digital SUS

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By JOYCE SOUZA & FABIO DE OLIVEIRA MALDONADO

The construction of Brazilian digital health and the deepening of technological dependence

Contemporary times are notably characterized by the ubiquitous dissemination of datafication technologies, that is, technologies focused on methodologies, principles and techniques inherent to the collection, storage, processing and categorization of data.

This phenomenon has had a substantial and wide-ranging impact on the most diverse social spheres in the 21st century. Among these spheres, the health sector is one of the most impacted, generating apprehension among researchers, scholars and activists, due to its impacts directly affecting human life.

The term “digital health” or digital health It has gained momentum in recent decades and has systematically composed official documents from global health organizations and institutions. Certainly some of the most representative sources in this field consist of publications from the World Health Organization (WHO), which, since 2005, through resolutions presented at the World Health Assemblies and the United Nations (UN) General Assemblies, states that the use Information and communication technologies (ICT) in Health have become a strategic and fundamental component to promote equitable and universal access to health.

To date, the WHO has published three resolutions on the topic. The first, titled WHA58.28, took place in May 2005 and recommended that countries create long-term strategies for the development and implementation of national e-Health programs and services (the first term coined to describe health permeated by digital technologies; a term that , later, in mid-2018, it would be replaced by digital health).

The second, WHA66.24, dated May 2013, guided countries on e-Health standardization and interoperability, urging them to consider developing public policies and legislative mechanisms linked to an overall national e-Health strategy. The third, WHA71.7, from May 2018, presented the need to develop a global strategy on digital health (digital health), identifying priority areas in which the WHO itself should focus its efforts and actions.

Following this resolution, in March 2019, the WHO began holding several online public forums, technical consultations and meetings in its regional committees to consolidate guidelines and actions aimed at implementing the propositions present in the third resolution, that is, in the achieving global digital health. These initiatives culminated in the development and publication of the official document called “Global Digital Health Strategy 2020-2025”.[I]

This WHO document presents a connection between guidelines already presented at other times, incorporates new studies that also rely on global perspectives, in addition to a concrete action plan divided into three stages: short term (1-2 years) medium term ( 2-4 years) long term (4-6 years), which countries should undertake to implement digital health in their territories.

To this end, the WHO highlights the importance of having close collaboration between actors that it calls interested in implementing the global digital health strategy at an international, regional and global level, which would be state agents together with non-state agents, contemplating from the market finance, health insurance groups and other health care funders to technology developers.

By mentioning that state and private sectors must work together to implement globalized digital health, the WHO does nothing more than reinforce the neoliberal precepts of privatization of public services and the State as an agent promoting the interests of capital, while , in the cases of peripheral countries, also means deepening dependence, since the implementation of “partnerships” in this context means the State contracting services, solutions and technologies from private multinational companies, with headquarters in imperialist countries.

WHO and the digitalization of the Unified Health System (SUS)

Brazil, one of the founding members of the World Health Organization (WHO) and with a remarkable history, including two decades in the organization's General Directorate (1953-1973), has an extensive history of absorbing WHO guidelines for development and improvement of public policies of the Ministry of Health (MS).

In the context of digital health, this commitment manifests itself consistently. Since 2005, inspired by WHO publications, the country has been developing and implementing policies and legislation aimed at the use and dissemination of Information and Communication Technologies (ICT) in the health sector. However, it was from 2019 onwards that WHO guidelines, especially those aimed at establishing global digital health with solid integration between the public and private sectors, gained greater momentum in Brazil. It was in this context that the Ministry of Health launched the “Digital Health Strategy 2020-2028”, a comprehensive initiative that not only updates previous actions, such as the review of the National Health Information and Informatics Policy (PNIIS), but also introduces new measures, exemplified by the Conecte SUS Program and the National Health Data Network (RNDS).

The former Conecte SUS, renamed in January 2024 to Meu SUS Digital, an official application developed by the MS, plays a crucial role in providing digital and integrated access to SUS services for citizens, health professionals and managers.[ii] Each profile has specific functionalities and access permissions to different information.

