By FRANCISCO BATISTA JÚNIOR*
The solutions to be presented for the SUS, rather than representing a surrender to private and market logic, should mean exactly the opposite.
In this third and final part of this article, I analyze the conflicts arising from what the Health Reform movement historically proposed, comparing what was proposed with the current reality of SUS management and the legal alternatives compatible with the Health Reform, to put SUS back on the path from which it should not have deviated.
Health reform and SUS management
The SUS is facing its most difficult moment in its relatively short history. It is definitely in check, and the difficulties highlighted, which are real, are the result of this entire process of conceptual, legal and political deconstruction. The aforementioned permanent crisis in federal hospitals in Rio de Janeiro, which I analyzed in second part of this article, now at an acute moment, is a classic example of what we have discussed so far.
It is essential to state that no form of management in the SUS will yield the results we expect and need if, in the short term, we do not confront the current care model, which inexorably feeds the demand for specialized and high-cost procedures, and if we do not strengthen the state SUS network, in order to greatly reduce dependence on the contracted private sector, vital axes where corporations and organized economic groups feed and strengthen each other.
We also need to reduce precariousness and value the workforce, as well as increase funding for the SUS by changing its current logic, replacing the mistaken payment for verticalized programs and procedures with the establishment of goals to be established according to the reality and needs of each location.
On the other hand, defending OS, OSCIP, “state” foundation, Autonomous Social Service and EBSERH by stating that “health is not a typical State activity and that it only needs inspection, regulation and control, that the private sector is complementary and that with market salaries it will co-opt certain professionals”, is a violation of the principles of the Health Reform and a lack of knowledge of the legislation (Art.197 of the Federal Constitution) and the reality of the SUS, which we cannot conceive of in a serious debate where the objective is to strengthen the System.
Furthermore, the aggressive stance of the proposal's defenders, revisionists who identify themselves as progressive and historical supporters of the Health Reform, while at the same time accusing those who oppose it of being "corporatists, of having no proposals and of colluding with the distortions" which, it must be said, are real and we denounce them, if it is not bad faith, only reveals the deliberate lack of debates with the contradictory and hides a blunt and enlightening fact: these proposals do indeed unify all the conservative anti-SUS sectors in our country, but they clearly divide all the Health Reform activists who, if they had been heard, would have presented alternatives such as the ones below.
About autonomy and “stiffness”
In view of the fragile argument that the “state” foundation modality and similar ones promote autonomy and managerial and administrative flexibility to properly manage public health services, in the face of a “heavy”, “bureaucratic” and “rigid” state, we cite our Constitution that leaves no doubt on the subject, simply regulating it without the need for the creation or intermediation of any other legal instrument.
Federal Constitution, art. 37, Clause XXI, § 8
“The managerial, budgetary and financial autonomy of direct and indirect administration bodies and entities may be expanded by means of a contract, to be signed between their administrators and the public authorities, which aims to set performance targets for the body or entity, with the law being responsible for providing for:
I – the duration of the contract;
II – controls and criteria for evaluating performance, rights, obligations and responsibilities of managers;
III – staff remuneration.
“Those who have the motivation to hire must have the motivation to fire”
Faced with the conservative, recurrent and unsustainable argument that “healthcare worker stability is a bad thing and benefits those who do not want to work” and that “healthcare workers should receive the same treatment as workers in the state-owned financial system or petrochemical sector” (as stated in the document released by the federal government at the time of the debate on “state” Foundations, in the first decade of the 21st century), who, it must be said emphatically, deserve all our respect, we find it strange and regretful the demeaning, disqualified and opportunistic comparison with those who work with the lives of their fellow man and who need job stability to fully guarantee their professional practice and the effective and emotional bond, including professional-service-client.
We also regret that the real political, physiological and corporate interests of the current majority management logic are not addressed, which make the system unviable and which, in addition to not being addressed, are also strengthened by the “state” foundation and similar institutions, which establish, among other things, the hiring and firing of workers according to, let us try to understand, the “needs of each service”. To counter this, we once again resort to the current legislation, the Single Legal Regime, which for any good connoisseur is clear, crystal clear and irrefutable and which, as we know very well, only needs to be complied with.
Single legal regime – Law 8.112, art. 127
“Disciplinary penalties are: warning; suspension; dismissal; revocation of retirement or availability; dismissal from a commissioned position; dismissal from a commissioned function”.
