SUS, 32 years old: this land has an owner

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By Paulo Capel Narvai*

Although underfunded, the system has resisted the pandemic and, above all, the brutal attacks that are relentlessly launched at it from the Planalto Palace and the Esplanada dos Ministérios.

Upon turning 32 on May 17(1), the Unified Health System (SUS) is one of the few Brazilian institutions, in addition to the national symbols and the national currency, present in 5.570 municipalities and in the Federal District. Also in these territories are Flamengo (and probably Corinthians), for its almost 70 million fans, and some religious denominations. But it is the SUS that marks the institutional presence of the Brazilian federal state.

The Constitution of the Republic, enacted in 1988, dedicates article 196 to the right of everyone to health and states that it is “the duty of the State” to ensure its exercise. Brazil is one of the few countries that constitutionally recognize this right. It is worthwhile, by the way, to review the entirety of art. 196, expressed in the following terms “Health is everyone’s right and the State’s duty, guaranteed through social and economic policies aimed at reducing the risk of disease and other diseases and universal and equal access to actions and services for its promotion, protection and recovery”.

Few realize how advanced this article is, by linking “social and economic policies”, which should be oriented towards “reducing the risk of disease and other harms”, to the idea of ​​health. Thus, in addition to ensuring everyone's right to “universal and equal access to health actions and services”, the 1988 Constitution recognizes and positively values ​​the role of the set of public policies in the “promotion, protection and recovery” of health. For everyone, without exception.

Article 197 affirms the “public relevance” of health actions and services, which is why it is up to “the public power to dispose, under the terms of the law, about its regulation, inspection and control”. Federal laws 8080 and 8142, both from 1990, regulate the SUS, whose principles and guidelines are the object of articles 198 to 200 of the Magna Carta of 1988.

In previous articles published on the website the earth is round ('rounding up health", "SUS: scorched earth' And 'SUS: no man's land') I addressed the important achievements of our universal system for Brazilian public health in the last three decades and identified its main difficulties, embodied in the chronic underfunding that has led to the scrapping of facilities and equipment and the precariousness of labor ties with a notable devaluation of health professionals. health. Devaluation that also affects, and most of the time unfairly, its directors and managers.

It is common to hear that the SUS “is good in theory, but it is poorly managed” and that this would be one of its main problems. Many health secretaries and directors of hospitals and health units are publicly presented by the press as if they were foolish and incompetent. The solution, they say, would be to privatize and “bring the excellence of competitive management to the SUS, the experience of the market”. Constitutional Amendment 95/2016, which froze resources destined for public health for 20 years, is further stifling SUS underfunding. According to the National Health Council, R$ 22,5 billion were withdrawn from the system in the last two years alone. This picture is aggravated by the fragmentation of management, which has been shared by the Union not only with States and Municipalities, as it should be.

Over these 32 years, hundreds of private companies, inappropriately called “social health organizations” (OSS), have gradually become involved in the management of the SUS, including philanthropic institutions ('Holy Houses of Mercy', for example), many of which operate in line with commercial interests, going against decisions by councils and health conferences. Asked about the legality of the transfer of public resources to OSS, the Federal Supreme Court (STF) decided yes, on 16/5/2015.

It so happens that some OSS present deviation of purpose in their operations, as they are controlled by groups of unscrupulous businessmen, who buy and sell them as if they were greengrocers, supermarkets, appliance stores or any other companies. Others are controlled by gangs that specialize in stealing public money. They are not social at all, nor do they refer to communities or ethnic groups. They are, at best, only companies managing the exercise of the social right to health, operating where the State should be, whether through direct or indirect administration. But, above all, only the State, with exceptions to this rule duly justified and periodically approved by health councils and other State control bodies.

On the other hand, many philanthropic institutions are nothing more than what, in the jargon of SUS workers, is known as “pilanthropic”, as their balance sheets are always in the red, while some of their directors hide fat bank accounts. Despite, or even because of this, they are always asking for more and more complementary resources from governors and mayors and, above all, directly from the National Congress, where there are deputies and senators whose electoral campaigns are “strengthened”, legally or illegally, with money from funds that should finance the SUS. Philanthropy, as an expression of the noble sentiment of charity, goes far, far away from “pilanthropy”.