For example, healthcare professionals feed and use patients' clinical data, including information about vaccinations, allergies, prescriptions, medications administered, exams, care and hospitalizations. On the other hand, managers have access to general information about care at Basic Health Units, while citizens can inform and consult their personalized clinical histories, in addition to searching for locations and service times according to their needs.

Meu SUS Digital is considered by the MS as a significant and essential step towards the consolidation of digital health in Brazil, given the fluidity of the information that passes through it. To ensure efficient traffic of this data, the application relies on the RNDS infrastructure, a national data integration platform in the health sector. In simple terms, RNDS is a platform that unifies the collection, storage and processing of data from various activities in the field of Brazilian health.

RNDS: fundamental infrastructure for the operationalization of Conecte SUS (My SUS Digital):

Source: Secretariat for Information and Digital Health (SEIDIGI).

According to a presentation made by the team from the Secretariat of Information and Digital Health (SEIDIGI) for the authors of this study, in December 2023, the RNDS already covers 72 million laboratory test records, 1 billion immunological records, 15 million authorizations of hospital admissions (AIH), 20 million authorizations for outpatient procedures (APAC), 582 thousand clinical care records and 10 million care regulations (SISREG). However, these numbers, still substantial, are considered modest given the significant potential that the RNDS can have for Brazilian health.

As emphasized by the team, in line with the guidelines of the Digital Health Strategy 2020-2028, the expectation is that by 2028 the RNDS will consolidate itself as the main national platform for innovation, information and digital health services. If this projection comes to fruition, the RNDS will become the central point where all information systems in the sector must connect, promoting a comprehensive integration of Brazilian health. This integration will encompass both the public and private sectors, culminating in the consolidation of a complete health datafication ecosystem in Brazil.

RNDS and the consolidation of datafication in the health sector

Source: Secretariat for Information and Digital Health (SEIDIGI)

The complexity of this scenario is found fundamentally, but not exclusively, in the consolidation of the RNDS itself, which, since its inception, has been in infrastructures of the Amazon Web Services (AWS), cloud computing services platform at Amazon, an American multinational technology company headquartered in Seattle, Washington. With a contract in force from the beginning of 2020 until December 2024, Big Tech from the United States was chosen by the Ministry of Health to take care of the storage and security of the health data of all Brazilian citizens. In effect, following the WHO guideline to unify public and private “efforts” to advance digital health, the Brazilian State opted for the disinvestment of national technological infrastructures, paving the way for the entry of international capital, through the hiring of AWS.

Fiocruz professor and researcher Ilara Hämmerli, in an interview, was emphatic when discussing the risks that this scenario presents. According to Hammerli, “by hosting the RNDS in private and transnational infrastructures, we are handing over to the capital all the health data of our citizens and professionals, as well as strategic information aimed at the development and advancement of Brazilian health science. We know that the central countries, where these companies are concentrated, began to act strongly in the 21st century in technological development and patent registration, so the more data they obtain, the more economic and political advantages they will have over other countries, such as Brazil”.

In December 2022, SUS signed a contract with the Federal Data Processing Service (Serpro) for it to manage its systems and data storage infrastructures. The contract, valid for 36 months, aimed at migrating RNDS to the Serpro MultiCloud platform.[iii]

The news raised expectations about a possible change in the trajectory of digital health. At first glance, this could mean a strategic turn towards the development of public national digital technologies instead of the privatization of the sector, the effects of which would consist of advancing the sovereignty of digital technology.

However, despite the initial enthusiasm, the real scenario points in exactly the opposite direction. Currently, the Serpro MultiCloud service consists of a partnership between Serpro's own infrastructure with the services of the world's multinational technology giants, namely, Amazon Web Services (AWS), Azure Stack (Microsoft), Google Cloud, Huawei Cloud, IBM Cloud e Oracle. In practice, this means that the storage of RNDS data continues in the RNDS infrastructure. AWS, and can also be allocated to other international corporations under the management of Serpro.

