No roof, no floor



Without popular participation, the government managed to approve in the Chamber of Deputies the complementary bill 136/2023, which removes resources from the SUS

The expression “technocrats of Brasília” was very frequent in political speeches against the dictatorship, in the 1970s and 80s. From Prestes to Montoro, Lula and Medeiros, Richa and Olívio, passing through Arraes and Brizola, and arriving at “Seo” Genezinho, As a neighborhood leader in São Paulo, I heard “Brasília technocrats” from several people. With this expression, citizens demanded democracy and the need to assert the people's voice in everyday politics.

In fact, these technocrats were not actually from Brasília, but in Brasília, where they worked in the federal government, coming from the most different places in Brazil. Serving the Republic, under the dictatorship, they took care of tasks that were entrusted to them by their superiors, the ministers of the dictatorship.

There were among those ministers, very qualified people, of the caliber of Ney Braga, João Paulo dos Reis Veloso and Mário Roberto Simonsen, to name a few. All, however, politically loyal to the authoritarian regime. To “run the administration”, they used the so-called “technocrats from Brasília”. Every now and then, of course, one of these employees would “step on the ball” and make some mistake, which required the boss's prompt intervention to correct the mistake politically.

It is impossible not to remember these “technocrats from Brasília”, when analyzing the political process in which the Lula government was involved, in the case of the complementary bill approved in the Chamber of Deputies and which is now being processed in the Senate, regarding non-compliance with the Constitution in relation to At the bottom of the health budget, it is worth mentioning the money that finances the Unified Health System (SUS).

Still young, in the fight against the dictatorship, I was among those who deluded themselves, believing that democracy would put an end to the “technocrats of Brasília”. Illusion. Today, in democracy, many remain as powerful as their counterparts in the dictatorship. The lack of appreciation for democratic dialogue and the lack of sensitivity to listening to popular leaders is similar. The technocratic perspective is that politics always gets in the way, that things have to be discussed and decided only by those who “understand the subject”.

After Lula's election, a Amendment to the Constitution, number 126, approved on December 21, 2022, changed the 2023 budget law, which meant adding more resources to the SUS, whose budget was estimated at R$183,8 billion, an increase of 12,85% compared to what the SUS received in 2022.

With the approval of the law establishing a new tax regime and which put an end to Constitutional Amendment 95, of 2016, the “spending ceiling”, sadly known as the “death amendment”, as it froze SUS resources for twenty years based on 2016, the oxygen seemed to finally return, taking away Bolsonarist suffocation of social policies, including health policies. The “fall of the ceiling” was, rightly, celebrated in the four corners of Brazil by fighters for the right to health.

With the end of EC-95/2016, the 1988 Constitution, which was amended in 2000 by Constitutional Amendment 29, provides (art. 198; 2º, § 2º) that the Union will apply, “annually, in public health actions and services minimum resources” derived from the application of percentages calculated on “the net current revenue of the respective financial year, and cannot be less than 15% (fifteen percent)”. It would return, but it seems that it will not return in 2023, only from 2024 – if nothing changes in the coming months. It will not return in 2023, as a success of the Lula government seems to have panicked “technocrats from Brasília” installed in the Finance and Planning ministries.

Success concerns the prospect of meeting the inflation target accompanied by GDP growth. The inflation target for this year, set by the National Monetary Council (CMN), is 3,25%, which may vary by 1,5 percentage points, that is, between 1,75% and 4,75%. A projection made in September based on the Broad Consumer Price Index (IPCA), which measures the country's official inflation, indicates that inflation in 2023 will be 4,86%. But these projections are being reduced every month. Therefore, it will not be a surprise if the inflation target is reached. The other part of success is the estimate of Gross Domestic Product (TAX ID No), which should be around 3,0%, well above the 0,6% which was considered in December 2022.

In this scenario, there is no justification, neither economic nor social, for trying to violate the law that defines resources for the SUS. This, however, was what technocrats in Brasília tried in August and September. First, there was consultation with the Federal Audit Court (TCU) on the interpretation of the budgetary rule, which, given the government transition, estimated the net current revenue, the basis for calculating the resources to be allocated to the SUS. The TCU denied the intended flexibility and reaffirmed that what counts is not the estimate made at the beginning of 2023, but the effective revenue, that is, what will actually have entered the government's cash flow, by the end of 2023.

Instead of taking the matter to the National Health Council and other councils that make up the SUS governance system, such as CONASS, which brings together the state health departments and CONASEMS, which represents the municipal bodies responsible for managing the SUS , thus strengthening social participation in health issues, and sharing a decision of this magnitude with organized society, the government opted for the legislative shortcut and, at the drop of a hat, managed to approve in the Chamber of Deputies the complementary bill 136/2023.

Once approved in the Chamber, the project went to the Senate. The government does not want the calculation of resources for the SUS to imply the government's success in combating inflation and GDP growth. It wants to allocate these resources differently, accommodating political pressure and leveraging budgets from other ministries.

But SUS defenders are reacting to this attempted amputation, which according to the Brazilian Association of Health Economics and others analysts would be in the order of R$18 billion. These are resources that will be needed to face the chronic underfunding of healthcare, one of the main victims of the neoliberal policies that have been imposed on the country. Today, the SUS is supported by low wages, precarious labor and scrapping of facilities. And that is intolerable.

Some criticisms of the government's initiative have, however, confused the loss resulting from the health budget allocation calculation model, with the withdrawal of resources from the SUS to serve “the market”. There is some basis for these criticisms, but they fail to consider two aspects:

(i) the weight of the market in this issue is small, perhaps irrelevant, because contrary to what is speculated, the health market loses with the government's proposal. It is necessary to take into account, in this regard, that the SUS is counter-hegemonic and the hospital-centric model, with 4/5 of the beds under private control. Furthermore, the SUS operates to support corporate health, represented by the misnamed “health plans”, which often rely on the public service. Thus, the health market loses with non-compliance with the constitutional rule, therefore having an interest in more resources for the SUS, and not the opposite as assumed. For the financial market, the issue does not have a major impact, except with regard to public accounts, which, judging by the destination that resources transferred from health would have, does not apply.

(ii) Contrary to what was estimated in 2022, that the SUS budget for 2023 would be reduced at around R$22,7 billion, the opposite happened. There was a substantive increase in the SUS budget: from R$149,9 billion to R$183,8 billion, an amount that would be further increased, by the end of 2023, by another R$30,2 billion.

Although it is not possible to guarantee that the government does not want to deconstitutionalize the minimum budgets linked to health, as there are indications that technocrats in Brasília have insistently talked about this, especially in the Ministries of Finance and Planning, it is not justified to say that “health is in risk” or that the government is promoting a “frontal attack on one of the greatest achievements of the 1988 Constitution”, or that the government’s initiative “put the lime shovel” in SUS. Not yet. But you can't take your eyes off Brasília's technocrats.

Lula, who has said and repeated that “health is not an expense, health is an investment”, does not seem to approve of these austerity plans. But that's what your government is doing. What will Lula do if the Senate approves the project that will withdraw R$18 billion from the SUS, when it receives it for presidential sanction? Lula knows that if he gives in to the “technocrats of Brasília”, and takes resources from the struggling SUS, the widespread feeling would be that he would be betraying himself and betraying those who elected him.

During the dictatorship, “Brasília technocrats” who made mistakes were corrected by their bosses, when what they did took on political dimensions.

What will Lula do in democracy?

*Paulo Capel Narvai is senior professor of Public Health at USP. Author, among other books, of SUS: a revolutionary reform (authentic). []

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