Although systematically hidden from the population by the large commercial media, which deliberately makes it invisible to please the companies whose commercials support it, and is constantly attacked for ideological reasons, the SUS boasts numbers that make its efficiency clear, as I emphasized in 'SUS: scorched earth'. There are management problems, which can and should be permanently improved, as is the case with all public administration, but, quite contrary to what the commercial press reports, the efficiency of the Brazilian health system is undeniable.

Now, in 2020, with the COVID-19 pandemic, SUS is facing yet another very tough test of its ability to face and solve public health problems. Indeed, although underfunded, the system has resisted the pandemic and, above all, the brutal attacks that are constantly launched at it from the Planalto Palace and the Esplanada dos Ministérios. As if the insults to reason perpetrated by the current occupant of the Planalto were not enough, who with his bravado and flashy appearances not only hinders technical actions, but creates additional difficulties in facing COVID-19, the Ministry of Health also chose not to act and, simulating that it does something, let the pandemic spontaneously run its course throughout Brazil.

States and municipalities that do what they want and how they can, seems to be the ministerial motto, whose current holder, Nelson Luiz Sperle Teich, is a Greek gift given by Bolsonaro to citizenship in celebration of the 32 years of the SUS. In the week in which our country officially registered more deaths and confirmed cases of COVID-19 than China, whose population is 6,5 times greater than that of Brazil, Teich said he was concerned about the financial situation of private hospitals(2).

an evident SUSCITED(3), placed in charge of the national health system with the mission of doing only what Bolsonaro tells him to do, but continuing to speak, as his predecessor did, about truisms about the pandemic. He reiterates, without conviction, that “we, as a ministry, have never positioned ourselves to get out of detachment”, maintaining the “scientific” stance of the folder.

A specialist in verbal contortions, he assured that the president "is concerned with people, with society". Now without Mandetta, but with a simulacrum at the height, and anodyne for Bolsonaro, the tweezers strategy runs its course. Before him, he distinguished himself as eminent SUSCITED in charge of the SUS, Michel Temer’s Minister of Health, Ricardo Barros, for whom “the size of the SUS” needed “to be reviewed”(4). Both Barros and Teich ended up in office legally, but illegitimately, as they never “moved a straw” even in the extremely difficult construction of the system. Their biographies only matched the trajectory of SUS in exercising the highest position in Brazilian Health.

Notwithstanding these SUSCIDATE, the SUS has been gaining new followers (SUSists)(3), some unusual until recently, such as journalists(5) and businessmen(6) seen as an expression of neoliberal thought and, therefore, in principle averse to the presence of the State, even in matters related to the exercise of social rights. Proof that intelligence, like ignorance, in its different modalities, is not linked to this or that ideological option.

Even before the 2020 pandemic crisis, but still in October 2019, when Latin America was shaken by massive uprisings in Ecuador and Chile, the SUS was seen as a necessary institution to mitigate the effects of possible “similar problems” in Brazil , if the ultraliberal agenda defended by minister Paulo Guedes, the “scissor-hands”, prevails, nickname dedicated to him for his obstinacy in “cut, cut, cut”, advancing (as effectively happened) on the Brazilian social protection system , which includes, alongside the SUS, social security and social assistance.

But it was with the pandemic, however, that radically changed the view of many about the SUS, now seen as the mainstay on which it is possible to face COVID-19, despite the trivialization of the disease by the federal government and the hostility to the idea of put scientific thinking, not the 'flat earthism' health, guiding prevention and control actions, or as required by the 1988 Constitution, “actions and services” for the “promotion, protection and recovery” of health.