This situation is very critical, given that the technology giants operate in a dispersed manner, with data centers located in different parts of the world, which suggests that data and information from Brazilian health could be allocated outside the national territory. AWS, for example, has more than 100 data centers worldwide, covering 36 Regions and is present in 245 countries and territories[iv]. One example of this scenario would be records originating from access to the Meu SUS Digital domain. In a brief consultation carried out on January 11, 2024, when the application was still called Conecte SUS, it was noted that access to the domain was established in one of the AWS regions in the United States. This suggests that this data may be present in other countries.

My Digital SUS Domain (Conecte SUS) is hosted on a server in the United States:

Source: article authors. Consultation carried out in January 2024

There are also other implications that deepen neoliberalism, through privatization, and the dependence of Brazilian digital health regarding the relationship between Meu SUS Digital and Serpro. In this sense, to access the Meu SUS Digital application, each and every citizen must have an account on Gov.br.[v] Although profile and login data are in government cloud infrastructures, other Gov.br applications, such as chat, are in multinational infrastructures, such as IBM Cloud (IBM), a technology multinational from the United States.

In a scenario in which data has acquired a fundamental input condition for capitalism, in its neoliberal stage, to advance in the 21st century, through the creation of services, products and technologies based on data, such as Artificial Intelligence, having a State financier of international capital and absent from the perspective of digital sovereignty and data sovereignty means a deepening of dependence and technological subordination.

Neoliberal digital health as deepening dependence on Brazilian capitalism

The introduction of new technologies in dependent countries like Brazil is not something new. Even so, each new round of dissemination of a set of technological innovations, absorbed on the periphery of the world system, is accompanied by optimism about the period that opens. In reality, this phenomenon obeys the very laws of the world capitalist movement, based on the needs and contradictions of the development of imperialist capitalism, with its large multinational monopolies. Thus, the export of machinery, equipment and capital is a characteristic of imperialism itself – as well as the tendency to monopolize different economic sectors.

That said, it is necessary to emphasize that dependence is far from being a merely external or exclusively internal phenomenon. There is a “dialectic of dependence” here. As noted by Ruy Mauro Marini (1973), dependent capitalism reproduces itself depending on the needs of imperialist countries. In this sense, the relationship between imperialism and dependence, as opposite and contemporary poles of the world economy, implies an international division of labor whose effects in the countries that are the object of imperialist expansion, condition a capitalism with its own and different characteristics from “classical path” capitalism. ”.

Among the phenomena characteristic of countries with dependent capitalism, it is worth highlighting the transfer of value. By entering into economic relations with imperialist economies, dependent countries transfer part of the surplus value produced internally to imperialist countries. This transfer can occur through numerous mechanisms: via payment of loans, royalties, patents; through the unequal exchange that occurs due to technological superiority that generates extraordinary surplus value (and, therefore, extraordinary profit) for large corporations in imperialist countries or that occurs through monopoly prices; between others. In effect, there is a relationship of expropriation of surplus value generated in dependent economies that is appropriated by imperialist countries.

It is in this sense that it is important to start a debate here about the expansion of Big Techs to sensitive sectors of the Brazilian economy and society, particularly in the digital health sector. As seen previously, two aspects seem central to the issue: (i) on the one hand, underinvestment or disinvestment in their own national digital infrastructures implies the hiring of Big Techs by the Brazilian government, since only these large monopoly corporations would be in a position to offer the required services. In this way, part of the value generated in the country is used to remunerate these corporations. The Brazilian case is even more remarkable if one takes into account that there is already a national digital infrastructure that could perform the service. However, national solutions have been successively left in the background by a privatization policy that replaces them with services and products sold by international capital.

(ii) In turn, the data that is stored in the clouds of Big Techs (and which, in some cases, as seen above, is hosted in imperialist countries) is used for the development and technological improvement of services and products from these corporations themselves , for artificial intelligence (AI) training, for example, which will later be sold to the country where the data is collected.

In the case presented here, this scenario appears to be even more pernicious as the massive collection of data from citizens and health professionals is carried out by the government itself, which, in turn, invests public money in the development of applications and systems. responsible for this collection, as is the case with Meu SUS Digital and Gov.br. In this sense, the government invests public money to develop applications that collect data from Brazilian citizens and professionals who, in turn, are required to access these applications to use government services.