Art. 132. Dismissal shall be applied in the following cases: “crime against public administration; abandonment of office; habitual absenteeism; administrative impropriety; public incontinence and scandalous conduct in the department; serious insubordination in service; physical offense, in service, to a civil servant or a private individual, except in self-defense or that of another person; irregular application of public funds; disclosure of a secret appropriated by reason of office; damage to the public coffers and squandering of personal assets; corruption; illegal accumulation of public offices, jobs or functions; violation of items IX and XVI of art. 117”.
Thus, and to give an idea of the period in which they defended the creation of state foundations and created EBSERH, in strict compliance with current legislation, between 2003 and October 2010, the Federal Government dismissed 2.500 civil servants. 1.471 were dismissed for improper use of their positions, 817 for administrative impropriety and 257 for receiving bribes. 177 had their retirements revoked and 223 were removed from positions of trust.
In addition, 243 were dismissed for negligence, which are minor offenses aggravated by repetition, and 406 for abandonment of office. These punishments affected directors, superintendents, auditors and inspectors of the Federal Revenue, Social Security and Labor Departments, prosecutors and undersecretaries of budget and administration (figures and data released by the government itself, in the aforementioned period).
Therefore, to claim that stability is an evil in itself, which allows workers to not fulfill their role and benefit from it, is a fallacy; it means denying the responsibility that falls to incompetent and uncommitted managers and violating a right that should be considered sacred to public service workers in fundamental areas, namely non-vulnerability to governments that use the exercise of power in violation of the constitutional principles of morality, legality and impartiality.
Likewise, we argue that this process should be improved with the inclusion of other relevant elements, such as periodic assessment.
Commercialization of the state foundation modality and similar institutions versus professionalization of SUS management
The current form of organization, structuring and functioning of the SUS, including a clear policy of devaluation and discouragement of professionals' salaries, in addition to the patrimonialist logic imposed by political groups and organized corporations, has often promoted inefficient and non-resolute management and an effective and deadly, when it comes to health work, commercialization in labor relations.
We strongly reiterate that this logic will not be reversed without strengthening the state public sector with a view to overcoming the practice of establishing financial ceilings and payments for procedures and without prioritizing prevention carried out by the multidisciplinary health team, with the aim of halting the geometric increase in demand for specialized and high-cost procedures.
It is essential for us at this emergency moment to not advance any proposal that could institutionalize, officialize and make this irrational and unsustainable process of commodification a path of no return, which proposes the benefit of a few to the detriment of the vast majority of professionals, as is the case with the “state” foundation, the Autonomous Social Service, the “Private Partners” and the Brazilian Hospital Services Company (EBSERH). In this sense, we defend once again that the current legislation, fully in tune with the principles of the Health Reform, can be effectively and definitively implemented.
It is therefore necessary, with this objective:
(a) Professionalize and democratize the management and administration of SUS network services, through the regulation of section V of Art. 37 of the Federal Constitution, which establishes that “the positions of trust, exercised exclusively by civil servants holding effective positions, and the positions in commission, to be filled by career civil servants in the cases, conditions and minimum percentages provided for by law, are intended only for the duties of management, leadership and advisory services”.
Furthermore, a legal instrument that defines technical and training criteria must be established and followed as a reference for filling management and executive commission positions, taking into account the premises of being a member of the SUS and Service staff, with adequate technical training, time of professional activity and worker participation/manifestation.
The proposal is to make the management of the SUS and the management of its Network services immune to political, clientelist and physiologist indications, prioritizing and valuing technical criteria and implementing professionalized and democratized management.
(b) Create and implement a broad National Program for Restructuring and Strengthening the State Public Network (ReestruturaSUS), in the three spheres of government and inter-institutional relations, with a view to enabling permanent intersectoral action, with emphasis on aspects related to employment, income and its distribution, combating violence at all levels, traffic education, sustainable development, environmental preservation and a proposal for access to public education at all levels that is radically qualified and democratized;
(c) Access to public service through a public competition with job stability and ongoing assessment, which is essential to counter the process of disengagement, disconnection and auction of professional remuneration, as a way of building a relationship that has as its fundamental axis the professional-service-client bond;
(d) Create a Single, National, Tripartite, Multiprofessional and Interfederative Career for all SUS workers, in accordance with the National Guidelines for the SUS Career, Position and Salary Plan (PCCS), agreed upon by the Tripartite Intermanagerial Commission and constructed in compliance with a process of voluntary adherence by the federated entities. Unlike the proposal for a PCCS by service, incorporated into the “state” foundation and similar institutions that devalue, discourage, disrespect and disqualify professionals with the logic of “market salaries”, based on the privilege of a few in some services to the detriment of the great mass of workers, we defend national minimum wages by level of education, incentives for exclusive dedication, internalization, length of service and qualification, as well as compliance with specific situations that are currently demanded based on the established reality.
