By Ana Carolina Navarrete*
SUS enters the fight against the pandemic as one of those worn-out family relics, but which, fortunately, still function and prove their value on a daily basis
The Covid-19 pandemic caught a Brazil in short pants. Although the SUS has always been underfunded, 2016 signaled a clear political break with the maintenance of social protection systems, initiating the dismantling of social security, social assistance and health policies. Constitutional Amendment nº 95/2016, which established a cap on public investments in health and education, signaled the movement and withdrew from the unified health system about 22,5 billion reais[I], an amount that is certainly needed at this moment.
An integrated health surveillance system is needed in view of our reality of underreporting, which prevents us from dimensioning the size of the crisis, including with regard to the duration of social isolation measures. Investments in science and technology, research grants and qualified people are lacking, which today makes us dependent on imports of strategic inputs for health. All that was left for us to do was get in line for international purchases, at a time of exchange variation and competition with countries like France and the USA for obtaining these inputs.
Public laboratories are lacking, even though some excellent ones have sufficient structure to coordinate clinical studies in the country and thus accumulate knowledge for local production, which gives us some chance of developing and producing medicines to face the pandemic. It is needed for the number of beds we have, insufficient to face the pandemic, as well as the health workforce.
SUS enters the fight against the pandemic as one of those worn-out family relics, but which, fortunately, still function and prove their value on a daily basis.
The comparison with the private sector is very illustrative. While the SUS, in fits and starts, has been managing to produce information on the scope of the pandemic, albeit fragmented, coordinating efforts in the States by evaluating and expanding the capacity of the CTI and ICU network, and considering centralizing the acquisition of essential inputs in order to avoid competition between federated entities (all depending on the new Minister), the private sector has not been able to coordinate or offer sufficient responses to the health crisis.
90% of the resources that move private health establishments come from payments through health plans, according to information from ANAHP[ii], and the plans did not take a position until April 17, 51 days after the first Brazilian case was announced. And after this silence, they proposed, as a concrete measure to face the pandemic, the postponement of tuition adjustments for three months, to be recomposed from October[iii]. The measure is a small-mindedness that makes you shiver. In addition to not having any obligation, it is silent on the problem of defaulters and does not guarantee that the network is sufficient to serve people.
At the government level, the measures announced by the regulatory agency, the ANS, are timid[iv]. Making the use of guarantee funds more flexible, created with money from consumers to cover health expenses in the event of failure by the operators, and the increase in service deadlines are old demands of the sector[v]. The latter has even generated considerable savings for the plans, without any compensation to face the tsunami of defaults that the economic crisis will cause in this market, which is extremely sensitive to formal employment.
The partial release of funds, although linked to the need to tolerate default, is limited in time and scope. The tolerance period runs until June 30, and the measure applies to just over 30% of the market (individual plans, which already have this tolerance provided for by law, collective membership plans and collective plans for up to 30 consumers). The majority of the market, made up of corporate collective plans with more than 30 consumers, is excluded from the obligation. The default tolerance period shows the limits of the regulator's strategic vision. Without enough tests to know precisely where we are on the infected curve, it is at least optimistic to assume that the pandemic will be behind us by June, not to mention the duration of the economic consequences for employment and income afterwards.
The case seems to be much more that of businessmen in the sector who were able to take advantage of the health crisis to approve an old agenda rather than a response to it.[vi].
But if we have some measures, albeit timid, at an economic level, we find a sepulchral silence on the capacity and expansion of the network, on the orientation of care and the follow-up of common coping protocols. Compliance with Ministry of Health protocols, although encouraged, is not supervised by the regulator. The consequence: health plans announcing that they follow treatment protocols based on drugs without evidence of consolidated efficacy and dubious clinical studies[vii].
Let's face it, we cannot say which health plans are being the true protagonists of this confrontation. They do not have the stature or even the will to play this role, naturally due to the burden it represents at an economic and public health level, so that who is actually guaranteeing a minimum level of response to the pandemic, together with social isolation measures, is the SUS.
