By PAULO CAPEL NARVAI*

Under the watchful eye of the centrists, will Alexandre Padilha be able to ensure that the victory of the right, forcing Lula to fire Nísia Trindade, does not turn into a defeat for Lula's electoral campaign program for health and the SUS?

1.

Late in the afternoon of Tuesday, February 25, 2025, a “Press Release” issued by the Planalto Palace made public what had already been taken for granted on social media: the Minister of Health, Nísia Trindade, would be replaced by federal deputy Alexandre Padilha (PT-SP). If the announcement was not a surprise, the bureaucratic, cold and distant tone of the text caused some perplexity, which caused an immediate negative reaction, even from government supporters.

There was speculation about the lack of management brand, competence, being a woman, dengue fever outbreak, waiting lists for surgeries, and even the crisis in Rio de Janeiro hospitals, among other justifications for her dismissal.

None of this, however, justifies her departure. She was removed for other reasons, and her departure represents a significant loss, for several reasons.

Firstly, for his competence, demonstrated by his professional trajectory and proven during the two years he was in charge of the Ministry of Health (MS) and in national command of the Unified Health System (SUS).

Since the creation of the Ministry of Health in July 1953, the agency has had 49 ministers. In recent days, while the now ex-minister was undergoing political “fried,” I reviewed the list and biographies of these leaders. Nísia Trindade, the only woman on the list, is certainly among the 12 best health ministers to have served the Brazilian Republic.

So why the resignation?

To the imperatives of political-partisan relations between the executive and legislative branches, in the context of the presidential system we have. Although the corporate media alleges problems such as “difficulties in the relationship with the National Congress” and the “failure to achieve goals”, wrongly highlighting the fight against dengue fever and “the failure” of the “More Access to Specialists” program, the facts demonstrate the opposite.

Dengue fever, whose four serotypes have been circulating worldwide for about 20 centuries, is endemic in more than 110 tropical countries. As of 2022, there was not even a vaccine against the disease. Due to its nature, any strategy for its prevention and control requires, according to the World Health Organization (WHO), much more than vaccines, which must always be included in an integrated public health program that includes, among other things, health promotion and social protection actions, with social mobilization, legislation to ensure the implementation of the necessary intersectoral actions in each community, therefore with collaboration between health and other sectors, both public and private, and appropriate use of available resources, which must be allocated to the implementation of actions whose effectiveness is supported by scientific evidence.

Therefore, it is recognized that combating dengue is very complex, in Brazil and throughout the world, requiring environmental transformations and combating social inequalities. Reducing the fight against dengue to the provision of vaccines is not only insufficient, but inadequate.

It is also clearly an exaggeration to ask Minister Nísia Trindade, or any other minister, to “solve the problem” of dengue fever in Brazil in two years. However, this is just a pretext to attack her.

The strategy adopted by the Ministry of Health involved investments of approximately R$1,5 billion in 2023-24. However, isolated actions by the health sector are insufficient to combat dengue fever, maintaining current sanitation standards in most of Brazil. Therefore, there are significant limits to the effectiveness of SUS actions in this fight. In addition, the strategy defined by the Ministry of Health has been severely hampered by the spree of parliamentary amendments, which hinder the planning and organization of SUS and harm the population, not only in relation to dengue fever, but also to other public health problems. Parliamentary amendments are harmful to health in several ways.

As for “More Access to Specialists,” another program that would explain Nísia Trindade’s alleged “poor performance,” the available data show a successfully implemented program. In order not to go into too much detail, I will only mention that in 2023, R$61,6 billion were allocated to high and medium complexity medical and hospital care, making it possible to expand the performance of outpatient and hospital procedures. R$2 billion were allocated to philanthropic hospitals and R$1,3 billion to university hospitals, in addition to the regular financing of the network of hospitals linked to the SUS throughout Brazil.   

In short, the allegations that underpin the criticisms of Nísia Trindade's performance do not stand up to a closer analysis of the performance data.

2.

It should be emphasized that, quite the opposite, she very competently carried out Lula's orders to recover and rebuild all the health programs that were either created or reoriented to the SUS guidelines during the governments of Lula and Dilma Rousseff. As is widely known, these programs were disorganized and financially asphyxiated during the governments of Michel Temer and Jair Bolsonaro.

Perhaps the most emblematic example of this strategy of destruction is the National Immunization Program, one of Brazil's health successes, which currently provides 48 immunobiologicals free of charge to all Brazilians: 31 vaccines, 13 serums and 4 immunoglobulins.

The National Immunization Program, reorganized and strengthened by Nísia Trindade, had been mercilessly attacked by the government of Jair Bolsonaro, through the so-called “hate cabinet”, installed in the Planalto Palace. During the COVID-19 pandemic, the health disaster was not even worse, due to the timely reaction of some states and municipalities, which maintained and strengthened it, within their scope.