These constitute measures to be implemented with the aim of creating and implementing a single SUS career as a State career, with a municipal base and duly agreed upon between the three spheres of government.
Those who work with the lives of their fellow man cannot and should not be subjected to “market logic”, which when it comes to health and people’s lives, is an absolutely anachronistic concept and incompatible with the Health Reform and with the principles of ethics and humanism.
(e) Define the tripartite responsibility for hiring and remunerating the SUS workforce, based on the diagnosis of the need for a multidisciplinary team, the regionalization and hierarchization of the network throughout the country, and public competitions within the scope of each federated entity with consequent insertion in the Single Career of the SUS; and,
(f) Create and implement training, qualification and career development prospects, through continuing education projects in health, with the participation of federative entities from the three spheres of government, and expand the number of multi-professional residency programs throughout the country, in accordance with the following legal provisions:
Art. 37, § 2 of the Federal Constitution
“The Union, the States and the Federal District will maintain government schools for the training and improvement of public servants, with participation in the courses being one of the requirements for career promotion, and for this purpose, agreements or contracts between the federated entities may be entered into”.
Art. 37, § 5 of the Federal Constitution
Laws of the Union, states, Federal District and Municipalities may establish the relationship between the highest and lowest remuneration of public servants, in any case complying with the provisions of art. 37, Clause XI.
Art. 27, Clause I of Law 8.080/90
“Organization of a human resources training system at all levels of education, including postgraduate studies, in addition to the development of ongoing personnel development programs.”
Art. 27, Clause IV of Law 8.080/90
“Valuing exclusive dedication to the services of the Unified Health System.”
Curricular restructuring and deprivatization of university and technical courses in the health area in order to align professional training with the reality of the country, with the SUS and its needs, as well as establishing the Civil Service in Health in the public network of the SUS for all graduated professionals, for a period of one year and Multiprofessional Residency as instruments of qualification, persuasion, improvement, visibility and affirmation of multiprofessional work and meeting the system's needs in the area of Work Management.
System Management and Service Management radically democratized, with the establishment of professionalization processes, Management Councils and other spaces for contribution and elaboration, which enable the end of political-partisan interference, patronage and nepotism, with the effective participation of workers and users in decisions concerning the functioning of SUS network services;
Claim the unconstitutionality (Art. 196 of the Federal Constitution) or modify the Fiscal Responsibility Law for the health sector, so as to enable managers to hire the professionals necessary to make the system viable, combating and eliminating precariousness in labor relations, and prioritizing the process of regionalization and hierarchization of services. At this time and in the opposite direction, PLP 98/23 is being processed in the National Congress, which proposes to leave the expenses of outsourced labor outside the limits imposed by the Fiscal Responsibility Law.
Some people might say, and we have already heard from some supporters of clientelist/patrimonialist/privatist institutions, that all of this will take a long time and that we need immediate action. If the SUS has heroically survived so many attacks, a little more time waiting and resisting other harsh attacks will not make it unviable. On the other hand, several of the proposals we have presented here can be implemented immediately and are exclusively dependent on political decisions. Some of them already have bills under consideration in the National Congress.
The solutions to be presented for the SUS, therefore, rather than representing a surrender to private and market logic, must mean exactly the opposite, the confrontation of this logic with the consequent affirmation of the precepts of a strong state that responds to the demands of its population in the social area.
We understand that with political decision, social control, effective practice of participatory democracy and compliance with current legislation duly improved when applicable, without the creation of any other legal instrument, we have effective conditions for the definitive implementation of the SUS in a way that is fully in tune with the principles of Health Reform in Brazil.
*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/
To read the second part of this series click on https://dpp.cce.myftpupload.com/gestao-do-sus-o-que-fazer-ii/
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