By Paulo Capel Narvai*

October 2019 was, well, no October 1917, but this time it wasn't earthquakes that shook the earth in Ecuador and Chile. Dissatisfaction with neoliberalism, especially in its ultra version, took thousands of demonstrators to the streets. In Chile, especially, posters, banners and speeches motivated by the abandonment of patients and the important restrictions on access to services offered by the health system were recurrent.

In Brazil, there was no lack of those who pointed to the SUS, “our SUS”, including card-carrying liberals, arguing that the Unified Health System would be a kind of antidote against the ills that plague Chileans and Ecuadorians. Here, they said, “the poor rely on the SUS and public schools. All very bad, but the poor know they can count on this support. Here, they have something to lose. Not there.”

These are very problematic arguments to “explain” the Chilean October. But it seems significant to me that the demonstrations registered the impact of ultraliberalism, of “austerity” policies, if the reader prefers, on the health of the population, democracy and the standards of coexistence imposed by the ideology of entrepreneurship, in times of “uberization”. ” of life and proliferation of applications.

In this context, it should be noted that the SUS is not “very bad”, nor does it serve as an antidote for anything, although it is very far from having become the “civilizing project” dreamed of by Sérgio Arouca, one of its founders. The scenario of “our SUS” is neither flat nor round, but scorched earth, the most appropriate expression to characterize its situation under Bolsonaro’s government.

Since the ousting of Dilma Rousseff (2016) I have been collecting qualifications that I hear from health counselors, leaders of social movements, students, managers and health professionals of the most varied levels. Defunded is by far the most cited. But I have also heard that the SUS is undervalued, scrapped, precarious, ideologized, fragmented and hidden, among other qualifiers. Many also consider it inefficient.

It is necessary to recognize in advance that the 2019 SUS is the opposite of what was desired by its formulators of the Sanitary Reform Movement who, even in the years of combating the civil-military dictatorship, outlined and proposed the creation of our universal system, which would occur in the National Constituent Assembly, on May 17, 1988.

But the SUS began to become unfeasible even before the historic session of October 5, 1988, when Ulysses Guimarães announced to the country the enactment of the Citizen Card. Cautious when announcing the new Constitution of the Republic, “Doctor Ulysses” warned: “It is not the perfect Constitution, but it will be useful, pioneering, pioneering. It will be light, even if it is a lamp, in the night of the wretched”.

The constitutional provisions of SUS were regulated two years later, in 1990, with laws 8080/90 and 8142/90. Since then, a set of infralegal norms has given the system its current configurations. One of the main innovations, pioneering on a world scale, is social participation, which in the 1988 Constitution was enshrined as “community participation”. Law 8142 makes official health conferences, held periodically, and health councils, at municipal, state and national levels, with permanent action, as the means by which this participation must occur, institutionally.

But the way of managing the social right to health, in a continental and federative country like Brazil, required the creation of administrative instances with this competence, creating inter-agency commissions, bringing together representatives of the Union, states and municipalities. A successful public administration model was forged, to the point of serving as a reference for other federal systems such as Social Assistance, SUAS (Law No. SUSP (Law No. 12.435, of 6/7/2011). The Brazilian experience has attracted many foreigners interested in knowing our institutional situation.

Internally, however, the public image of the SUS is not good, with negative information predominating in the news throughout the country. They are, sometimes, news that start from facts, but that are, in most cases, deformed by the ideological bias of the media committed to health plan operators, interested in reproducing this negative image, useful for the sale of their products. Cases reported in quick, superficial news are rarely detailed in reports whose analysis could get to their causes, unraveling the “scorched earth” of the SUS.

unfunded

One of these causes is the chronic underfunding that, with Constitutional Amendment 95/2016, the “expenses cap”, imposed on the SUS the freezing of public resources for 20 years that should be used to maintain the network of services, from the ICU to vaccines, going through urgency-emergency and health surveillance actions. EC-95/2016 marks the transition from chronic underfunding to underfunding of the SUS. What was insufficient becomes a veritable scorched earth, as it is not possible to treat patients and prevent diseases and epidemics with only 3,7% of GDP, when most countries invest, as public expenditure, at least twice as much. I mean, possible, it is; but in a scorched earth scenario.

Devalued

Another frequent reason for “bad news” about the SUS is the queues, the long waiting time for appointments, surgeries and exams. But since 2016, the lack of medicines and vaccines has also been recurrent and is becoming, dangerously, routine. There is talk of bad public management, which in many cases is correct, but there are many situations in which there are excellent management standards that, per se, are not enough to solve the lack of resources, only to alleviate it. Without having their problems solved, especially those that require immediate attention, the population tends to devalue the SUS and its professionals. Hostilities are commonplace.

scrapped

The Fiscal Responsibility Law (LRF) (Complementary Law No. 101, of 4/5/2000) sets limits on public spending on personnel (up to 54% of net revenue, in municipalities). Many see the LRF as something positive precisely because of this, for “putting the brakes on” governors and mayors who are “spending” and irresponsible with public finances.

But there is a difficulty with regard to health services, which depend heavily on professionals from various levels and sectors of activity, whose salaries and charges generally represent more than 70% of the operating costs of the establishments. Therefore, the account does not close and the mayors, to “get rid” of health, outsource everything they can. It is the path to the scrapping of direct administration services and labor precariousness by outsourced workers.

