SUS, 36 years old – consolidation and uncertainties

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By PAULO CAPEL NARVAI*

The SUS was not the “stillbirth” that many predicted. Almost four decades later, the SUS is institutionally consolidated and has developed a notable process of republican governance

All illusions, derived from the myth of market freedom, that the private segment of health care production would be powerful in ensuring the health of the population because, supposedly, it is “more efficient and modern” than the private sector, fall to the ground. public. What is observed, in the post-pandemic period, is an unrestrained increase in the prices of products offered to consumers who cannot afford them. These are uncontrolled prices and are defined, in practice unilaterally, by companies that, under the control of transnational corporations, operate under mercantile logic. Without any link to the health needs of those who purchase their “plans”, they follow a course of increasing oligopolization.

Worse: with the tax waiver in the health sector, it is estimated that the Federal Revenue stops collecting annually, according to research developed by economist Pedro Eduardo Santana Tupinambá, at the School of Government of Fiocruz/Brasília, something around $ 55 billion, a value that corresponds to approximately one third of the budget of the Unified Health System (SUS). The private health sector therefore operates as a relevant mechanism for transferring resources from the bottom to the top of the socioeconomic pyramid, deepening inequalities in the country.

It is the opposite of what the Health Reform Movement has always proposed, which conceived the SUS as a public policy that, linking health and democracy, would contribute to reducing inequalities and promoting equity, refusing to transform health care into a commodity.

“There is no free market or free initiative in the private health sector,” said Eduardo Magalhães, coordinator of the Permanent Education Center of the Center for Studies in Public Health (CESCO) of the University Center of the Faculty of Medicine of ABC (FMABC), in an interview to Inês Costal and Patrícia Conceição, for the Health Policy Analysis Observatory (OAPS), at the Institute of Public Health, at the Federal University of Bahia.

Reproduced by the website “Other Health”, the interview shows that companies that operate in the private health segment of the Brazilian health system, oligopolize the sector shared by seven corporations – which Magalhães calls the “Seven Sisters of Health (SIS)” – and are part of the group of 200 largest business conglomerates operating in Brazil. These companies account for 63,5% of the country's GDP. Those that operate in the private health segment (which are more like necrobusiness than sanbusiness), together with the electricity and finance sectors, “are part of the economic elite that controls the Brazilian economy”, says Magalhães. According to the research carried out under the supervision of Ladislau Dowbor, there are “6.235 companies and funds linked to each other through 7.257 shareholding connections”.

Necrobusiness, represented by private healthcare, has hegemonized the Brazilian healthcare system since before the creation of the SUS. Eduardo Magalhães' research updates the mechanisms through which this hegemony is effective and induces the predominant health care model in Brazil and against which the SUS struggles, as counter-hegemonic political project, proposed by the Health Reform Movement, since the struggles against the dictatorship.

But, if the business of necrobusiness is to accumulate, reproduce and concentrate capital, draining public resources via tax waiver and renouncing health care by excluding everything it can from the list of procedures, the counter-hegemonic project represented by the SUS continues to encounter many difficulties to enforce the ideas of the Health Reform. What we have today as the SUS has gradually moved away from the system designed in the 1980s, approved at the 8th National Health Conference and established by the constituents of 1988.

For this counter-hegemonic project, healthcare is a right to which access must be “universal and equal” and actions and services must be guaranteed to everyone. But as health does not only derive from health care, the SUS as a health system needs to ensure that the set of “social and economic policies” operate with the aim of “reducing the risk of disease and other health problems”, so that achieve the “promotion, protection and recovery” of health for all.

It is like this inclusive public policy that promotes rights that the SUS has been built. It is admitted that it is institutionally consolidated as a state health system and, effectively, the single health system of the country (and not merely a health service system, which produces consultations, procedures and exams). But the SUS has “moved forward” with the difficulties that are visible to everyone, as its consolidation at the institutional level does not eliminate the many uncertainties about its future.

36 years ago, in 267th Session of the Assembly, on May 17, the 1988 constituents made the decision to create the SUS. A historic agreement with the 'centrão', a conservative parliamentary bloc that hegemonized the Constituent Assembly, made the proposal politically viable and the system was created. The 'centrão' of the Constituent Assembly was a kind of grandfather, and not much better, of the 'centrão' that we have today in the National Congress which, as we know, distorts parliamentary representation, contaminates politics in many ways and contributes, daily, to setbacks in Brazilian democracy.

But the “grandfather”, still afraid of the political effects arising from the formidable “Diretas Já!” campaign, agreed to the agreement to create the SUS. Today, with the “centrão-neto”, don’t even think about something like that.

In 1988 there were 472 votes in favor of the creation of the SUS, 9 against and 6 abstentions.

