Federal hospitals in Rio de Janeiro – dust under the carpet?

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By PAULO CAPEL NARVAI*

The main problem with federal hospitals in Rio de Janeiro is that they are still federal hospitals in Rio de Janeiro

What the corporate media characterized as “the health crisis” was the highlight of the ministerial meeting that President Lula held, on March 18, 2024. Among several ingredients, the “crisis” in the department under the command of Nísia Trindade would be composed , according to this view, due to “failures” on three fronts: (i) in indigenous health, in which Nísia would be responsible for the “increase in mortality” of Yanomami, especially children; (ii) in epidemiological surveillance, in which there were “mistakes” in the control and prevention of the dengue epidemic, which continues to kill people in several states; and, (iii) in the management of federal hospitals in Rio de Janeiro.

The Minister of Health defended her actions, both at the meeting of ministers and the following day, when, alongside members of the first echelon of the Ministry of Health, she answered the call to the palace, made by the President of the Republic. Basically, she argued that (a) there was underreporting of indigenous deaths in recent years and the interpretation of data from recent months requires care, with no increase in the number of deaths attributable to a possible failure of federal management; (b) in the dengue epidemic, the Ministry of Health has been carrying out the actions that correspond to it as a federal body and that, taking into account prioritizations made by the technical area, the available vaccines were destined for the population group for which they were indicated; and, (c) administrative measures were being put into practice to address the chronic problems affecting federal hospitals in Rio de Janeiro.

These are all health problems whose relevance no one questions. The management of indigenous health, a responsibility of the federal government, remains as complex and challenging under Nísia as it has always been since federal law no. 9.836, of September 23, 1999, created the Indigenous Health Care Subsystem, with the Special Indigenous Health Districts as its operational base.

Tackling dengue fever, which the media has reduced to the “vaccine campaign”, is very far from being able to be resolved with vaccines alone without simultaneously considering the complex range of factors involved in the current epidemic and the characteristics endemic of dengue, both in Brazil and in a few dozen countries in the Americas, Africa, Mediterranean Europe, the Western Pacific and Southeast Asia. Holding a Minister of State for Health, Nísia Trindade or any other, responsible for the fact that vaccines are being lost due to “loss of expiration date”, or is it the ignorance of those who criticize, because they are unaware that in the SUS governance model it is not the responsibility of the Ministry administer Basic Health Units, or is it just bad faith.

Nor will I take up the reader's time with additional considerations about Nísia's remarkable resistance to the pressures and pretensions of the President of the Chamber, Arthur Lira, day-to-day since Nísia Trindade's first day at the head of the Ministry of Health. About her thirst for power and money, For the insatiable amendments from parliamentarians, the reader will find more details in “Lira wants to govern health?”, which I published on the website the earth is round. In this regard, note the order given to Nísia by Lula to “improve the relationship with the National Congress”, something that the corporate media celebrated, even though the media itself pretends to be “concerned” with Arthur Lira’s headquarters. Concerned?

While the corporate media makes statements of “concern” about Arthur Lira's actions, which violate the Constitution, trample the Republic's tripartite powers and ignore the legislation that governs the SUS, interference by deputies and senators continues, through amendments parliamentarians, in the activities of the Ministry of Health, disrupting SUS planning and disorganizing the governance of the system, which has been remaking itself since the beginning of last year.

But the “fault” for the “crisis”, says the opposition, lies with the Minister of Health who “doesn’t talk big, doesn’t have the flexibility and doesn’t play politics”. If the opposite were the case, the minister would be accused of being “authoritarian”, “a fan of the spotlight” and of “talking a lot and working little”. Ultimately, the problem is not what she does or doesn't do, the problem, for these critics, is that she has a direction, she knows what she does and knows why she does it - and this displeases those who have their personal or group interests contradicted. .  

What remains of this “Health crisis”, which is relevant, under Nísia’s governance, are the federal hospitals in Rio de Janeiro and what she and her team at the Ministry of Health could have done to “solve the problems”.

Problems, in fact, that are chronic and whose origins date back to the old “INAMPS hospitals” which, in the process of creating the Unified Health System (SUS), had their administrations transferred, across the country, to state and municipal governments. But, I need to correct myself: “across the country”, no.

One of the many problems in the SUS implementation process concerns, precisely, the management of its own public hospitals, inherited from “social security”, as the SUS was being structured.

By determination of the 1988 Constitution, which in its art. 198 determines that “public health actions and services are part of a regionalized and hierarchical network”, whose decentralization implies “single direction in each sphere of government”, hospitals owned by INAMPS became part of the SUS. Its administrations were therefore attributed to the federative entities responsible for exercising, within their scope, the “single direction” of the SUS.