During Nísia Trindade's administration, the “Farmácia Popular” program, one of the victims of denialism and disorganization in the health sector, was also successfully resumed. In addition, areas where innovation is needed, such as digital health, saw notable implementation during Lula's third term, with the launch of the “SUS Digital” program, despite the current huge challenges, involving disputes between big tech companies and Brazil's delay in seeking sovereignty in the area of ​​digital information and communication technologies. According to the Ministry of Health, R$464 million was transferred to states and municipalities to strengthen digital health.

It has been said that President Lula complained about the “lack of a brand” for the work carried out by the Ministry of Health. In fact, this “lack of brand” argument was first used by the corporate media. And it is unjustified, because if there is a ministry that has a good brand, it is precisely the Ministry of Health. And that brand is the SUS.

In an article (“Covid-19 pandemic: the SUS is more necessary than ever”), which I wrote with colleagues from the School of Public Health (FSP) at the University of São Paulo (USP), published in USP Magazine in 2021, we stated that after the start of the pandemic, the SUS began to be valued positively, with testimonies being recorded in its defense, “coming from mouths and fields in which they were never present”.

The SUS is currently a positive brand, although under permanent pressure from neoliberal ideology, which considers everything that is not done by the private, corporate, and profitable sector to be “bad, poor, and precarious.” It is clear that, in this context, the SUS brand needs to be valued and reaffirmed by government advertising, which has not occurred with due intensity in the current Lula government, in which the SUS symbol itself continues to be hidden daily throughout the country, as has been the case since the creation of the system in 1988, and its symbol.

3.

But one aspect that I have highlighted as one of the most positive in Nísia Trindade's two years in office as Health Minister is the expansion of financial resources for the SUS, with the support of the government's economic department. Not only was the constitutional minimum wage for health maintained, but there was also a significant increase in federal resources allocated to health.

In 2023, the Ministry of Health's budget increased by R$23,5 billion compared to Jair Bolsonaro's last year, reaching R$184,4 billion. This resource includes the amounts to be transferred to the management of the SUS by states and municipalities. In 2023, federal investment in health corresponded to 1,69% of GDP. The historical standard for this type of investment is around 1,7%. Although recognized as insufficient by economic experts, Nísia returned SUS funding to historical levels in her first year, overcoming the risk of underfunding that marked the previous government.

But it was in her second year at the helm of the Ministry of Health that the minister achieved her greatest success in this financing issue, with the increase in the Ministry of Health's budget in 2024 to R$222,9 billion, which corresponded to 1,98% of GDP. This difference, from 1,7% to 2,0% of GDP, is very significant, given the circumstances in which it occurred. The forecast is that, in 2025, the Ministry of Health will have R$241,6 billion to maintain, expand and improve health actions and services linked to the SUS.

Any analysis of Nísia Trindade's management should consider some relevant achievements of the work carried out. One of these achievements was the reorganization of the SUS and, with it, of the main public health policies in Brazil.

This was done in several ways, starting with the reconstruction of governance, with the resumption of the Tripartite Inter-managerial Commission (CIT), which brings together representatives of the federal government, states (CONASS) and municipalities (CONASEMS). The CIT had been transformed into an entity in which the Temer and Bolsonaro governments intended to “give orders” to the other federative entities, communicating their decisions about the SUS. Nísia radically changed this practice and, by strengthening the CIT as an inter-federative entity, within the scope of the republican pact enshrined in the 1988 Constitution, recognized the autonomy of the federative entities, enshrined in the 1988 Charter, and resumed the practice of decision-making based on consensus, resulting from dialogue on health issues with all SUS managers, at all levels of government.

But this reconstruction also reached the National Health Council, with the uninterrupted maintenance of activities that ensure “community participation,” also enshrined in the 1988 Constitution, in decisions on health policies, plans, and programs. All health conferences, at all stages, from the local to the national level, were maintained, organized, and had the participation of representatives of the federal government. The President of the Republic himself and several ministers of State participated in the national stage of the 17th National Health Conference, held in July 2023.

Regarding the actions of the Ministry of Health, it is important to consider that, in the SUS governance model, the ministry is not responsible for directly carrying out healthcare actions or managing healthcare units, whether primary care, outpatient clinics or hospitals. This is mainly the responsibility of municipalities, with the participation of states where necessary. For this reason, the evaluation of the actions of a ministerial administration in healthcare is not equivalent to counting the number of dressings applied, or medications distributed, or transplants performed, or vaccines administered, or any other item related to healthcare.

But many people do this and make a serious error of judgment.

4.

Many criteria that are usually used to evaluate the performance of the Ministry of Health, as if it were the responsibility of the Ministry of Health to carry out assistance actions at a local level, are not, in my opinion, suitable for evaluating the performance of any minister.

For example, it is often said, and not only in relation to the administration of Minister Nísia Trindade, that “the SUS does not work”. However, it is important to consider the fact that Brazil has 5.570 local health systems. The SUS is unique, but the realities are unique in each of the 5.568 municipalities, and in the Federal District and Fernando de Noronha. So, when a politician, or someone, anyone, criticizes “the SUS”, stating that it “does not work”, they are saying this based on their own experience, or on the complaints they receive, as a councilor, deputy or senator.

