By PAULO CAPEL NARVAI*

The decentralization of Rio's federal hospitals should not be opposed or welcomed, it is a necessity

1.

With the SUS planning area in his sights, the president of the Chamber of Deputies, Arthur Lira, continues to attack the Ministry of Health day in and day out. Based on parliamentary amendments that allocate SUS resources to the pleasure of the deputies who voted for him to preside over that legislative house , Arthur Lira does political business at the expense of the planning and organization of the Brazilian health system.

Although “legal”, such parliamentary amendments are immoral and violate in several ways the federative pact, SUS legislation and the tripartition of powers, enshrined in the Brazilian Republic. The very legality of these amendments is quite questionable, since they were approved by the parliamentarians themselves who benefit from them to, indirectly, buy votes and deform the electoral process. In short, they violate democracy, distorting popular representation in the National Congress.

Arthur Lira, however, does not care about so many attacks on the 1988 Constitution and the plebiscite of April 21, 1993, which gave only 29,4% of the votes to parliamentarism. Placing himself above the CF88 and the 1993 plebiscite, the deputy from Alagoas wants to change the government regime, defending what he called “semi-presidentialism”. When running for a second term as president of the Chamber, at the beginning of 2023, said wanting to establish with the Executive Branch “not a relationship of subordination, but of a pact to improve and advance public policies based on careful listening and suggestions from our committees”.

It is not surprising, therefore, that Arthur Lira wants govern health, placing the holder of the portfolio as a kind of executive secretary for health and SUS matters. Nísia Trindade, the minister, has been resisting and negotiating – as it needs to be, in these cases.

At the meeting of ministers held on March 18, 2024, President Lula placed on the agenda what the corporate media characterized as “the health crisis”, with emphasis on the management of federal hospitals in Rio de Janeiro and asked the Minister of Health that would improve “the relationship with the National Congress”, without going into detail about what this improvement would be.

However, the right-wing attacks coming from Praça dos Três Poderes, by the heavy artillery commanded by Arthur Lira, were not enough. Now in July, more than three months after the triggering of the management crisis in federal hospitals in Rio de Janeiro, new batteries open fire against Nísia Trindade.

2.

This time, however, they are attacks coming from the left-wing opposition to the government, motivated by the publication in the Official Gazette of the Union of GM/MS Ordinance No. 4.847, of July 5, 2024, which “establishes the decentralization of services from Hospital do Andaraí, a federal public agency, to the Municipal Government of Rio de Janeiro” (PMRJ). The ordinance, signed by the Minister of Health, guarantees the Hospital Federal do Andaraí (HFA) resources and personnel so that actions and services are not interrupted and provides that the management of the HFA is shared by the Union and the PMRJ, for 90 days, extendable if necessary, until administrative normalization.

But, in a note titled “In defense of the Federal Network!”, addressed to the “Andaraí community, patients and employees”, parliamentarians linked to PSol asked for the decision to be revoked, basically arguing that it: (a) was taken “without any dialogue with social movements, unions or control bodies SUS social network”; (b) it is a cause for “much concern and perplexity”; (c) “threatens the existence of the HFA as a public health facility, especially with regard to assistance to cancer patients”.

(d) It does not take into account that the City of Rio de Janeiro does not directly manage the SUS in the city, but outsources management to “OS [Social Health Organizations], PPP [Public-Private Partnerships], among others, the consequences of which are the lack of assistance to the population, fraud and corruption committed by managers and public agents, in addition to the violation of the labor rights of health professionals”; (e) repeats what was attempted “in the past and brought serious consequences for the population and employees”; (f) ignores that “what the network needs is an end to political interference in the management of units, a public competition to restore the workforce and a career plan to give dignity to employees”.

The signatories of the note conclude by stating that “as parliamentarians elected by the population of Rio de Janeiro, we stand alongside the civil servants and the population to fight against this decision and we will take all appropriate measures so that the Ministry of Health revokes this ordinance, defending the right to quality public health.”

3.

As an activist for the right to health and participant in the Health Reform movement that bequeathed the SUS to Brazil, I allow myself to disagree head on with these arguments. To understand the divergence, I present counter-arguments for the consideration of readers who grant me the privilege of their attention. To them.

Although the note calls for “dialogue with social movements, unions or SUS social control bodies”, it concludes with a knife to the minister’s neck, threatening her with “all applicable measures so that the MS revokes this ordinance”. In other words, for the signatories of the note, there would be no alternative: the HFA, and by extension all federal hospitals in Rio de Janeiro, must continue to be SUS health units, managed from the Esplanada dos Ministérios, in Brasília. The only argument that supports such an uncompromising position is that it was “tried in the past” and it didn’t work.