It is the capillarity of SUS, with its presence throughout the territory (there are about 43 thousand Basic Health Units - UBS and 550 Emergency Care Units - UPA) composing what is defined as a basic network, forming an articulated and coordinated set, combined with the shared and participatory management capacity (of users organized in councils) that gives the SUS competence and power to resist the new coronavirus and the 'mandonist' outbursts of the authoritarian tradition that once again took the Brazilian Republic by storm.

SUS resists and is at the forefront of facing the COVID-19 pandemic. The system is, effectively, a fortress, despite its known frailties and has been built through a lot of political action by the actors interested in its consolidation and development as a public institution. It is important to emphasize this aspect, as the SUS is a State policy and, therefore, is not linked to this or that political party, to this or that government, even though parties and governments value it to varying degrees or even do not value it.

For this reason, what it is, concretely, in the country and in each municipality, results from political actions, negotiations, agreements, pacts. But this is your strength, not a vulnerability. Certainly, politics and clientelism must be repudiated. What must be done to reject such practices is the defense and deepening of democracy and the principles that govern public administration. No, as sometimes happens, denying the policy, because it is not “the policy” that harms or hinders the SUS, but the opposite.

It is precisely the ideological negation of politics (and, it should be noted, of political parties and democracy), as the Bolsonaro government does, in its Christian fundamentalist crusade to install in the country the “permanent conflict”, ideologically based and denying the role of politics, which greatly harms and hinders the elaboration and implementation of public policies that produce and protect rights. Including the right to health. By the way, it is always worth emphasizing: “Health is democracy. Democracy is health”, as Sérgio Arouca repeated and as he inaugurated the 8th National Health Conference (1986) and reiterated its 16th edition, held in 2019.

Contrary to what Bolsonaro thinks (“I have the pen”; “I’m in charge”) and his Minister of Health (“we don’t have information”; “the government doesn’t know the reality of events”; “I don’t know and nobody knows ”), the SUS has an owner and has a direction. Its owners are the Brazilians who finance it with the taxes they pay. Its direction, defined by users and health professionals in Health Conferences, periodically held in municipalities, states and nationally, is the affirmation of the right to health and the refusal to transform health actions and services into merchandise. It's no small thing.

For the “new” world that will come post-COVID-19, Castells(7) points to new ways of living, thinking and organizing the economy, revitalizing the public sector and reforming it, to rid it of bureaucracy and politics. Relying on the SUS to reorganize the intervention of the Brazilian State in economic and social policies that make them operate to “reduce the risk of disease and other injuries” and ensure the right of all to “universal and equal access to actions and services” of health, is an excellent starting point.

But for that to happen, it will be necessary to politically defeat the arrogance of the federal government in its relations with the other federative entities. The regrettable episode of the impediment of the participation of official representatives of States and Municipalities in the inauguration ceremony of Nelson Teich, on 17/4/2020(8), an unprecedented fact in the history of the SUS, shows the size of the government's lack of understanding about what the SUS is and how it works, who owns it and what is its direction. The minister's later apology only made matters worse. Daily meetings, even if virtual in the current situation, on the national management of the SUS, including measures related to facing the pandemic that is plaguing us, with the participation of representatives of the Union and of States and Municipalities, simply did not take place in the weeks that followed to the loss of possession.

Teich has been evasive and innocuous in direct meetings with governors. The federal government's promises related to the purchase and distribution of ICU equipment and basic supplies, such as gloves, masks and other personal protective equipment, have been taking "an eternity" to materialize. The conviction that became widespread among SUS managers is that the system is without its national command, in one of the most serious moments of its history. Manaus is today just the most eloquent example of the consequences of the federal manager's omission, and of the abandonment to which Brazilian municipalities have been subjected, a fact that is dramatically worsened in large cities, especially the metropolises.

It is now up to the representatives of States and Municipalities to take the reins of the national management of the SUS and show that, at 32 years old, the SUS is a “land with owners”, an effectively national heritage, and that it cannot be reduced to just another “program”. of the federal government”. It is necessary to demand respect for federal entities so that national solutions can be built for problems that go far beyond the restricted scope of action of the federal government, although it plays a central strategic role.

