State SUS – what does it mean?

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By PAULO CAPEL NARVAI*

The discussion about the nationalization of the SUS is idle, as the system is owned by the Brazilian State

Amidst the recognition that Brazil is the country that records the worst public management of the covid-19 pandemic, the news and digital social networks have been showing children who, in various locations, effusively celebrate the possibility of being vaccinated and by immunizing themselves, they also protect relatives, friends, the entire population. Cheers to science and SUS!

It's a breath. The people, due to their remarkable sensitivity and adherence to vaccines, are forcefully defeating the denialism radiated daily by the Planalto Palace since the beginning of the epidemiological phenomenon. It also imposes a humiliating retreat on the Minister of Health, a fake anti-vaccination – an unusual case of a doctor who believes in vaccines, but pretends not to, in order to suck up to his boss – and to various leaders and medical organizations that would make Hippocrates blusher than a cherry.

The country rebelled against the cretinism of giving course to a public consultation to find out whether the application of anti-covid-19 vaccines in children should have a medical prescription as a requirement. The measure, evidently delaying, did not produce the expected effect, but it is recorded in the annals of history as one of the most infamous acts originated by the Brazilian State against its own people.

The blackout of health information systems – under the responsibility of the Ministry of Health – is part of the necropolitical strategy of letting die and, above all, of “removing evidence” to facilitate the denialist narrative that is produced in the present and that will be reproduced in the future. Without records, without data, nothing will have happened. It will be the word of some against the versions of others. The federal government's health negligence, which is expressed as prevarication, boycott and sabotage, among other manifestations of unprecedented incompetence at the head of the Republic, continues to produce deaths. But the data blackout makes it practically impossible to estimate, with a reasonable degree of accuracy, how many children died in the country as a result of the pandemic, although the figure of approximately one thousand deaths is mentioned in one or another journalistic source.

The wave resulting from the introduction and very rapid dissemination of the Ômicron variant reactivated health alerts and concerns about the vulnerability of children without vaccine protection which, in a way, have been protecting adults and the elderly.

The WHO has been warning against the mistake of considering the Omicron variant to be milder, or with less important effects, although it is less lethal. In Brazil, in the middle of summer, health units, both state and private, again register the lack of tests and vacancies for medical consultations, equipment, resources and equipment.

It highlights, once again, the lack of structure and underutilization of the SUS public network – which marked the entire period of development of the covid-19 pandemic in Brazil. In this context, there is again the need to “nationalize the SUS”, “put an end to its privatization” on the one hand and, on the other hand, “privatize services”, “modernize the SUS”, “improve management”, “bring private experience in service management to the health system”, but provided that “public management” is ensured.

The speeches line up and pile up words and expressions whose terms don't seem to mean much to anyone who reads or listens. Indeed, the environment of speeches is polluted, to the point that each word used usually generates many questions about what it means; what you mean. Worse: many who enunciate them, asked to clarify them, use so many other words that, in the end, end up not being able to communicate anything.

“State” and “public” are two such words.

In mid-January, two former Ministers of Health were invited by the Brazilian Center for Health Studies, CEBES, to analyze the prospects for this year 2022 and, of course, the tasks facing democrats and those who defend the SUS and the right to health. José Gomes Temporão and Arthur Chioro presented, with the brilliance and intellectual clarity that characterize both, their vision of the problems in this area, the political perspectives and, already moving towards the end of the program, broadcast by CEBES channel on Youtube, the question of the “nationalization” of the SUS arose, something that both promptly rejected. They explained their reasons and the program was terminated.

Because, being a tireless defender of the nationalization of the SUS, I feel the need to develop the theme a little further, since the discourse and analyzes on SUS management sometimes end up being truncated, due to the superficial or even inappropriate use of terms that in the language colloquial assume many, and even opposite, meanings, as is the case of state, public, private, private and privative, among others.

In classes and academic activities on health management, I have pointed out that, despite the fact that it is possible to assign many meanings to each of these terms, it is very important to take into account, in order to assign them appropriate meanings, the dimensions of “ownership” and “ownership”. type of use” necessarily involved when it comes to providing services.

I always emphasize that the terms “state” and “private” refer to the dimension of property, as it is property that is state or belongs to a private individual. For health management, however, in addition to ownership, the type of use made of the property and what it produces is very important, which can be “public”, “private” or “private”.

The use of some resource, good or service, can be public for private property (any hospital, for example), because regardless of who is “the owner”, any citizen can, according to public rules and supported by legislation, have access and make use of said resource.

But the use can be private for state property (a military hospital, for example), because although the property is “everybody's”, through the State, to have access and make use of that resource, a citizen needs to meet specific requirements. specific, which make it private. This is the case of the military hospital in this example: to enjoy the benefits it provides, the user needs to be a member of the military or a dependent. It should be noted, for example, by the way, that in the middle of the covid-19 pandemic, with a notorious shortage of beds for the hospitalization of seriously ill patients, military hospitals refused to admit non-military and dependents.

That is why, in the field of management, the opposite of state is not necessarily private, but private, as this is what concerns the form that property takes.

There are also state properties that should be for public use, but that end up being appropriated by private users, as is the case of some stretches of beaches, river and maritime islands that are illegally occupied by powerful people who use these properties of the State as if they were private property, and that make them of private and even private, or exclusive, use.

The SUS is, by definition, a Brazilian state system. In that sense, it is state-owned. But, as is known, the SUS is a complex organization, which constitutes a network, comprising and articulating services, whose properties may be state or private. The actions and care provided are, however, always open to the public, in accordance with operational rules and regulations. Therefore, in my opinion, the discussion about the nationalization of the SUS is idle, because, I reiterate, the system is, as such, property of the Brazilian State.

Another issue, connected to the “problem” of the nationalization of the SUS, is the constitutional determination that the federative entities (the Union, Federal District, States and Municipalities) must exercise command of the system in the territorial scope that corresponds to them. The 1988 Constitution is, in this regard, very clear: it is the responsibility of these federative entities to administer the health system and, given that this competence is an essential function of the Brazilian State, it must be exercised by direct administration, and cannot be delegated. to private individuals. If the subnational federative entity alleges incapacity, incompetence or expressly refuses to directly manage the SUS, commanding it within its scope, then the State, or in the last case the Union, must assume this command, with the corresponding financial resources being allocated no longer to the entity that refuses to command the system, but to the one who replaces it in functions.

This does not mean that privately owned organizations cannot “provide services to the SUS”, but it does mean that they cannot replace the respective federative entity in the command functions of the state system, which has been happening in hundreds, perhaps thousands of municipalities, in flagrante delicto. violation not only of ordinary legislation, but of the Constitution of the Republic itself.

It is this privatization that needs to be stopped immediately. This is the nationalization of the SUS that Brazil needs to do. In at least half of the Brazilian municipalities, there is no capacity in the direct municipal administration to assume the state command of the SUS. So that the system is not captured, even more so, by the commercial interests that have been hitting it since its creation, it is essential that the “modernization of the SUS” that is being considered, and that will be on the agenda of the presidential candidates in 2022, contemplate alternatives of solutions to this problem, seeking solutions, simultaneously, for the administrative viability of the health regions, with a view to ensuring universal and integral access to the health care they need for all Brazilians.

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

 

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