But there are many problems with this argument. In a politically similar way to the arguments of Arthur Lira, who wants to govern health because he does not respect the 1988 Federal Constitution, nor the plebiscite that defeated parliamentarism, the position of keeping hospital units under federal management at any point in the national territory violates the article 198 of the 1988 Constitution, which created the SUS as “a regionalized and hierarchical network” of health actions and services, decentralized and “with a single direction in each sphere of government” and also law 8.080, of 1990, which regulates the SUS , which states (Chapter II, Principles and Guidelines, art. 7, IX) “political-administrative decentralization, with a single direction in each sphere of government”.

Regarding there being a “threat to the existence of the HFA as a public health facility, especially with regard to assistance to cancer patients”, this is just an opinion. Respectable, certainly, but nothing can be found in the ministerial order that constitutes a threat to the existence of the HFA.

By the way, note the unusual manifestation of the Rio de Janeiro Municipal Health Council which, in its session on 9/7/2024, “repudiated the transfer” of the HFA “to the Eduardo Paes government” (sic), giving up the direction of the SUS in the municipality, a competence attributed to it by CF88 and law 8.080/90 , absurdly confusing the PMRJ institution with the figure of the mayor of the moment. The repudiation expresses a misunderstanding of the principles and guidelines of the SUS, which should be a reason for “a lot of concern and perplexity”.

I agree with the criticism of the City Hall of Rio de Janeiro for not directly managing the SUS in the city and outsourcing its management to Social Health Organizations, and establishing Public-Private Partnerships, which would lead to “lack of assistance to the population, fraud and corruption practiced by managers and public agents, in addition to the violation of the labor rights of health professionals”. But instead of, coherently with this criticism, fighting for participatory management and respect for the Municipal Health Council and the decisions of health conferences in the city, those who oppose Minister Nísia's decision direct their focus to the government federal government, as if expecting some help from him in this fight. It is to Rio de Janeiro City Hall, not the federal government, that this criticism should be directed.

Another criticism with which I agree is that “what the network needs is an end to political interference in the management of units, a public competition to restore the workforce and a career plan to give dignity to employees”. This is exactly what the SUS, under the command of Rio de Janeiro City Hall, should do. To achieve this, it can and must count on the support of the federal government. But the way it was made makes this just another misdirected criticism. Its recipient is not in Brasília, but in Rio de Janeiro.

However, in my opinion, the most serious conflict, extremely serious, due to its implications for the future of the SUS, refers to the fact that the position of keeping SUS hospitals federalized reopens a debate, closed in the pre-SUS period, about centralizing or decentralize system management. The position of decentralization prevailed, as stated in the legislation. The central argument, supporting this position, was that, in health, the closer to the users, the better and more appropriate the administrative decisions related to the performance of actions and services would be.

At the end of the 1980s and until the 9th National Health Conference, postponed for two years by Fernando Collor, supporters of the centralization of the SUS, in the federal and state governments, still had political strength and argued that the municipalities “did not have the competence or administrative experience to take care of the SUS”. There were “operational standards” that restricted, through ordinances, the powers of municipalities in the SUS. During that period, notable leaders defended “Municipalization, Now” (Conasems), understanding that “Municipalization is the Way” (central theme of the 9th National Health Conference, 1992), among which Paulo Dantas e David Capistrano Filho.

I won't go into length, but it is necessary to note that even among the defenders of the municipalization of health, there were those who warned about the naivety of believing that, with decisions taken at the local level, “all our problems will disappear”. They considered – and time proved them right – that many local leaders could be as or more harmful to democracy than some general dictators.

I do justice by quoting professor Paulo Eduardo Elias, from USP, who was one of the most critical in this regard, and one of the first to oppose municipalization as a mere “prefecturalization” of health. Averse to “dogmatism and principism”, as he said, I often heard him warn that “it is not enough to municipalize, it is necessary to democratize and publicize the SUS”. Currently, it is obvious that it is necessary for SUS management, at all levels, to advance in the institutionalization of regional health care networks, without reducing the decentralization of the system to “prefecturalization”.

4.

To move in this direction, the Ministry of Health created, still in March this year, a “federal hospital restructuring program”. I do not know whether the ministry received, from those who claim to be very concerned and perplexed, any document with proposals to overcome the impasse. As far as I know, nothing has been forwarded to the Ministry of Health by workers' organizations, social movements, political and scientific leaders, with a view to outlining possibilities for the Rio de Janeiro City Hall to fully assume the sole direction of the SUS in the city.

