazil, including the current ones, as shown by frequent media coverage. Furthermore, they have a serious problem in their origin: they were conceived behind closed doors, without the two main stakeholders – users of the system and workers – being heard at any time.
In 2007, the National Health Council had to address the issue of Foundations so that it could be heard by the government. In a flagrant disrespect, the government sent the Bill (PL) to the National Congress despite the opposing position of the highest collegiate body of the SUS Social Control and the Health Conferences.
Even though the bill had been suspended due to the widespread national mobilization against the proposal, initiated by the National Health Council, on the last day of its term, the Lula government, in another deeply unfortunate moment, created, linked to the Ministry of Education and through a Provisional Measure, a worsened state foundation under private law, under the name of Empresa Brasileira de Serviços Hospitalares (EBSERH) and, surprisingly, as a corporation. What draws our attention in these political processes is the authoritarian method practiced by the government in such vital areas and with an important history of popular participation and collective construction.
Without going into the legal merits of the proposal, which has been widely contested, the defenders of private law state foundations, the Autonomous Social Service and EBSERH state that “only activities that are specific or typical of the State require certain protections, such as stability, which protects the public servant from influences that prevent him from exercising his public functions. The exercise of activities that the private sector also undertakes, which often even complement public services, as is the case with health, do not require the same protection as supervision, regulation and control” (text published by the Government at the time of the Foundations Bill).
The same actors argue that the foundation, the Autonomous Social Service and EBSERH should have full autonomy and tax exemption, should not be subject to the limits on personnel expenses imposed by the Fiscal Responsibility Law, and should not be subject to the salary cap. A “cocktail” of good promises – some not so good – without, in the opinion of renowned jurists, first agreeing with the constitutional text. Therefore, they would have every possibility of “co-opting” certain professionals in accordance with market salaries.
They wrote the following: “the concept of professional positions, remunerated based on market values, grants greater managerial effectiveness and efficiency to these organizations, in addition to the possibility of co-opting and maintaining qualified professional staff.” Regarding this, we state: poor is a health system that proposes to “co-opt” professionals, using the market as a reference and not a broader process of valorization and consequent persuasion!
At a time when they certainly make the most liberal thinker about labor relations in the public sector envious, they are implementing Job and Salary Plans with a distinction in remuneration and treatment between professional categories with the same level of training, in a gesture so bold that not even the heralds of neoliberalism had enough courage to verbalize it, much less implement it.
They state emphatically that the “rigid and bureaucratic” public/state management model is dead. We ask: which management model are they referring to? If it is the majority and predominant model over which we have no influence or participation and which goes against the principles of the SUS, is based on patronage, the exchange of political favors, and the filling of positions based on personal, corporate, and political interests, to the detriment of competence, professionalism, and committed relationships, we agree. In fact, we have always been against it and denounced it, since it directly violates the SUS rules. After all, this is not the model that the SUS advocates.
Finally, they get angry when we reiterate that the private law foundation, the Autonomous Social Service and EBSERH are privatization processes. They say that “they are state institutions, public and controlled by the government”, as if privatization could be summed up in the classic concept of selling a public company on the formal market.
Given the legal impossibility of classic privatization, in healthcare it has historically occurred in a more elaborate and perverse manner. The assets continue to be public, but their administration and literally, their exploitation, both economically and politically, is carried out by organized groups that manage them according to their interests and to meet their political, personal and group demands. It is for this purpose that foundations and, as we say, similar institutions have been established in Brazil.
It should be noted that even public law foundations, as well as, to be honest, basically the entire structure of public services in Brazil, regardless of whether they are foundations or not, are, to a greater or lesser extent, privatized in this way. This is the modus operandi Brazilian patrimonialist who is at the root of our social, economic and political miseries.
The issue under debate regarding private law state foundations and similar entities is that in these – unlike public law foundations –, without complying with the dictates conceived in the concepts of the Health Reform and having all the autonomy that is outlined, the process of political plundering of public assets becomes more extensive, uncontrollable and harmful to the interests of the population and the country. Our experience leaves no room for doubt about this and this has indeed been, in our past history, the most vile and dishonest form of privatization of the Brazilian State.
Clientelist appointments and political nominations are maintained, deepened and strengthened, differentiated salaries for the privileged are guaranteed, and patrimonialist interests are fully met by “autonomous and differentiated” management outside of social control.
The proposal for a private law state foundation and similar projects is actually so discredited that even states that created it through laws either did not implement it or implemented it and saw their problems worsen or simply joined the Social Organizations, as is the case of Rio de Janeiro and Pernambuco and, to our greatest surprise, Bahia, which, among other excrescences, was the first Brazilian state to adopt the infamous “public-private partnerships” in healthcare. This is because their defenders advocated the aforementioned “state foundations” as an alternative to the Social Organizations, which until then were considered illegal and “deconstructive” of the SUS.