Finally, these citizens' data is stored in the cloud services of large technology corporations. Big Techs, in turn, use the massive data that is stored in their infrastructures to improve their technologies, train their Artificial Intelligence and develop new products and services that will later be sold to Brazil. This relationship of dependence and subordination is brought to a paroxysm as these multinationals not only do not even have the work and cost of collecting the data, a function exercised by the Brazilian State, but they are remunerated by the Brazilian State for receiving this data for free and store them in your cloud computing services – including outside the national territory.

On the other hand, the Brazilian case draws even more attention due to the fact that the country already has its own digital infrastructure, such as the Serpro infrastructure. Furthermore, Brazil has great researchers, researchers and specialists, with research centers at excellent Federal and State Universities, as well as public Foundations, such as the Osvaldo Cruz Foundation (Fiocruz), which, under the guidance and with encouragement and investment public and state, could develop and improve national infrastructures, using free and open technologies, which would be responsible both for the storage and security of health data, as well as for the management and operationalization of the entire digital health ecosystem.

This economic policy exposes the Brazilian State's negligence and renunciation of the development and advancement of its own digital technologies and Brazilian health science, as emphasized by researcher Ilara Hammerli.

As Theotonio dos Santos observed in Scientific-technical revolution and capital accumulation (1987), the concentration of investment in Research and Development (R&D) became one of the central characteristics of imperialist countries, having been fundamental to the scientific-technical revolution that occurred. Dependent countries, as implied by the imperialism-dependence relationship itself, would once again have to acquire finished technologies. Indeed, giving up existing and potential scientific and technological capabilities is a hallmark of dependent capitalism.

This is one of the aspects of the history of dependence in Brazil, which has few exceptions. One of them is the “The oil is ours” campaign, responsible for the creation of Petrobrás and for defeating the interests of the bourgeoisie dependent on and subordinated to international capital, which asserted that, without forming partnerships with foreign oil multinationals, the country would not be able to adequately explore the Petroleum. Another exception is the creation of the Brazilian Unified Health System, with the 1988 Constitution. Against national and international private interests, which grew during the military dictatorship, the campaign for free, universal public health crystallized in the SUS.

This suggestive association between the campaign for the nationalization of oil exploration and the creation of the SUS – since data is considered by certain privatist and neoliberal approaches as the new oil – may give the tone that there is an alternative beyond digital health neoliberal. Therefore, in the third decade of the 21st century, it is essential that Brazilian society acquires critical awareness about this trend that seems to be imposing itself. The pair “data and health” can and must shape a public, national, safe, free and universal digital health.[vi]

Joyce Souza and csocial scientist and journalist. PhD in Human and Social Sciences from the Federal University of ABC.

Fabio de Oliveira Maldonado holds a master's degree from the Latin American Integration Program at the University of São Paulo (PROLAM-USP).

Notes


[I] World Health Organization (WHO). Global strategy on digital health 2020-2025. Geneva: WHO; 2021. Available at: https://iris.who.int/bitstream/handle/10665/344249/9789240020924-eng.pdf.

[ii] In mid-January 2024, Conecte SUS Cidadão, Gestor e Profissional was renamed and its terminologies changed respectively to: Meu SUS Digital, Saúde Digital Gestor and Saúde Digital Profissional.

[iii] SERPRO. SUS has the security and availability of Serpro MultiCloud professional services.

Available in: https://www.serpro.gov.br/menu/noticias/noticias-2022/sus-contrata-serpro-multicloud

[iv] AWS. AWS global infrastructure. Available in: https://aws.amazon.com/pt/about-aws/global-infrastructure/

[v] The Gov.br Platform was created by the Ministry of Management and Innovation in Public Services in partnership with the Federal Data Processing Service (Serpro), and was established by Decree No. 8.936, of December 19, 2016.

This platform covers several guidelines on the provision of digital public services, including authoritative convergence and the federation of digital service authentication processes. View more: https://www.planalto.gov.br/ccivil_03/_Ato2015-2018/2016/Decreto/D8936.htm.

[vi] This study was carried out with the support of the Heinrich Böll Brasil Foundation.


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