By FRANCISCO BATISTA JÚNIOR*
The care model and financing of our universal health system, public-private relations in health, and labor relations in the SUS
Even taking into account the historic achievement that the Unified Health System (SUS) represents in our country, we must be very clear about the enormous difficulties that its implementation entails given our history of treating the State with relationships of physiologism, clientelism, patrimonialism, division and privatization by organized groups and corporations, as well as insufficient and mistaken financing and a distorted care model.
Thus, if on the one hand we have a system with significant advances and which has been of immeasurable importance for the entire Brazilian population, on the other hand there are still bottlenecks that are products of our entire culture and which require correct treatment in tune with the principles of the Health Reform.
In this article, divided into three parts, I discuss strategic aspects of SUS management, based on analyses and reflections that I have shared with SUS health professionals in union forums and policy-making forums, such as conferences and health councils, held in different regions of Brazil. In Part 1, I address the care model and financing of our universal health system, public-private relations in health, and labor relations in the SUS. Part 2 will cover topics related to the forms of organization that have been proposed for the SUS, such as the “state” foundation under private law, the autonomous social service, and the public company, such as the Brazilian Hospital Services Company (EBSERH). In this part, I will also analyze the case of federal hospitals in Rio de Janeiro. I conclude the article by analyzing, in Part 3, the conflicts arising from what the Health Reform movement historically proposed, the current reality of SUS management and the legal alternatives compatible with Health Reform, to put SUS back on the path from which it should not have been diverted.
Part 1 follows.
Care and financing model
Our current practice has been to treat the disease to the detriment of actions that enable the effective promotion of health. When we analyze the SUS, in its 34 years, after its regulation by laws 8.080 and 8.142, we realize that despite important and specific advances of relevance and impact in the socio-epidemiological context, we continue to be stuck with a logic focused on medicines, hospital beds, medicocentric and, more recently, on high-cost exams.
The lack of commitment to effective and aggressive health promotion practices, including ongoing and coordinated intersectoral actions, has meant maintaining a situation typical of impoverished countries with a high incidence of diseases that have long since ceased to be part of the civilized world, of which dengue fever, tuberculosis and others are classic examples. At the same time, this has also generated an ever-increasing demand for increasingly specialized treatments at increasingly higher costs, putting at risk not only the financing capacity, but the system itself as a whole.
We do not have programs that enable early diagnosis and rational and comprehensive monitoring of diabetes, hypertension, ophthalmology, mental health, pharmaceutical assistance, oncology, oral health and others and we are forced, as a result, to bear the inhumane and unsustainable costs of hemodialysis, surgical procedures, transplants, poisoning and cancer, just to name a few.
As a result, it is also essential to change the overall financing method of the system, overcoming the counterproductive verticalized logic and payments for procedures – which encourages commercialization and corruption – where the table of procedures is the greatest symbol, and defining the budget proposal according to the needs of each referenced location, agreeing on goals to be achieved and defining the corresponding and permanent monitoring and evaluation processes.
To this end, the elimination of the infamous parliamentary amendments, a powerful instrument of coercion, co-optation and electoral political clientelism never in tune with the Health Plans and the real and immediate needs of the System and the population, is absolutely fundamental.
Therefore, an aggressive policy of disease prevention and health promotion, of intersectoral actions that encompass the areas of security, transportation, education, employment and income and violence in its most varied forms are fundamental, aiming at the construction of a new health model that is coherent and in tune with the conceptual dictates of our System.
Concomitantly and in parallel, the structuring of Primary Care in all municipalities in the country with a fully valued multidisciplinary team, reference services to meet the demand for specialized actions and a regionalized and hierarchical public network will provide the necessary conditions to achieve the desired universality, comprehensiveness and resolution.
Public/private and primary vs. complementary relationship
The Brazilian government has always had the recurring practice of providing healthcare services to clients by contracting third parties, rather than structuring its own service network. This process, which makes healthcare one of the country's largest economic businesses and generates billions of reais annually, was greatly intensified during the implementation of the SUS. This was due either to the financing logic established through payment for purchased procedures making this option politically more profitable and faster, or because the administrator maintained some direct relationship with private sector service providers, a situation that we know is quite common in the System.
As the Public Power dismantled its specialized services, created at the beginning of the SUS, replacing them with contracted private services, it produced the breeding ground and the necessary conditions for the establishment and development of supplementary health, which has grown at levels well above the general growth of the country, also benefiting from the increase in population.
At the same time, and in a process of self-flagellation, the SUS encourages and drains its resources and specialist professionals to this same private sector that leverages itself at its expense, whether directly through its financing or indirectly through the encouragement of the structuring of services and tax immunity or exemption.