This is understandable, as it is indeed real.

But there are hundreds of Brazilian municipalities where the experiences are different and positive. These are situations in which, on the contrary, “the SUS works” – even though it presents problems and difficulties. In these different and contradictory situations, it is necessary, in my opinion, to consider that in each location, the SUS expresses, because it translates as a public policy, the power relations that are established in each municipality, the capacity for organization and accumulation of power of the communities, and the relations of civil society with the public authorities, especially the executive branch.

There are situations in which people, as voters, elect reactionary, conservative governors and mayors with an anti-state ideology, who hate social policies, who detest public education and who mock the difficulties of the SUS, and at the same time, these same people who elect these political leaders complain that “the SUS doesn’t work”. Of course, in these situations, it really doesn’t work, because nothing about “public affairs” works in these cases. There’s no magic in this. The SUS is not an antidote to mayors and governors of this type. And no health minister, or the federal government, or the state government, will solve SUS problems that have this origin.

I often say that there is no administrative solution, regardless of the type of management, for political problems, because what solves political problems is political action. Without political action from those who defend social rights, from those who defend the SUS, the political actions of those who oppose rights and the SUS will prevail.

For these reasons, I have disagreed with negative assessments of Nísia Trindade's management, based on data about the production of the SUS, such as more-or-less-this or more-or-less-that. This rule is, in my opinion, inadequate and should not be used. I do not even refer to nonsense like "she is weak" or "she does not understand medicine", because these are crude or merely corporate arguments.

During her time as head of the Ministry of Health, Nísia Trindade implemented the health program for the Lula-Alckmin campaign in 2022. This program indicates a direction for the SUS, to strengthen it, organize it nationally with coordination involving all federative entities, value health professionals, develop strategies and organize the SUS to prevent and control epidemics and endemic diseases, overcome the chronic underfunding of the SUS, and implement health actions and programs with the objective of universalizing access to comprehensive, public and free health care, intensifying health actions aimed at vulnerable social groups, such as indigenous peoples, quilombola populations and those with specific demands such as LGBTIQIA+, women, black people, combating structural and institutional racism, among others.

5.

This direction seems to have been consolidated in the Lula government and the management that is taking over the Ministry of Health, now under the command of Alexandre Padilha, should be one of continuity. There is no indication that there will be changes that represent a rupture with what has been done in the Ministry of Health and in the SUS.

However, achieving the campaign's objectives will continue to be a challenge, as they are not easy to implement, especially under siege and pressure from the majority of the National Congress, which is marked by neoliberal ideology and the strong belief that health is the result of medical procedures and that it is enough to ensure this for all people, with the privatization of the SUS, to solve all the problems in this area. This is naivety, but it is a naivety that is convenient for those who want to do all kinds of business with health and the public resources allocated to it.

When assessing Nísia Trindade’s first year as Health Minister, I wrote: “It’s a good thing that Lula can count on Nísia Trindade to lead the health system and the SUS.” But I added that “it is widely recognized that the Health Minister, because she is a woman and not a doctor, has been the target of furious attacks from the far right. But that’s not all. Right-wing sectors that are at the base of the federal government, notably in the National Congress, have also periodically called for Lula to remove the Minister from office.”

These sectors won. Lula no longer counts on Nísia Trindade in healthcare and in command of the SUS.

Time will tell what the victory of the right in this arm wrestling match means. Alexandre Padilha is a seasoned politician and a competent public administrator. His time as a health minister between 2011 and 2014, in the Dilma Rousseff government, and as municipal health secretary of São Paulo from 2015 to 2016, when Fernando Haddad was mayor of the city, are proof of these qualities.

But, under the watchful eye of the centrists, will the current Minister of Health, Alexandre Padilha, be able to ensure that the victory of the right does not turn into a defeat for Lula's electoral program for health and the SUS? I hope so, but it is important to bear in mind that, with the centrists lurking, his work will not be easy at all, because no one is ever sufficiently shielded against the actions originating from this parliamentary bloc.

One of the challenges – this one is immediate, but will continue until the end of Lula's term – is to contain the centrists' attacks on the health budget. A lot of effort will be needed to protect and expand this budget and seek to overcome the chronic underfunding of the SUS.

Since the budget amendments, presented by members of parliament to meet their clientelistic political and electoral interests – to say the least – have a disruptive impact on sectoral planning, Padilha will have a lot of work to do to ensure that the Ministry of Health's projects and programs for the SUS follow the path indicated by social movements and what is organized in society in defense of the SUS. It is not difficult to identify which projects and programs these are: it is enough to take into account and respect the proposals and guidelines approved at health conferences, from the local to the national level, in recent years.

However, to be successful in these tasks, it will be essential for Alexandre Padilha to maintain and further strengthen relations with health councils, entities and social movements interested in health and the direction of the SUS. Without this, there is no small risk that the SUS will become a business counter – something that it already is, unfortunately, in many municipalities, according to abundant police reports.

But, as social movements say: “health is not a commodity”.

*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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