Precarious

The tendency to outsource SUS services is overwhelming. In cities like São Paulo, direct administration health services are already a minority and are on the way to being residual. So-called “social” and “health” organizations, the OSS, are privately owned companies that have been assuming, increasingly and overwhelmingly, the management of SUS services and, in many cases, of the municipal system.

Public control mechanisms are fragile and very vulnerable to clientelism. The number of complaints in court for defaults applied by the OSS and complaints of precarious work, salary degradation and terrible working conditions is also growing. Three decades after its creation, SUS professionals still do not have a State career, the Career-SUS.

Ideologized

In times of predominance of the ideology that "everything that is state-owned does not work and must be privatized", the SUS is hit hard, because even in municipalities whose successful experiences are recognized and awarded, nationally and internationally, the pressure to " privatize everything” are daily. They originate, basically, in the municipal legislatures, but also in the Judiciary, since the ideology of “excellence of the private” predominates in the powers of the Republic. Thrown into the mass grave of “non-functioning public services”, by a State hostage to rentiers and incapable of recognizing and valuing its actions in the public interest, the SUS suffers.

Fragmentado

Although the 1988 Constitution states that the SUS will have “single command” in each federative entity, privatizations and outsourcing have, in practice, broken this constitutional precept in municipalities. In many, the territory is fragmented: the capital of São Paulo, for example, is subdivided into a few dozen territories, commanded by different OSS that operate the municipal SUS, through management contracts. The Municipal Health Council, which is legally responsible for approving health plans and programs, is, in practice, ignored.

hidden

The SUS is deliberately hidden by the media. It works more or less like this: everything that goes wrong, or doesn't work, or is a problem, is attributed to the SUS. But the SUS, due to its brands and symbols, disappears for the population, because everything that should give it visibility, from the professionals' clothing to the ambulances, including facades and other spaces of public visibility, simply disappears from people's view and perception.

In institutional advertisements, on radio and TV, the “health agents” are not “from the SUS”, but “from the City Hall”; outpatient clinics and public hospitals are not “owned by the SUS”, but “owned by the state government”; excellent services maintained with public resources, are not “from the SUS”, but from this or that ethnic-religious group, etc. Hidden from itself, the SUS is not recognized even by the workers who give it life. There is no reason to be “proud to be SUS”, if the image of our universal health system is mocked daily by public authorities who should be promoting it.

But this is just a part of the SUS occult. The other part stems from the fact that work in public health requires the concurrence of both assistance to patients and preventive actions aimed at the population as a whole. The irony regarding disease prevention is that the more effective they are at preventing disease, the less visible successful actions are.

There is, therefore, an “invisible SUS”, whose activities are not perceived by people since, by its nature, its success produces a non-fact, a non-news, according to the journalistic perspective. Thus, when SUS is most effective, when it works best, it is precisely when it is not perceived by the population. This is one of the reasons why it remains so difficult to value and defend it in times of flat-Earth fundamentalism and heralds of the objectivity of spreadsheets and “indicators”.

Inefficient

Despite the scorched earth scenario imposed on the SUS, especially and notably after Dilma's ousting, the system resists, thanks to social movements that fight in its defense and to local managers and public servants who do not give up and who seek better times. Believe in the verse of the song What was done indeed (of Vera) (Milton Nascimento & Fernando Brant) who assures that “other Octobers will come, other mornings”, announcing some hope (https://www.youtube.com/watch?reload=9&v=BLAEK2xRoWA).

It is due to these segments that, despite all the daily aggressions, the annual production of the SUS is approximately 1,9 billion actions and procedures in primary care (vaccines, dressings, consultations and varied outpatient care) and the country has maintained, despite the problems mentioned, levels of vaccination coverage higher in some cases than those registered in the United States and countries of the European Union.

In secondary and tertiary care, also called medium to high complexity, the SUS registers more than 13 million hospitalizations and approximately 200 million tests per year, performs more than 2,5 million deliveries, 3,5 million surgeries and more 260 million dental procedures.

It provides more than 700 million units of medication and three quarters of urgent and emergency care is provided by SUS units. The system is also responsible for 96% of organ transplants (in Brazil, a lung transplant is performed every three days and a pancreas transplant every ten days and, daily, on average, 16 kidney transplants, 6 liver transplants and 1 decoration).

It is for “doing all this” that “our SUS” ended up making its way into the news and analysis of the Chilean October, praised even by notorious liberals. Even so, Ministers Guedes (Economy) and Mandetta (Health) want to end the floor (the floor!) of health spending. They consider that a lot is spent and reproduce Bolsonaro, for whom it would be “possible to do much more with current resources” in health.

It is worth noting, by the way, that in 2017 consolidated public expenditures on health were BRL 265 billion, including all federal entities. Health economists estimate that this expenditure corresponds to approximately R$ 3,60 per person/day, with a share of federal expenditure of 43,1%. There is a consensus that, contrary to what is said, with this level of performance the SUS is probably the most efficient health system in the world.

At the expense, certainly, of low salaries, precarious installations and equipment, lack of instruments, materials and medicines and many other well-known problems. Ulysses Guimarães would perhaps tell us that the SUS is “light, even if it is a lamp, in the night of the wretched”, because the scenario is one of scorched earth. But in scorched earth there is also life, after all. And where there is life, there is hope. Yes, “other Octobers will come, other mornings”.

*Paulo Capel Narvai Professor of Public Health at USP