Are we all SUS?



Decisive battles are under way over the future of the Brazilian universal health system

After four months and almost two hundred free conferences held throughout Brazil, on August 5th, in São Paulo, the Free, Democratic and Popular Health Conference-2022. Launched in Brasília, at the Chamber of Deputies, by front for life em April 7, World Health Day, the conference, as expected by the organizers, constituted a broad process of social participation that brought together, in person and virtually, thousands of people to analyze the health situation of the Brazilian population and the working conditions of the Unified Health System (SUS).

As health is strongly connected to living conditions, environments and ways of producing goods and services, these aspects were also in the participants' sights, with reference to the economic and social policies in progress in the country, under Jair Bolsonaro and the hegemony of ultraliberalism, whose leitmotiv it is the extermination of rights, with mortal preference for social rights such as education and health.

During this period, in the most different conditions and resources, throughout Brazil, organized by territorial areas or areas of action and assistance modalities, such as mental health and oral health, conferences were held that expressed the concerns and propositions of the participants about the health and SUS.

Users of public services, managers, leaders and activists of social movements, parliamentarians, researchers, sanitarians and professionals working in the SUS stood out among the citizens who, having something to say about health, actively participated in this process mobilized around the social right to health, with the objective of proposing directions to follow to face the sector's problems, from the most varied approaches and views, notably those related to the SUS and to the set of public policies that, as a whole, must, when effective in their spheres, to produce health and not diseases and health problems.

As it should be, the SUS was one of the axes of great strategic importance in the event-process represented by the Free, Democratic and Popular Health Conference-2022, as it is around it that decisive battles are underway over the future of the system universal health service in Brazil, opposing, on the one hand, segments linked to the financial system, interested in deepening the transformation of health services into merchandise and, on the other hand, social segments for whom the right to health, due to its characteristics, cannot be an object of business.

It is an unarmed but fierce clash, fought amidst attempts to impose narratives that, lying about the performance of the Bolsonaro government, seek to recount the tragic evolution of the Covid-19 pandemic in Brazil. In dispute, however, are much more than the destination of the financial resources allocated directly to the SUS, but above all the role that the set of public health services can play in the economy as a whole, whether as a buyer of materials, equipment and inputs in general , among which drugs, or as a policy inducer and market regulator, within its scope of action. This characteristic of the SUS places it at the center of social protection strategies, with all the economic and, above all, political implications that come from this condition.

In this regard, segments interested in defending the social right to health should learn from the many mistakes made since the creation of the SUS in 1988.

One of these errors can be summarized in the expression “we are all SUS”, which gained strength in the context of the 12th National Health Conference (Brasília, December 7 to 11, 2003), right at the beginning of the first government of Luiz Inácio Lula da Silva. Silva. Although it is an illusion, derived from the observation – which is indeed correct – that “we all use the SUS”, the false idea that “we are all SUS” every now and then sensitizes hearts and minds, and re-emerges with great persuasive power.

Indeed, the actions carried out on a daily basis by our universal health system reach all of us in some way, whether when we receive care, or when we are irremediably affected by its actions of collective scope, in the areas of promotion and surveillance, among which the most recognized and highly valued by the population is, to the despair of denialists and anti-vaccinationists, the application of vaccines. The most recent demonstration of this appreciation is being seen now, in the midst of the covid-19 pandemic. The population ignored the many anti-vaccination maneuvers put into practice by the Bolsonaro government and searched for vaccines to protect yourself from the coronavirus.

But if the statement that we all use SUS is correct, it cannot be said that “we are all SUS”, as life has shown the opposite. By the way, it is a risk to believe in this and to divulge it – even if this desire is legitimate. This belief, unfortunately, does not match the reality of the facts about the SUS and thus, instead of strengthening, it weakens those who defend it, as an indispensable institutional instrument to implement everyone's right to health. In the historical conditions in which the SUS has been daily constructed – and deconstructed – in Brazil, many people who oppose the recognition of the social right to health, enshrined in Articles 6 and 196 of the 1988 Constitution, take advantage of this illusion to, by -If you impersonate defenders of the SUS, attack it from within or externally.

