SUS: no man's land

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By Paulo Capel Narvai*

SUS money is being “disputed with bullets” in many municipalities. It's not a metaphor. Resources from the Union budget destined to finance public health actions are transferred from the National Health Fund to the corresponding funds in the States and Municipalities. According to rules defined in laws and infralegal norms, these resources, added to state transfers and own resources, must be applied in the payment of salaries, investments and other expenses with materials, medicines and equipment of the units of the health network. In most municipalities, this is what happens, but in several, serious deviations in purpose have been observed.

In many situations, the money transferred to the municipalities represents a proportionally high volume, sometimes equivalent to the total collection of the municipality. Although they are resources with a specific destination, the controls are fragile and the inspection precarious. As a result, “hands on” public health money. With impunity. Resources that should be applied to disease prevention, pain relief, and to prevent deaths and promote life, end up being destined for the opposite of that.

The cases of Santa Luzia, a municipality in the metropolitan region of Belo Horizonte, and Igarapé-Açu, in northeastern Pará, are exemplary. In Santa Luzia, a gunman accused of being the killer of a journalist was paid with health money [1]. In Igarapé-Açu, Paulo Henrique Sousa, elected president of the Municipal Health Council, interested in examining the accounts of the local SUS, did not take office: he was murdered with four shots to the back of the head [2].

Outside of health services, SUS money is literally killing. Gangs that have been specializing in stealing money from the SUS are at the final end of the chain of interests that produce murders. In the middle of the chain are venal officials and public authorities, from the three powers, criminals who specialize in leaving the scenes with clean hands and full pockets. The instruments are known and varied.

They range from fraudulent bids to illegal hiring of so-called “social” and “health” organizations, the OSS. Many OSS, other than “social” people, have nothing left, if they ever did. They are just companies. Some are even offered for sale by their real owners, as if they were any other company [3]. There are certainly ethical OSSs everywhere that could continue to provide services to the SUS. But a large number of OSS are involved in police reporting [4] [5]. There are, not infrequently, cases in which SUS directors are directly involved with the direction of OSS [6].

The lack of transparency when dealing with public resources fuels the greed of bandits. In certain municipalities, the SUS seems like a “no man's land”. It is therefore urgent to put an end to these specific situations which, although in the minority, harm the populations of the affected municipalities.

There are democratic solutions to face this “no man's land” and show that “this land has an owner”. One of these solutions was pointed out by the 16th National Health Conference (CNS), a complex process of social participation in health that involved social movements, entities and public institutions, in 4.612 municipalities.

In the municipal and state stages of the conference, 22.839 people participated in the discussions and preparation of proposals, approved in the national stage, held in Brasília, from 4 to 7/8/2019. The central theme of the 16th CNS was “Democracy and Health”. Its final report is a massive 254-page document that details the 31 guidelines and 328 proposals approved in Brasilia. Health conferences, in municipalities, states and at the national level, have been constituting, since the historic 8th CNS, held in 1986, an example of participatory democracy.

The 16th CNS dedicated five guidelines and 88 proposals to the theme of “adequate and sufficient funding for the SUS”. It noted the chronic underfunding of the SUS and the risk of underfunding and indicated, among other aspects, “the repeal of Constitutional Amendment No. 95/2016, which froze public investments in health for 20 years”, the creation of a “Law of ”, unlinking health from the bottlenecks of the Fiscal Responsibility Law [7], “increasing the minimum percentage of the municipality devoted to health, from 15% to 20%, with an increase in investment in primary care”, and “building and implementing for all categories (...) a plan of positions, careers and salaries", Career-SUS, "guaranteeing the floor in the three spheres of government, according to the national guidelines for the management of work in the SUS".

However, another way to face and overcome the banditry that advances on SUS money is being imposed by the Ministry of Health (MS), as if the entire SUS were really a “no man's land”. MS alleges concern with the optimization of public resources and with the best performance of the system, in primary care, aspects of which, register, nobody disagrees. To this end, it set out to approve, at the October 31, 2019, meeting of the Tripartite Intermanagers Commission (CIT), composed of representatives of the Union, States, DF and Municipalities, a “new financing policy” for Primary Care, of which much of people disagree.

This is a radical change that establishes that, after a transition in 2020, and definitively from January 2021, the current mechanisms for transferring resources will be replaced by four types of federal funding. Basically, the 'Fixed Basic Care Floor' is extinguished, as a continuous transfer mechanism, based on demographic criteria, and a value is introduced per capita fixed, whose amount to be transferred will be disconnected from population criteria, but will be defined based on managerial criteria, notably productivity and performance.

The new funding policy clashes head-on with all the guidelines and proposals approved at the 16th CNS. With it, the MH goes back to the 1990s and, becoming competent to protect and decide what States and Municipalities can or cannot do in health, within their spheres, it starts to consider them no longer as autonomous federative entities and participants in the management and institutional development of SUS, but as mere “service providers” to the federal government, according to the contractual logic that governs relations between private companies.

The measure, essentially authoritarian, was the subject of Ordinance No. 2.979, of 12/11/2019, which institutes a federal program called “Previne Brasil” [8]. By refusing the nominations of the 16th CNS, Bolsonaro’s program was received as a true health “counter-reform”, as it goes against legal provisions and denies an entire tradition of participatory democracy that marks the trajectory of construction of the SUS, since its creation in 1988 .

The announcement of the CIT's decision, to respond to pressure from the federal government, generated a significant number of criticisms and denouncements from the democratic camp, gathered in the Brazilian Sanitary Reform movement (RSB) [9]. “It will be the final straw for the SUS, definitively burying our universal health system” is the summary phrase of the general tone of these demonstrations, as the new model is based on “people registration”, restricting the actions of the SUS to this public, violating the Constitution and the organic laws of the SUS, ratified by Federal Law nº 141/2012, which refer to the universality of health care, as a “right for all”.