Despite the forcefulness of this vote that created it, the SUS staggered in its first years. Once the Constituent Assembly was concluded in October 1988, just two years later, in September 1990, it was possible to approve in the National Congress the law 8.080, which regulated the constitutional provisions on the SUS. Even so, then-president Fernando Collor vetoed some articles of the bill that regulated our universal health system, related to financing, as it would involve transferring resources from the Union to municipalities and effecting decentralization, and the regulation of councils and conferences. health system, ensuring “community participation” in the SUS, throughout the country.

Fernando Collor wanted to keep health resources centralized in the federal government and make any possibility of participatory management in the SUS a “dead letter” in the 1988 Constitution, with social movements, health professional entities, workers in general and representatives of organized society, deciding on public health policies in health councils and evaluating them periodically, through national, state and municipal health conferences. But, under great pressure not to violate the Constitution, Collor was defeated politically and in December 1990 the law 8.142 regulating what had been vetoed.

In that two-year period, between 1988 and 1990, the “Municipalization is the Way” movement grew and strengthened, still under the government of José Sarney (1985-90), led by the Council that brings together municipal health leaders, the CONASEMS. Under the leadership of the late Pernambuco native Paulo Dantas, one of the founders and its first president, CONASEMS resisted attempts to restrict decentralization to the state level, and energetically defended, contrary to the wishes of some governors and state health secretaries, the need for decentralization to reach municipalities.

The strategy SOUTH, made official in 1987, was considered by some leaders of the Health Reform to be an important step for the SUS to begin to take effect. But others considered that it was just a reaction to the immediate implementation of the SUS on a municipal basis, trying to maintain INAMPS as a strategic institution for the functioning of the system. There is no consensus in the Health Reform movement on the role of SUDS in the political process of institutionalization of the SUS.

The Collor government (1990-92) tried to take advantage of the uncertainties of that moment to keep decisions on the management of health programs and actions centralized in the federal government and transform municipalities into mere service providers to the SUS, a decisive aspect to the time for the implementation of the SUS on its municipal basis. Has been defeated.

The SUS was, therefore, not the “stillborn” that many anticipated. Almost four decades later, the SUS is institutionally consolidated and has developed a notable process of republican governance, with the participation of federative entities in all spheres of government, throughout the country, which today serves as a model for public management in the Democratic State of Right. SUS governance has been a model for other public systems, such as in the areas of social assistance (YOUR) and public safety (SUSP).

The most scathing test of resistance faced by the SUS took place during the Covid-19 pandemic, when our universal healthcare system showed great resilience. Brutally and systematically attacked since his command in the federal government, he quickly found ways to reorganize himself on his municipal basis, to face in each locality the international health emergency, which killed thousands daily throughout Brazil, developing regional and state management processes that were decisive in confronting the pandemic, mitigating its dramatic effects in the country. Today, as I wrote with colleagues at USP, the SUS is more necessary than ever.

But what will the SUS be like in 36 years? Will our universal system survive the chronic underfunding that has marked it since its birth? And, as important as having more resources, it will be able to improve its control processes over the destination of public resources, whose failures have allowed criminals and corrupt people, through criminal organizations that pretend to be philanthropic and non-profit entities, to target your hand in public health money? It is worth remembering that among those 15 constituents who did not agree with the creation of the SUS in the 267th Session of the Assembly, they were members of the PCdoB who explained that their vote was contrary, as the volume and source of budgetary resources were not explained in the proposal being voted on. that should finance the SUS.

Almost four decades later, the problem of financing sources has been overcome, on a legal level. Currently, there is definition (law 141/2012) of the percentages of their respective budgets that the federative entities are obliged to invest in the SUS. But a “sword of Damocles”, represented by the economic policy that seeks to delink budgetary sources from the SUS and its financing resources, continues to hover alarmingly over the system.

Regarding the future of the SUS, I heard from two leaders who were at the head of the National Health Council (CNS) in recent decades. The CNS is made up of 144 members, of which 48 are full councilors, each with two substitutes. Half of the board is made up of counselors who represent SUS users, through entities and social movements. The other half includes representatives of workers and the scientific community (25% of the total) and managers from the public and private health sectors, including the federal government, the National Council of Health Secretaries (CONASS), the National Council Municipal Health Departments (CONASEMS), complementary health and business entities (25% of the total).

I spoke with Eliane Cruz, who was Executive Secretary of the CNS from 2003 to 2008, and with Francisco Batista Júnior, who presided over the body between 2006 and 2011. The conversation should have included the current president of the CNS, Fernando Pigatto, resident of Rio Grande do Sul. in Rosário do Sul, located on the banks of the Santa Maria River in the southwest of Rio Grande do Sul, and which has been at the head of the CNS since 2018. But, due to the floods in that State, evidently its participation had to be interrupted, as Pigatto is involved in the extremely important work of supporting victims.