These specialized workers then began to have access to a much wider and more varied range of options for their professional practice and to have another work routine based on differentiated, individualized, commercialized remuneration and per procedure performed, and no longer on work activity in shifts with predetermined working hours and shifts.
For this reason, these professionals have ignored, and if the current logic continues, they will continue to ignore, the SUS, which they will use exclusively as an instrument for professional development and affirmation and for quick financial returns. For this reason, they have left the SUS and the Brazilian population hostage, refusing in many cases to provide services in a formal manner and in accordance with the rules established for the System's workforce.
Professionals who should be trained to serve the population choose to serve themselves. They prefer to organize themselves through labor intermediation instruments or as legal entities, so that they can earn very different remuneration, often above market values. It is a market that the SUS itself promotes, stimulates and feeds.
In this way, dramatically, the SUS directly feeds the shortage of certain professionals in its own network, while it is willing to finance the remuneration of these same professionals in a very different way through the services they provide in the contracted and agreed private network.
This political/economic/ideological option made the Brazilian population dependent and in many cases completely hostage to the private/contracted sector, mainly in reference and specialized services.
In practice, this means that the manager accepts a service provision that has as a rule the establishment of a limit of procedures to be made available by the provider, which in turn is directly related to the increasingly limited capacity for public financing. In a market logic, therefore of an endless debate of values to be practiced and honored by the public entity, and of underfunding that is the rule, the population is subjected to a practically uninterrupted crisis, translated into the non-fulfillment of the increasingly repressed demand (due to the perverse combination of the lack of prevention with the established financial limits and ceilings) and the constant interruptions in services, motivated by the dispute over values and power.
Therefore, it is our duty and right to state that the growth of the private health sector beyond the limits of complementarity established by the Federal Constitution is incompatible with the full affirmation and consolidation of the SUS. It is impossible to have certain professionals at the disposal of the System since they will always prefer the most comfortable and commercialized relationship with the private sector, and we will never have enough budget to finance the purchase of services in the unsustainable logic of the market.
Work relationships
With the process of municipalization that began in the 90s, the states of the Federation and the Federal Government adopted a policy of absolute disregard for the hiring and valorization of workers for the SUS network. At the same time, the “Productive Restructuring” encouraged precarious employment relationships through low wages, the multiplication of bonuses, and the cult of commercialization and multiple activism, that is, working in several places and institutions, generating professional disconnection from the service.
Municipalities were overwhelmed with the task of hiring workers and were consequently subjected to unsustainable situations. With financial limitations and the prevailing logic at the federal level, they began to establish completely precarious employment relationships such as temporary contracts, cooperatives, code 7, outsourced workers, legal entities and others.
As a result of the established process of commodification, managers began to establish differentiated remuneration for workers in general, in a process that promoted discouragement and a lack of quite reasonable commitment from a considerable part of the professional body.
Still in line with the established commercialization and the growing demand for specialization, municipalities were either forced or simply began to submit to the demands of strongly organized corporations, mainly cooperatives.
Pressured by the Fiscal Responsibility Law – in our understanding blatantly unconstitutional in relation to health – or even by political/ideological choice, as was often evidenced, managers carried out a vigorous outsourcing process in hiring workers.
Finally, also due to political/ideological choice and directly violating constitutional provisions, the process of privatization of the Management and Administration of SUS services was launched throughout the country, through Social Organizations, OSCIPS, Private Law Foundations, “Private Partners”, Autonomous Social Services, EBSERH and others, which exercise their role with the broadest freedom, disregarding the limits established by direct management legislation as well as the principles of SUS.
It should be noted that the hiring of labor through “cooperatives” as well as the delivery of public services to the administration of private companies such as Social Organizations, OSCIPS and other “partners”, are presented as legal ways of complying with SUS legislation in the matter related to private complementarity.
In fact, what happens, if not in bad faith, is a mistaken interpretation of Article 24 of Law 8.080/90, which clearly establishes that “When its resources are insufficient to guarantee healthcare coverage for the population of a given area, the Unified Health System (SUS) may resort to services offered by the private sector”.
It is impossible for us to understand the intermediation of labor and the outsourcing of the administration of SUS services itself, which among other things violently circumvent the constitutional provision of public competition as the only form of access to public services, as effective complementary assistance services.
There is no doubt that a worker cooperative is a workforce, a workforce that must be hired through a public tender, a provisional public selection process or temporary contracts with a pre-determined term, as required by law. Social organizations, OSCIPS and other “private partners” as administrators of public assets are managers who make the workforce precarious and not provide complementary health care services to the population. There is no doubt about that.