Above all, it will be necessary to defend the SUS as a universal health system, since one of the most important lessons from the COVID-19 pandemic was to demonstrate the fragility of the strategy known as “universal coverage”, according to which health actions and services do not need be rights enshrined in the constitutions of countries, nor that governments invest to implement this right, it being sufficient that they assure everyone the ownership of 'health plans' (which, incidentally, are neither 'plans' nor much less 'health plans') .

What is being seen around the world is that the market and its much vaunted self-regulation fail miserably when it comes to health. Extreme situations, such as COVID-19 show that not even vouchers, consultation checks or health plans (“top”or “popular”), not even “cash-in-hand”, are capable of generating resources and, above all, competences, where this does not exist. On the contrary, it appears, once again, that countries that have universal health systems have been responding more appropriately to the challenges of the pandemic, when compared to those that adopted the strategy of commodifying health care.

The example of the United States is only the most expressive, but not the only one. Incidentally, there, as here, the heads of the executive branch disdain the pandemic, increasing its risk by repeating statements whose sole purpose is to please the most uninformed segment of their voters. They partisan the epidemic. They get in the way a lot. Professor Marcio Moretto, from EACH/USP, analyzed the correlation in São Paulo municipalities with more than 300 voters, between the percentage of votes for Bolsonaro in the first round of the 2018 elections and the degree of adherence to social distancing, as of 25/3/2020. It found a strong negative correlation (r = -0,77). Those who voted the most for the president least followed the guidelines of the health authorities of the SUS and also the World Health Organization.

Source: Moretto M (EACH/USP, 2020).

Attitudes and statements by heads of state and government are very important in facing epidemics, as such positions, whose exercise requires balance and composure, give credibility to actions and command respect. In a federation of continental dimensions like Brazil, this is even more important. Without this credibility and respect, as is happening in Brazil, the function of coordinating the fight against the epidemic ends up having the figure of the President of the Republic not as its main manager, but the main problem.

Regrettably, Bolsonaro established himself as one of the main obstacles to actions, not only by the federal government, but by other federal entities responsible for the SUS across the country. States and municipalities, in addition to dealing with their specific difficulties, have the duty of trying to neutralize the harmful effects of actions originating from the Palácio do Planalto, which persists, irresponsibly, in projecting to the nation the idea that we face no more than a “little flu”, which can be faced with fasting and faith, combined with miraculous “medicines” that “our hospital X discovered”.

This attitude, as negative as it is farcically optimistic, induces individual behaviors and business practices that increase the number of fatal victims of the pandemic. The sanitary “terraplanismo” that shapes the presence of the President of the Republic in the epidemic scenario, with his actions and omissions as Head of State, has thus become a relevant part of the problem we face to overcome the pandemic.

At the age of 32, the SUS continues to live with relevant uncertainties that make the present difficult and threaten its future and that need to be faced, now more than ever. These are not new problems, but they have been aggravated in recent years and have gained emphasis with the COVID-19 pandemic. Solution possibilities have been identified at health conferences and other forums, but unfortunately they have not been valued at the political level by decision makers.

Among them are, in addition to the repeal of EC-95/2016 and the spending ceiling that financially suffocates the SUS, the urgent recovery of resource losses imposed on the system since its creation, as well as the Social Security system as a whole, from which deals with Chapter II of the 1988 Constitution, whose fragility as an instrument of social protection was evidenced by the inability of the Brazilian government to deliver, with due urgency, resources intended for people's subsistence. Millions of citizens were humiliated across the country, in queues and depressing crowds and not epidemiologically recommended, to receive aid of R$ 600,00 that took several weeks to be released, when you have the technology and resources to carry out such operations in a few hours, or at most a few days.

It is extremely urgent to develop, strengthen and consolidate the Brazilian Social Security system, ensuring it has the resources it needs to protect citizenship. This recovery of Social Security's financial capacity should be used, within the scope of the SUS, to create an inter-federal multidisciplinary career, nationwide in scope and administratively based in the health regions, under joint management by the Union, States and Municipalities.