I asked everyone to identify three achievements of the SUS since its creation, three aspects in which our universal health system has been finding it difficult to advance in fulfilling the mission assigned to it by the 1988 Constitution, and what they consider to be the main current challenge and of the coming years.

The institution of the SUS itself as a strategic element in the social security and protection system in Brazil, was indicated as one of the three achievements of transcendental importance in this historical period, by ensuring everyone's right to health and attributing to the State to guarantee its exercise and consolidate the principles of universal access and comprehensive health care.

For Batista Júnior, the creation of the SUS “signified a milestone in the exercise of citizenship, in a country where social exclusion has historically always been the rule”, even though these principles are not, even today, “guaranteed in their entirety”. Eliane Cruz highlighted the notable “expansion of the public service network and the consolidation of spaces for social participation in the SUS management processes, enshrined in laws 8.142/90 and 141/2012”.

The importance of social participation in the SUS through the various spaces constituted, the councils, plenaries and health conferences, was also emphasized by Batista Júnior who warned, however, that “this possibility is a process under construction, in a fierce dispute against authoritarianism and centralization that guide power relations in the country”. For the former president of the CNS, in these almost four decades the SUS contributed significantly to “transforming and improving the living conditions and socio-epidemiological profile of Brazilians”. This fact, he says, is highlighted “in all studies on the actions and services developed by the SUS in all regions of the country”.

Among the difficulties that persist challenging the SUS are, for Eliane Cruz, “improving medium complexity care, organizing the professional training system based on the SUS and expanding the financial resources allocated to health actions and services”. Batista Júnior identifies the continuity of problems for the “full structuring of basic care as a gateway and solution”, noting that the inadequate resolution of this difficulty so far has “direct implications for the permanent increase in demand for specialized and high-cost procedures” , which could lead to the “economic and political unsustainability” of the SUS, if we are unable to move forward in overcoming this scenario.

He also considers that the SUS “owes it to the country and the population to expand its own network of secondary and tertiary care services, in order to make it possible to meet all the pent-up demand held hostage by contracted and contracted private services”. It also draws attention to “a significant range of demands related particularly to chronic degenerative diseases, whose adequate care requires the participation of professionals who, unfortunately, are not made available by the SUS, in its own network”.

Both converge in the recognition that the SUS needs to overcome precarious work relationships and professionalize healthcare personnel. Batista Júnior defends for the entire workforce that operates the SUS, “a Single and Interfederative Career for all workers across the country” covering “the entire multidisciplinary team, valued, with stability and structured”. For Eliane Cruz, it is necessary to “make work relationships less precarious”, as in this regard “there is a lot of inconsistency in the formulations and few initiatives”.

Among the challenges for the coming years, “reaching 6% of GDP for public health and taking the SUS to training processes (including social control), from technical education to postgraduate studies” was highlighted by Eliane Cruz. Batista Júnior reiterated the strategic importance of facing the serious difficulties of management and underfunding, but pointed out as “the biggest and most serious problem of the SUS, the elitist, specialized, privatist and doctor-centered model that has been imposed on it” and continues to be reproduced .

To overcome these obstacles, Júnior recommends “investing heavily in disease prevention and health promotion actions, including a permanent process of intersectoral actions, the expansion of our own service network, in order to gradually replace the contracted private network, and replace all forms of privatization currently underway, establishing direct contractualization between services and their respective management levels and professionalizing service management and system management, as a general rule, to be obeyed by all federative entities, in all the management levels of the SUS.

For the former President of the National Health Council, the creation and development, permanently improving it, of “a State Career for SUS workers, unique, multi-professional and inter-federative, financed with the budgetary resources of the SUS at the federal level, is decisive. , state and municipal, with a public competition as a form of entry, job stability and single remuneration rules covering all SUS workers, throughout the country”, highlighting that for this purpose it is necessary to “recognize, value, support, strengthen and provide the conditions required for the democratic exercise of social participation in health, through so-called social control, as a mainspring in facing challenges and in defining and evaluating policies”.

It could be a lot. “A dream”, those who only have their eyes on the present-day horizon will say. But it wasn't a dream that leaders of the Health Reform like David Capistrano Filho wanted when he stated that with the creation of the SUS it was necessary to “avoid the birth of a bureaucratic monster, of national character, impervious to the real participation of citizens and the organized community ”? Capistrano wanted “the Union and the states [to have] multi-annual health plans, drawn up by collegial, democratic bodies and approved by the legislative powers”, understanding that “only winning hearts and minds will guarantee the continuity of what is positive and prevent setbacks.” Health and democracy. Democracy is health.

Why today, 36 years later, should our dreams be smaller?

*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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