In this regard, the same law 8.080/90 establishes in its articles 17 and 18 the competence of the state and municipal directorates of the SUS to manage the services that are under their administrative sphere. Therefore, and it is the organic law of the SUS that states this, the management of its services cannot be delegated to third parties.
We then conclude that, through a process that was thought out, coordinated and politically elaborated, the SUS was gradually deconstructed, its legislation was widely undermined and its principles were violently disrespected, always with the easy and opportunistic discourse of the need to overcome bureaucracy and to give quick and immediate responses to the population that said and says, “cannot wait”.
In fact, what actually happened, as we have always stated and have confirmed to our knowledge, is that a project was put into practice to transfer financial resources and assets from the SUS to political and economic groups and private corporations, in accordance with our culture and history. As a practical and concrete result, we have the fact that almost all cases of corruption reported, investigated and proven in the SUS occurred precisely in outsourcing contracts with social organizations, civil society organizations (OSCIPs) and the so-called “private partners” in general.
It must be said that everything happened under a frightening, embarrassing, shameful and compromising silence from those who had, among other things, the task of supervising and monitoring the system, ensuring compliance with legislation and regulations, particularly the Ministry of Health, the Public Prosecutor's Office and the Judiciary.
The hiring of Social Organizations, OSCIPs and similar organizations, as well as “cooperatives” violate the constitutional principles of legality, morality and impartiality, undermine the legal instrument of public tender as the only form of access to public service, disregard the laws of bidding and Fiscal Responsibility, among others, and, even so, have had the connivance of several Courts of Justice throughout the country.
In 1988, the Workers' Party and the Democratic Labor Party filed a Direct Action of Unconstitutionality with the Supreme Federal Court challenging Law 9.673/1998 — Social Organizations Law — and item XXIV of article 24 of Law 8.666/1993 — Public Procurement Law. With Ayres Britto as rapporteur, its proceedings began in 1998 and were suspended on May 19, 2011, due to a request for review by Marco Aurélio Mello.
During this period of 13 long years, the process of deconstructing the SUS and consolidating the OS advanced throughout the country in governments of the most varied ideological hues. After all, public administrators said, as long as the Supreme Federal Court did not rule against it, they could not be accused of committing illicit acts.
On the other hand, the Ministry of Health directly financed, year after year, the contracting of private services to replace the public network – inverting the constitutional dictate of private complementarity and, therefore, failing to comply with the law – as well as the delivery of public services for administration by private companies.
This movement can be interpreted as a political option, which meant a major tactical and strategic mistake and disrespect for the sovereign decisions of the Conferences and Health Councils, and serious omission and connivance with illegality.
The aforementioned ADI only came to its final conclusion in 2015, with the STF declaring Social Organizations “partially constitutional”, disregarding all legal violations that terminate their contracts, particularly the access of civil servants to the public service without a public competition and exempting them from compliance with the bidding law when acquiring goods and supplies.
It is important to emphasize that between 1998, when the ADI was filed, and 2015 when the STF made a definitive statement, the Workers' Party changed its position, all of its governments joined the process of conceptual deconstruction of the SUS and the Dilma government worked through the Attorney General of the Union to have Social Organizations declared constitutional by the Supreme Federal Court.
The truth is that the SUS has been transformed into the largest business counter involving public affairs in our country, privileged business, with guaranteed financing and without any risk, as is the case with contracts with Social Organizations, OSCIP, outsourcing in general and other “private partners”. With each new mayor or governor that is elected, a total and absurd turnover of workers has been the rule in accordance with the economic and political interests of the actors involved.
The thousands of people who today suffer in waiting lines for a procedure that is not always so specialized are victims of this irresponsible and illegal process of privatization of the system that, it has been proven, is statistically, mathematically and economically, absolutely impossible to be financed in its entirety.
In fact, and precisely because of the impossibility of subjecting healthcare to market logic, in recent years and as a result of the significantly increased demand, even Health Plans, which, unlike the SUS, as we know, are not guided by universality or comprehensiveness in care, are facing great difficulties in meeting their responsibilities, consequently increasing the amounts charged for monthly fees, always above inflation rates, and the demands made on their insured. On the other hand, with the growth in demand, of the SUS in market logic and of private healthcare, healthcare today represents the third most powerful sector of the economy, surpassed only by the energy sector and the financial system. In other words, with the SUS in market logic, healthcare has become one of the largest business areas in Brazil.
Obviously, in a situation like this, the Unified Health System is mortally wounded in its fundamental pillars, its financing, its workforce and its management, therefore requiring changes that promote the necessary course correction.
*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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