After all, with 6,7 million inhabitants, the city has almost twice the population of Uruguay, is larger than Costa Rica and demographically tied with Paraguay and Nicaragua. There is no reason for the city not to have a Health Secretariat that has an institutional size equivalent to that of a Ministry of Health. Why isn't this happening yet? What political forces in Rio de Janeiro are preventing the institutionalization of the SUS in the city? What can be done to overcome these obstacles?

In this aspect, the argument contained in the Reposting Note published by the RJ Nurses Union (SindEnfRJ), entitled “Municipalizing Andaraí is not the solution to anything”, that “Rio City Hall does not have the minimum conditions to efficiently and competently take care of the city’s hospital units”. Could it be. But this is what Brazilian legislation orders PMRJ, and not the federal government, to do. Maintaining federalization, as Rio de Janeiro leaders who work in the health sector want, could even be a successful fight. But this will not resolve the contradictions inherent in this “solution”.

It appears that, instead of taking care of an institutional project of this magnitude, civil society in Rio has turned its attention to the “one-note samba” of maintaining the status quo which, over time, has only made it worse. things in the SUS. The nightmare that was the management of federal hospitals in Rio de Janeiro, during the government of Jair Bolsonaro, unfortunately does not seem to have stimulated any reflection contributing to overcoming institutional anachronism.

In the last three months, no proposals were produced in line with the social construction of a 100% public SUS, with services under public control by health councils and conferences, and management councils in each health unit, state owned and managed by bodies of the public administration, direct or indirect. Is this possible. But it needs to be created.

I have been saying to interlocutors in recent days 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 RJ.

In this sense, opposition to GM/MS Ordinance No. 4.847 It's a mistake you shouldn't make. Clinging to the single flag of federalizing or federalizing is placing oneself in opposition to the Health Reform. Just like “prefecturalization” (municipalization without democracy, without public control and without participatory management), the mere maintenance of the status quo would not solve anything, as it does not correspond to a structural solution to the problem – therefore making it even worse. It's not good at all. Paraphrasing, and reversing the meaning of the Reposting Note from SindEnfRJ, it can be said that federalizing the HFA “is not the solution to anything”.

From the historical perspective of SUS defenders, opposition to decentralization to Municipalities and States is contradictory, especially if this position is influenced by characteristics of the current government. For this reason, it is so important to have a strategic direction for the SUS, which guides the political action and tactics to be adopted in each situation.

If there is no direction, a medium and long-term project, the risks of important decisions being taken according to momentary, cyclical interests, such as those that currently concern the HFA, are relevant. If there is no direction, circumstantial, or just corporate, interests of more combative professional categories prevail. The risk in these situations is “going in circles”. The remedy for cyclical comings and goings is to outline strategic objectives that can guide cyclical struggles. This seems not to be clear to SUS defenders in several Brazilian cities and, as can be seen, in Rio de Janeiro.

In this case, Minister Nísia Trindade's decision is, in my opinion, consistent with the Health Reform movement and the legal bases of the SUS. Therefore, the decision to advance decentralization should be welcomed, applauded and defended. Opposing it, I reiterate, is in my opinion a political, tactical and strategic error. Those who oppose it would be better off organizing political forces to impose on PMRJ, with the support of the Municipal Health Council, a state solution, based on the public interest, for this and other hospitals. Oppose privatization and enable the creation of a state-owned institution to manage all units of the SUS network in the city, by public administration, whether direct or indirect.

The first years of implementation of health decentralization were also years of resistance to municipalization, with municipalities reduced to the status of partners that “provided services to the Ministry of Health”, regulated by operational standards. One expression was, at that juncture, recurrent in the speeches of the “health party”: the so-called “inampization of the SUS”. It was intended to criticize the attempt to maintain in the SUS some characteristics of Inamps, the social security health body that, surviving for almost half a decade since the creation of the SUS, would become extinct in July 1993.

One of these characteristics, and against which many battles were fought, was precisely the persistence of the federal government as a provider of health care at the local level. The end of Inamps administratively put an end to this characteristic. But the “Inampan culture” persisted and, as seen in the episode of “federal hospitals” in RJ, is still alive within the SUS.

The reaction to the decentralization of these hospitals, inherited from the former “INAMPS hospitals”, which no longer exist as “federal hospitals” in any other State or Municipality, not even in the current Federal District, is a late, untimely and anachronistic manifestation of culture of the lack of support for the SUS. It must be fought, not welcomed, as some parliamentarians, social leaders and trade unionists in Rio de Janeiro mistakenly did.

*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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