By AMELIA COHN*
The urgent reaffirmation of SUS and health as a right
From 2016 to 2022, SUS was the target of attacks against its financial viability, its principles of universality, equity and comprehensiveness. In the first post-coup government of 2016, with the impeachment of Dilma Roussef, through the deconstruction of the SUS: its framework was maintained, but it eroded it from the inside, as in the game of toothpicks in many of our childhoods.
The game consisted of removing sticks from a randomly thrown set without moving the others, so that they remember. The SUS is budgetary asphyxiated with the spending ceiling in the federal budget, and as a result, the work relationships of health professionals are precarious and the direct administration of state health services is privatized. Health programs are excluded or drastically reduced, all in the name of market efficiency versus inefficiency of the State, and the private responsibility of families for their health, according to the classic neoliberal primer.
As of 2019, the political game becomes brutal, and health becomes one of its main targets, whether due to the volume of resources it involves, the social capillarity of the SUS, the economic interests encompassed by health, the government of Jair Bolsonaro (2019- 2022) attacks health, historically the object of the wishes of rulers. The attack is frontal and brutal against the SUS. And just when we are hit (and not by surprise, as we would have had a three-month "advantage" with regard to developed countries to prepare ourselves) by the SARS-CoV 19 epidemic. The tragedy was overwhelming. Over 700 dead. And that there would be thousands more, were it not exactly for the resistance and capacity of the SUS, even scrapped and boycotted, to react.
This scrapping during the Jair Bolsonaro administration did not only occur with regard to the suppression of a good part of the programs, the emptying of others, but also with regard to the virulent demolition of the Ministry of Health. Its technical staff were purged and in their place were appointed, the vast majority of military personnel ignorant of the health area, but with strong privatist and lucrative convictions of what the policy of that ministry should be.
For example, women's health, no way, as it was contrary to the values of the “exemplary family” model. Sex education for children and teenagers either, as that would encourage early sex among teenagers, and so on. In the name of morals and good customs, a minister of health who only heard about it and went to see what the SUS was about after his appointment, a military from the army's logistics area, takes the reins of health in the middle of a pandemic.
Disaster is not long in coming and the catastrophic results are well known. The next minister follows the same policy, but perhaps because he has a degree in medicine and has to preserve his diploma, he does not stay in government for long. And then comes another minister, also a doctor and owner of a powerful health network in a Northeastern state, and deepens the policy of destruction of the Ministry of Health and the SUS, even proposing in 2022 that another format of care be created in the medical care, the open health, which would make all information available to users of health services, public and private, among themselves, aiming at “greater efficiency” of the private health subsector. Significant that it was an inspired proposal from the Open Banking, in force since 2021 in the country.
In the scientific policy sector, including the health area, the same was done. Not only via underfunding of public education, research and training of researchers, but also via the promotion of discrediting science in favor of belief. And with that vaccination boycott campaigns – against Covid and other contagious diseases – and the promotion of the use of inefficient medicines to combat the virus. The PNI, National Immunization Program, which for its excellence made the country internationally recognized as a model of vaccination coverage of the population, is destroyed. Chloroquine and ivermectin, refused even by the emas of the Planalto, are distributed among the Yanomami. And Brazil then becomes internationally recognized not for the successes and achievements thanks to the 30 years of construction of the SUS, but for the lethality of health policies from 2016, and deepened from 2019.
What remains of these years of social slaughter policies? Alongside the high mortality rates during the pandemic, the acute lack of vaccination coverage, ignorance about violence arising from sexual assaults, generally domestic, which result in high pregnancy rates among our adolescents, high maternal mortality , the visibility of the SUS on its positive and affirmative side: the resistance of our public health system in caring for those affected by Covid, especially on the part of not only exemplary state and municipal initiatives (the federal government was present by its absence and irresponsibility in the face of this “little flu”), but above all human resources, which demonstrated their commitment to health as a public good.
It is opportune to register an unprecedented fact: while in Amazonas there was a lack of oxygen in hospitals due to the absolute (intentional?) private sector. Until this, overcrowded, warns that it will no longer see these potential patients; and he is still led to ask for help from the SUS because its infrastructure was no longer meeting his demand. For the first time, the private sector resorts to the SUS.
But in the face of this horror picture, Lula's victory is achieved, and in 2023 the new government begins. A 180 turn is then evident.o in the direction of health policy in the country. Nísia Trindade is appointed, a historian by training, and the first woman to hold the post in Brazilian history. Although important, it is not a question of emphasizing the gender issue involved there, but rather their professional profile, which in terms of defining the health policies that the ministry is and will define, proves to be strategic.