For this reason, currently, there are no more SUS “federal hospitals” in the States and Municipalities. There are no federal hospitals in Paraná, Pernambuco, Acre, Paraíba, Amapá, Santa Catarina… Not even in the Federal District. There are teaching hospitals in the States, linked to public universities. They are intended to be linked to the SUS, but they are not, strictly speaking, SUS hospitals. The best-known exceptions to this general guideline are the Grupo Hospitalar Conceição, in Porto Alegre, and the six “federal hospitals” in Rio de Janeiro (Andaraí, Bonsucesso, Cardoso Fontes, Ipanema, Lagoa and Servidores do Estado). These are exceptionalities that are exotic to the general rule, but whose situation concerns the history of each of these institutions.

One of the reasons alleged by SUS proponents for command of system management (the “single direction”) being the responsibility of each sphere of government and not of the Union government, that is, the federal government, was that management decisions , including financial, would be more appropriate the closer to the population and health units the local authorities responsible for making these decisions were.

It is exactly the violation of this SUS guideline, which appears in item I of art. 198, and that by determining the “decentralization” of its management, it institutes what is recognized as a federative pact in health, which is related to the problem that currently puts federal hospitals in RJ in the spotlight. The construction of the SUS in the capital of Rio de Janeiro has been incomplete since 1988, 35 years ago. It is necessary to face and overcome the challenge of completing the construction of the SUS in Rio de Janeiro.

This guideline, which guided the decentralized structuring of the SUS and which constitutes the basis of the federative health pact, sought to rationalize public administration in this sector and was applied to the set of health units that would become the SUS. However, to understand the implications and severity of the delay in the construction of the SUS in Rio de Janeiro, it is worth remembering, in the case of federal hospitals installed in the city, what Carlos Gentile de Mello, an attentive analyst of health policies in the 1970s, wrote. and 80, in an article (“Difficult paths“), published in FSP, on 19/10/1981 (page 3).

Referring to Bonsucesso Hospital, at the time one of the INAMPS hospitals in Rio de Janeiro, Gentile de Mello said that “it is producing less and less and more expensively, with the aim of demonstrating that the public hospital company is unviable. This is a perverse plan by those who do not have the courage to openly propose the privatization of medical care. They then use these unfair subterfuges, with a view to immobilizing services”. As you can see, you didn’t even need any “investigative journalism” to learn about “corruption, abandonment and waste in Rio’s federal hospitals”.

At this point, the reader must be wondering why these hospital units, whose administration is not at all simple, continue to be administered, more than four decades after Gentile de Mello's warning, directly by the Ministry of Health, whose headquarters in Brasília are more than a thousand kilometers from Rio de Janeiro (and more than two thousand kilometers from Porto Alegre).

“But isn’t the direction unique in each sphere of government?”

In December last year, at the end of the first year of the current government of Luiz Inácio Lula da Silva, I heard from a friend, doctor and former municipal health secretary of a city in the interior of São Paulo, that “It's a good thing that the Lula government has Nísia Trindade in health care and in charge of the SUS".

Last week, after the repercussions of the March ministerial meeting, we talked again. I asked about what I considered to be Lula's abuse of Nísia Trindade, dismantling a movement of hers that I considered very opportune and in the right direction, which was to call Helvécio Magalhães, specialist and experienced in the key subject of the Rio de Janeiro imbroglio, to manage the crisis in Rio de Janeiro. “Lula hindered the correct movement she was making”, I argued, adding that “she had to cut her own flesh and that was not necessary, in addition to harming the ongoing actions”.

My interlocutor, experienced in political conflicts and public administration issues, listened to me patiently and said: “your perspective may be correct, yes, but who would take that knife that was in Arthur Lira's hand from Lula's neck? You?".

In the days that followed, in conversations with other friends, in other spaces, I couldn't argue without talking about “Arthur Lira's knife in Lula's neck”.

Worse: the metaphorical knife is still there, in Arthur Lira's hand. Whoever could take away this knife not only doesn't do it, but wants Nísia Trindade's head. For now. When they can, they will also want Lula's head.

Hopefully we can get rid of these threats. A Brazilian Academy of Sciences and Brazilian Society for the Progress of Science, among dozens of entities and social movements, have been speaking out in favor of the Minister of Health and her actions in charge of Health and the SUS. Many people are betting that Nísia Trindade will emerge stronger from the “crisis” manufactured by the opposition to the Lula government, which takes her as a scapegoat.

However, while Lula governs, it would be good to take a leap of more than four decades and, taking into account the teaching of Carlos Gentile de Mello and the dictates of the 1988 Constitution, ensure that federal hospitals in Rio de Janeiro are placed under the “direction unique” of the SUS in Rio de Janeiro. Treating them as if they were teaching hospitals would not only be uneducational, but would be like “sweeping the dust under the carpet”.

There is no doubt: if “ah, but this is very complicated” prevails, half a century from now the “federal hospitals in Rio de Janeiro” will continue to threaten the stability of Health ministers.

*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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