The mechanism created by the Bolsonaro government, recommended by the World Bank, imposes significant losses, which could reach more than half of the resources they have received so far, on hundreds of municipalities, notably those with smaller demographics, even though an increase of about of R$ 2 billion for the transition to 2020, the year of municipal elections. It is estimated that such losses will reach almost a quarter of municipalities across the country. But the announcement is that there will be more resources and that the decision would have been taken democratically, as it had the support of Conasems, the council that brings together representatives of the municipalities, with the objective of assisting the “most needy”. But the councils equivalent to Conasems in the states of SP and RJ, among others, released technical notes exposing relevant divergences. 

What the Bolsonaro government effectively wants is to deny, in practice, the constitutional right to health, which is necessarily universal, and replace it with so-called universal coverage. These are not simple words, nor synonymous expressions: universal health systems operate so that the set of public policies socially produce health, with the health sector integrated into this set. Ensuring everyone's health is, for universal systems, an attribution of the State, which must be democratic and develop actions based on the public interest.

In universal coverage, on the contrary, what is sought is to expand the coverage of medical assistance to people, thus reducing the entire complexity of health to medical-hospital services, which may be public or private. In this regard, health is considered an individual responsibility, which can be “bought” as if it were a commodity. The deformations imposed on health actions and services when commercial relationships are adopted to replace the conception of social rights, to mediate access to health care, are well known: in general, coverage drops and, with it, the quality of programs.

In a meeting in the first week of December 2019, the National Health Council announced an agenda for debates on Ordinance No. 2.979 and the 'Previne Brasil' program. However, this agenda does not have a suspensive effect and the Ordinance for the new funding will come into effect from January 1, 2020.

Representatives of the Bolsonaro government counter the criticism by arguing that its decisions are democratic, that they have been discussed for several months and have the support of the municipalities. But this “democracy in health” is very strange, which, instead of deepening the degree of participatory democracy, combating party-political clientelism and the nepotism of some councils, scrambles words and distorts meanings.

In this context, it makes no sense to talk about democracy in health if the Bolsonaro government is essentially authoritarian and does not even want to appear to have any commitment to democracy, according to daily demonstrations by its leaders, from flat earthers to openly fascists and their notorious contempt for values ​​and democratic coexistence. In health, however, the government pretends to be what it is not, although it imposes, in an equally authoritarian way, radical measures that affect millions of Brazilians, disregarding any divergent position and dealing with the institutional complexity of the SUS as if it were a 'no man's land' ', waiting for orderly and rational measures.

It ignores the more than 4 million health professionals linked to our universal system and the entities that represent them and disregards health councils and conferences when making decisions about the SUS. But this “democracy” in health should not deceive anyone, because it is a democracy fake, a gross forgery. The consequences, however, are not those of placebos. They have, on the contrary, destructive side effects, harmful for the SUS and the right to health.

In its own way, this democracy fake also kills.

* Paulo Capel Narvai Professor of Public Health at USP

Notes

[1] Mayor paid journalist's killer with health money, says police. FSP [Internet]. 12 Sep 2017; Available at: https://www1.folha.uol.com.br/poder/2017/09/1917671-prefeita-pagou-matador-de-jornalista-com-dinheiro-da-saude-diz-policia.shtml

[2] Teacher who denounced corruption is shot dead in Igarapé-Açu. 27 Aug 2017; Available at: http://dev.portal.diarioonline.com.br/noticias/policia/noticia-445820-professor-que-denunciou-corrupcao-e-executado-a-tiros-em-igarape-acu.html

[3] Satriano N, Carvalho J. Entrepreneur tried to sell OS for BRL 100 million, according to MP from RJ. The Globe [Internet]. January 14, 2016; Available at: http://g1.globo.com/rio-de-janeiro/noticia/2016/01/empresario-tentau-vender-os-por-r-100-milhoes- Segundo-mp-do-rj.html

[4] Operation targets gang that embezzled R$ 110 million from SUS in Amazonas. A Criticism. September 20, 2016; Available at: https://www.acritica.com/channels/manaus/news/operacao-mira-quadrilha-que-desviou-r-110-milhoes-do-sus-no-amazonas

[5] The Globe. PF arrests 14 people during an operation that investigates misuse of health resources in Maranhão. November 16, 2017; Available at: https://g1.globo.com/ma/maranhao/noticia/pf-prende-14-pessoas-durante-operacao-que-apura-desvios-de-recursos-na-saude-no-maranhao.ghtml

[6] Rebuildables. CPI of Social Health Organizations ends with a poor report. 13 Sep 2018; Available at: https://www.redebrasilatual.com.br/politica/2018/09/cpi-das-organizacoes-sociais-de-saude-termina-com-relatorio-pifio/

[7] Brazil. Complementary Law 101/2000, of May 4, 2000. Fiscal Responsibility Law – LRF [Internet]. Brazil; 2000. Available at: http://www.planalto.gov.br/ccivil_03/leis/lcp/lcp101.htm

[8] Brazil. Ordinance No. 2.979, of November 12, 2019 [Internet]. Official Diary of the Union; 2019 p. 27. Available at: http://pesquisa.in.gov.br/imprensa/jsp/visualiza/index.jsp?data=13/11/2019&jornal=515&pagina=97

[9] Abrasco. Movimento Sanitário writes to Minister Mandetta about changes in PHC funding. Available at: https://www.abrasco.org.br/site/outras-noticias/movimentos-sociais/movimento-sanitario-escreve-ao-minister-mandetta-sobre-mudancas-no-financiamento-da-aps/43712 /

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