To this “SUS State Career”(3) all management and advisory positions in public health systems and services must be linked, the provision of which must comply with technical-administrative criteria and result from prior submission and appointment of holders approved by the respective health councils, of which professional representations are part acting in the SUS, in participatory and democratic management processes, aiming to curb political party clientelism, electoralism and nepotism in public administration.

Some, like Angela Merkel, the German Prime Minister, have referred to the COVID-19 pandemic as if we were in a war. There is talk of a “war budget”. Others compare the economic impact to that caused by World War II. The “Pracinhas”, veteran Army soldiers who fought Nazi-fascism in that conflict are today, justly, recognized as national heroes and, with their families, supported by the Brazilian State.

Similar treatment should be given to health professionals fatally victimized by COVID-19, as proposed by the National Health Council. After all, in the “COVID-19 war”, such professionals are a kind of “Pracinhas” of the SUS, whose families and dependents also deserve, in their absence, support from the public authorities.

Nursing professionals held, on May 1st, an act in celebration of World Workers' Day, with a silent and peaceful protest at Praça dos Três Poderes, in Brasília. They denounced, with the support of the Union of Nurses of the Federal District (SindEnfermeiro), the neglect of their conditions, resources and work environments, especially the lack of PPE.

They also sought to draw attention to the number of deaths caused by COVID-19 and to draw attention to the importance of physical distancing in controlling the pandemic. All wore face protection masks and maintained the recommended minimum distance of two meters. Although they demonstrated peacefully, the participants were the target of hostilities, insults and aggressions by a group of fanatical supporters of the federal government, wrapped in or wielding Brazilian flags.(9).  

Health professionals, who were justly applauded on many autumn 2020 nights across the country for their dedication and courage in facing COVID-19, need to be recognized for what they are: professionals. Therefore, nothing fairer than creating, with them and them, a State Career of the SUS, because without health workers there is no SUS. And without SUS we would live in a kind of “sanitary hell”(10).     

* Paulo Capel Narvai is senior professor of Public Health at USP.

Notes

  1. Narvai PC. SUS: 30 years of resistance and counter-hegemony. Abrasco blog [internet]. May 17, 2018. Available at: https://tinyurl.com/y8sz487z
  2. Leitão M. Teich defends “health” in private hospitals and causes discomfort in the ministry. See [internet]. Apr 23, 2020. Available at: https://tinyurl.com/yck3mevq
  3. Narvai PC. They want to kill SUS-4: SUS National Career in them! CEBES blog [Internet]. 4 Aug 2015. Available at: https://tinyurl.com/y84gmtls
  4. Collucci C. Size of SUS needs to be reviewed, says minister. Folha de S.Paulo [Internet]. May 17, 2016. Available at: https://tinyurl.com/y8wyl2xx
  5. Azevedo R. Go to Chile! Folha de S.Paulo [Internet]. 25 Oct 2019. Available at: https://tinyurl.com/y7f8rxgn
  6. SUS is the best health system in the world, what is lacking is management, argues Luiza Trajano. By Giovanna Reis. Folha de S.Paulo [Internet]. March 31, 2020. Available at: https://tinyurl.com/y9j8ad9s
  7. Castells M. Time for the big reset. Other Words [Internet]. 27 Apr 2020. Available at: https://tinyurl.com/yaqjd6yl
  8. Health secretaries are barred in Teich's possession. By Daniel Adjuto. CNN Brazil [Internet]. 17 Apr 2020. Available at: https://tinyurl.com/y83vzoko
  9. Nurses honor victims of Covid-19 and are harassed in the DF. By Cibele Moreira. Correio Braziliense [Internet]. 1 May 2020. Available at: https://tinyurl.com/y8fur4pj  
  10. Narvai PC. The control of SUS by society. Folha de S.Paulo [Internet]. Feb 23, 2007. Available at: https://tinyurl.com/ya8dwb8e
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