The truth is that health systems, especially those with universal access, remain the most effective way that contemporary societies have found to guarantee the health of their populations. The difference in response from countries like Germany or South Korea, on the one hand, and the United States on the other[viii] is an example of this. The sufficiency of the network ensured a high response capacity in Germany, while in South Korea massive testing and surveillance allowed good results in containing the virus. In the United States, however, barriers to accessing services, such as the high price of tests (and partial or non-coverage by private insurance) implied the underestimation of the pandemic, and, in the dramatic case of New York, led to the need for the State to take the financial responsibility for the tests, something previously unthinkable for a system like the American one[ix].
What the health crisis of the new coronavirus made possible, at the painful cost of irreplaceable human losses, and in spite of an ongoing project in the Brazilian government that serves, at the limit, the death and objectification of people, was to show the value that systems of social protection has on maintaining life and social cohesion, and, in the case of health systems, how they are still the best possible response to what threatens humanity. There is no health voucher that faces pandemics.
Pandemics are naturally unpredictable and entire health systems cannot be built overnight to respond to them immediately. They require time, skilled manpower, scientific intelligence and adequate funding to respond accordingly. Some say they are inefficient and wasteful compared to their private counterparts. This is not what the Brazilian numbers say, which show that 60% of the total resources invested in health are private, but are intended to serve only a quarter of the population. Public health cares for three quarters of the population (plus expensive treatments and transplants that the health plans of a quarter do not want to cover), carries out sanitary and epidemiological surveillance and regulates the quality of medicines and health products with 40% of the resources[X].
There is no plan to take care of it. We hope that this notion survives for the times to come.
*Ana Carolina Navarrete She is a lawyer and activist for the right to health, a researcher at the Center for Studies and Research on Health Law and coordinator of Idec's health program.
Notes
[I] According to estimates by the National Health Council: https://drive.google.com/file/d/1_uXadxs-e-sSe5kNDjNtqhjUjiMfdwnm/view
[ii]https://valor.globo.com/empresas/noticia/2020/04/15/com-leitos-ociosos-hospitais-privados-pedem-a-ans-liberacao-de-cirurgias-eletivas.ghtml
[iii] https://extra.globo.com/noticias/economia/plano-de-saude-associacoes-de-operadoras-recomendam-suspensao-de-reajuste-dos-contratos-por-90-dias-24378353.html
[iv] http://www.ans.gov.br/aans/noticias-ans/coronavirus-covid-19/coronavirus-todas-as-noticias/5459-combate-ao-coronavirus-ans-define-novas-medidas-para-o-setor-de-planos-de-saude
[v] The flexibility in the use of guaranteeing assets is part of a substitute opinion for 150 bills in the Chamber of Deputies, prepared in 2018 by then-deputy Rogério Marinho (PSDB), now Secretary of Social Security and Labor of the Ministry of Economy in the Bolsonaro government. The increase in service deadlines was ventilated in 2017 in the proposal for “accessible plans” prepared by the then Minister of Health, Ricardo Barros. Both were strongly opposed by consumer protection entities and even by entities representing the medical profession.
[vi] This is the conclusion reached by researchers from the Health Plan Research Group – GEPS, from the USP Medical School and from the Research and Documentation Group on Health Entrepreneurship, from UFRJ. Available in: https://sites.usp.br/geps/
[viii] New York State has become the epicenter of the new coronavirus pandemic in the US, the country with the highest number of infections in the world, with nearly 60 confirmed cases and 1 deaths, and New York City is the hardest hit , with more than half of the total positives. Available in: https://noticias.r7.com/internacional/governador-de-nova-york-diz-que-tsunami-de-covid-19-esta-chegando-30032020
[ix] https://www.bbc.com/portuguese/internacional-52025734
[X] World Health Organization. Global Health Observatory data repository. Health expenditure ratios, by country, 1995-2014, Brazil. Available at: < http://apps.who.int/gho/data/view.main.HEALTHEXPRATIOBRA?lang=en>