Nísia Trindade developed her professional career with teaching experience in a public school, and later as a researcher at the Oswaldo Cruz Foundation. She stood out for her academic works, but above all for her profile as a “builder” of institutions. She stood out as an institutional activist at Fiocruz, even managing to be named the institution's first president despite the fierce opposition of the then head of government, and consolidated the ideas, fundamentals and proposals of the Sanitary Reform from that institution.
She did not spare herself from participation in health meetings and events and in defense of the SUS, but she participated in them with a mixture of expertise in the field and an institutional activist with enormous capacity for “sewing” (the term can be bad for being a woman...) among different interests and power disputes without, however, identifying himself as a political personality of the Brazilian system. She did not run for elected office for political parties or executives in direct administration governments.
And why is this profile of yours brought up? Precisely because it is he who, associated with his skill in micropolitics, allows the minister to advance in the agenda of rebuilding the SUS, since he does not dispute political forces within the political field that makes up the government, and with that, on the one hand, disputes over the portfolio are located outside its field of action, and on the other hand, it frees it up to face the great questions and disputes of economic interests within the sector itself.
But there's more: Nísia Trindade begins her term with immediate actions for the reconstruction and resumption of health programs dear to the health movement and SUS defenders. Even when, after Law 8080/1990, it was a question of starting to build the SUS, perhaps there has not been an experience in the Ministry of Health of so many immediate actions after the holder of health takes office.
It's not just programs that resume; This resumption takes place based on a new systematic line of articulation: having the Economic Industrial Health Complex as a development vector as its flagship, these programs are resumed with the aim of seeking transversality between them, and between them and the others. programs, economic and social. This, although always sought in the construction of the SUS, is now no longer about adding to access to health, but how to articulate them with each other. An example is the Popular Pharmacy, which, by providing women with free access to contraceptive medication, for example, strengthens the relationship between SUS users and the Women's Health program. This is just one example.
Soft-spoken, but with firm attitudes and consistent actions, the Minister of Health is moving forward in the search for governability and governance with the main subjects involved – representatives of the legislative and executive branches – with direct regard to health and the SUS. With regard to the fact that the health portfolio has historically always been the object of desire of privatist and retrograde political forces, this issue is left to the macro policy, the negotiations between the Executive and Legislative branches. President Lula has shown signs of support for the minister at various times; however, there is no way to guarantee this explicit support without a strong social mobilization in support of the SUS and what it represents in terms of progress in the country's democratic order.
What the experience of these almost six months of Lula's government shows is that negotiating health in the name of governability is shooting yourself in the foot, because the right is insatiable, and the private health sector itself, if it weren't for its financialization, is also seeing its profitability, strictly as far as health care is concerned, will decline. And second, and fundamentally, health is a public good of non-negotiable collective consumption. The third ministry in budgetary terms, with the capillarity it achieved in the construction of the SUS, especially in PT governments, will always be the object of the desire of backward political forces. But it is necessary to make it clear to society that health is non-negotiable!
The challenge, therefore, consists of how to make the SUS and the right to health, especially at a time when they become the target of insatiable greed for what is most backward in our country, mobilize society in its defense, also making the transversal social movements in their demands. In the most recent period, the country was the scene of strong social mobilization for health, given the more than 100 free conferences held from the Frente pela Vida initiative, and soon there will be the 17tha National Health Conference. Promising events in terms of social mobilization. But that did not prevent, for example, that in the “Conselhão”, of the 11 representatives of the health area appointed, only one represented the ideals of SUS and health as a right, the rest being from the private sector.
It is undeniable that health increased its mobilization during this period. It now remains to burst the bubble and make it appropriate for other social movements and their leaders. Only with strong support from society and from the leaders of the different social movements will the Minister of Health be able to follow the steps she has been taking in a competent manner, and the Executive will be able to resist the greedy advances of representatives of the health market. And that the non-poor from the upper middle class and upwards do not rely on the health market to guarantee medical assistance for themselves. This already gives strong evidence of being unable to cover the health needs of even the 25% of the Brazilian population covered by it! Its queues for medium and high complexity exams already compete with those of the SUS.
More than ever, SUS for all represents a guarantee of the right to health for the entire population! Nísia Trindade stays!
Amelia Cohn, sociologist, is a retired professor at the Faculty of Medicine of USP. Professor of the Master's Program in Health Law: individual and collective dimensions/UNISANTA. Author, among other books, of Letters to President Lula: Bolsa Família and social rights (editorial quicksilver).
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