For now, the Autonomous Social Services have found fertile ground in Minas Gerais, where they have contributed nothing to resolving health issues. The EBSERH, with a billion-dollar budget, implemented in practically all states of the federation with the promise of solving all the problems of the University Hospitals, not only has not solved them but has created much worse ones, such as privileges for ruling castes and moral harassment against workers as a rule. The structural problems remain.
The truth is that, created and implemented by political actors who claim to identify with the left, with the defense of the Unified Health System (SUS) and with the Health Reform, the Private Law State Foundations, the Autonomous Social Services and the EBSERH constitute the ideological option for the creation of true political apparatuses and devices where they wallow in clientelism, patrimonialism and the occupation of the State by groups that exercise political negotiations to the fullest while at the same time enriching themselves with their privileges and super salaries, the most perverse privatization there is. And this is, let us remember, everything we want to eradicate from the State and the Brazilian public administration, never to strengthen.
The Brazilian State, and the SUS in particular, are therefore victims of their worst enemies, actors disguised as defenders of the project presented by the Health Reform, true revisionists who have long since abandoned the principles of the transformations advocated by it – the health reform – and have fallen into the arms of the historical and previous Brazilian culture based on clientelism, patronage, patrimonialism and the assault on the structures and institutions of Power in the country. Dazzled by this (temporary) Power, they exercise authoritarianism and brutality in full, see no problem in the fact that health is a market product and are against the Single Legal Regime and the stability of SUS employees. After all, these are things that, if they do not make their Power project unfeasible, make it very difficult.
Unquestionable conclusion: where the SUS was attacked and victimized by Social Organizations, OSCIP, “State” Foundations of Private Law, Autonomous Social Services, EBSERH, “Private Partners” and the like, in addition to not resolving any challenge that was placed in the management, they deepened the problems that existed and created new ones in a process that has increasingly suffocated our System and penalized the population and the State.
The Rio de Janeiro case – the hot topic
Once again, the Federal Hospitals of Rio de Janeiro are under fire, accused of a wide range of irregularities, ranging from legal issues to what is conventionally called incompetence and inability to serve the population. Providers of specialized, high-cost services and historically performing excellent work of immeasurable importance to the state and the country, the federal hospitals of Rio de Janeiro have been exemplary victims of the dictatorship of political groups that exploit their management as a form of clientelism and political cronyism.
Allegations of corruption and inefficiency are made without ever putting a finger on the wound, and this time the situation has become unsustainable. Divided up by politicians from the Lula government's base, the hospitals are suffering under the baton of people who, rather than working to strengthen them, act primarily by "operating" to serve the interests of the groups and political collusions that appoint them.
It was not difficult to imagine what would happen when the latest crisis finally broke out. We knew that this was the opportunity that the dazzled revisionists were waiting for to deploy, also in Rio de Janeiro and at the federal level, their political apparatus ready for negotiations for Power. Handing over one to the city of Rio de Janeiro, where it will inevitably be negotiated with a Social Organization; another to the Oswaldo Cruz Foundation; another to the Conceição Hospital Group of Rio Grande do Sul; yet another to EBSERH; and the possibility of transferring another to a “public-private partnership”. Without any debate with social control, with workers, academia or social movements, this reveals how determined the revisionists are in their uncontrolled and insane saga of deconstructing the SUS.
It is striking how, when it comes to managing and administering the SUS network, they cannot see anything other than handing over this task to an intermediary who can be used as a political apparatus to be manipulated according to the forces involved in the process. It is striking how they put the real interests of the population and the Unified Health System itself in the background, historically victims of these interests and the permanent dispute for power.
The process of municipalization in any form and at any cost without complying with minimum criteria that guarantee the basic principles of the SUS in its management and workforce is absolutely unacceptable. The management of the services of the SUS network urgently needs to be freed from the interests of political groups that perpetuate themselves in power at the expense of the exploitation of its institutions and the collusion that disputes their shares. Professionalized, democratized, with an adequate workforce and with administrative and financial autonomy, the federal hospitals of Rio de Janeiro, as well as all the SUS services in the country, can perfectly provide the response that the population needs, free from the oppression practiced by the physiologists and patrimonialists on duty.
What is being proposed to be done with the federal hospitals in Rio de Janeiro is to remove them from one form of oppression, the tutelage of politicians and organized groups, and subject them to another, more organized form of oppression with the same essence, this time through privileged political apparatuses. The alternative proposals, direct contracting with administrative and financial autonomy and professionalization of management, will be listed in the third part of this series.
*Francisco Batista Júnior He is a hospital pharmacist at SUS in Rio Grande do Norte. Former president of the National Health Council (2006-2011).
To read the first part of this series click on https://dpp.cce.myftpupload.com/gestao-do-sus-o-que-fazer/
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