There are many tactics used for this purpose and those who effectively defend the SUS must always be aware of the subterfuges and postponements used to institutionally weaken the system. The best thing to do, in this confrontation, is to identify the pitfalls and, not wasting time talking to put the ox to sleep, propose propositions that improve the quality of the actions developed by the SUS and strengthen it institutionally.

At the end of the 2022 Free, Democratic and Popular Health Conference, the expectation cannot be anything other than a clear indication of how the SUS must avoid the “contributions” that the pro-market sectors they want to give you, supposedly “bringing the excellence of private administration to the public service”.

For this, it is very important that the Conference identifies the main “critical knots” of the current situation of the SUS and indicates possibilities for untying them.

One of these concerns concerns the administrative fragility of the SUS, which does not have a federal body to support municipalities in their limitations to manage the SUS within its territorial scope. State capitals and large cities do not suffer so much from these limitations, but a few hundred municipalities simply do not have the administrative capacity, in the so-called direct administration, to handle the management of the SUS in their territories, especially in times of digital health and complex data processing systems.

The successful governance model of the SUS, with the inter-federal management commissions responding very well to the demands of the political dimension of management, does not, however, correspond, until today, to a powerful organization of the public administration with the mission of supporting the municipal federative entities , administratively enforcing the decisions made by the managers. Inter-manager committees do not make purchases or maintain employment relationships, to give just two examples of administrative competences that are crucial to management at the local level.

A extinction of the former INAMPS by Law No. 8.689, shortly after being incorporated into the structure of the Ministry of Health, on July 27, 1993, left a void that had never been filled in administrative terms. The assumption of that extinction, that the municipalities would have direct administrative capacity to manage their municipal health systems, proved to be a mistake, committed by defenders of the SUS. The exact opposite has been happening: the municipalities have been increasingly privatizing their services and systems and what is being observed is that what was sought after the extinction of INAMPS in 1993 is being reproduced at an accelerated pace: to put an end to the privatization of services and the corruption that always accompanied privatization, both tolerated by the governments of the civil-military dictatorship imposed on the country in 1964.

The regional level of management is, at present, the one that most suffers from this absence of public administration. In this context, there is a growing number of municipalities, large and small, that think they are solving this difficulty by privatizing services and even the entire municipal health system of the SUS. But they are deeply mistaken, as shown by several surveys good quality on the topic. Exceptions, and there certainly are, only confirm the rule of increased costs, questionable quality and user dissatisfaction.

Another “critical node” refers to a State Career for SUS professionals, as I emphasized in article posted on the website the earth is round. It is urgent to move forward with propositions that fill this void, either because there is no SUS without the professionals who give it life, or because it is necessary to establish, always in democratic inter-federal dialogue with the representative entities of these professionals, parameters for employment relationships to be observed throughout the country. In thousands of Brazilian municipalities, not only are labor links with the SUS precarious, via direct municipal administration or by privately owned entities – such as the so-called Social Health Organizations –, but social security protection for these professionals is also very precarious.

For this reason, it is urgently necessary to create a federally-based social security framework for these workers and their dependents, as this will not be adequately resolved by small and medium-sized municipalities. Without a federal social security intervention, SUS professionals will undoubtedly remain unprotected in the vast majority of Brazilian municipalities. By the way, there is talk, even more broadly, of a Social Security State Career, of which the Career-SUS would be one of the pillars, along with social security and social assistance itself, from the perspective of valuing and professionalizing the set of public servants of the Federative Republic of Brazil.

The “owners of power”, the patrimonialists and those who conceive the State as a big business desk certainly don't want to hear about these careers and the professionalization of public servants. The virulence with which these sectors and their ideologues react to these propositions gives, on the other hand, the dimension of the political right that it is to fight for them.

Alongside the chronic underfunding of the SUS, aggravated by the approval of Constitutional Amendment 95/2016, known as the “expenses ceiling”, the lack of a national administrative body for the SUS and the career of the State for its professionals, should be emphasized among the problems that have hit him hard at the present time. These problems need to be adequately resolved. Without facing them, it will be useless to reiterate that “we are all SUS”, because, in fact, while many defenders of the SUS repeat this, in the vain hope that by doing so their wish will come true, the enemies of the SUS are not deceived and treat to boost its mercantile project of denial of the right to health.

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


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