SUS: a synthesis for democratic struggles

Image: Erkan Utu


The expansion of popular and middle-class sensibility in support of the SUS makes up the core of the important transformations that took place with the pandemic

Over the 34 years of struggle to build the SUS, structural challenges to its implementation persist, such as underfunding and the rooting dynamics of the public-private hybridity of interests on various fronts of the system. This reality is anchored by a set of fiscal and administrative reforms that defined a liberal State regime resistant to more daring forms of social leveling. In this complex journey, the democratic invention of an unprecedented institutionality in the country's history made incrementalism the possible ground for extraordinary advances in guaranteeing the public right to health. After the 2016 Coup, however, these structural constraints qualitatively changed the front of the political dispute to the sanitary field. Given the political conditions that formed after 2016, the understanding that it is necessary to build a second major cycle of construction of the SUS is not excessive – bolder and more consistent than the form acquired from 1988 to 2016.

This need is evidenced by the approval of Constitutional Amendment 95/2016, the regressive direction of the Reforms of the National Primary Care Policy, in 2017 and 2019, the advancement of Therapeutic Communities on the national alcohol and drug policy in the area of ​​mental health, the vulnerability health in the face of international dependence on technological and pharmacochemical inputs, the economic strengthening of operators and other segments of the health industry that seek to control the public regulation system built in the SUS. All these dimensions constrain state planning for the sector. More than transformations of an institutional nature, these alterations must be understood as a result of a profound change in the balance of political forces between the conservative liberal field and the segments of the fight for the SUS, showing even how public health is directly connected to the recovery of its own Brazilian democracy.

Faced with the deepening of these historical adversities, Gramsci's thesis gains relevance that the central challenge of the struggles of politically subaltern segments consists of overcoming the barriers of isolation placed by hegemonic groups. As a consequence of this marginalization, the challenges of preserving the political program and counteracting the trend of fragmentation of counter-hegemonic movements are presented. In this process, in which the dominant culture marginalizes the health field by discrediting the viability of its program, it becomes necessary to demarcate the frontier of division with the ideology that acts by dissolving the political identity of the resistance forces.

In this regard, the thesis of the complementarity between public and private interests is eloquent, spread by health market representation centers such as the Coalizão Saúde Institute (ICOS) and the Brazilian Institute of Social Health Organizations (IBROSS). This orientation today represents a historical countermovement to the matrix project of the Sanitary Reform of transforming the Brazilian State from the implementation of the SUS. More than the marginalization of the sanitary audacity, its influence seeks to promote the dissuasion of the identity and cohesion of the sanitary field, which, to a certain extent, is constrained to the calculation of pragmatic adaptation in the face of the urgent demands of the system. In this path of saturation, an important part of the fight for the public right to health was delimited based on the argument of fiscal austerity, the pressure for public management shared with the Social Health Organizations (OSSs), or even with the thesis that the SUS it is unmanageable without maintaining and deepening the current pattern of State interactions with the various circuits of the health market – such as tax incentives for plan operators, dependence on the hospital network and private services for imaging exams and other diagnostic procedures.

To a large extent, these various fronts of attack always had the deconstruction of the Brazilian State as a strategy. Since the 1990s, the initial moment of the implementation of the SUS, the growing delegitimization of currents that thought the country from a national training project dehydrated the planning capacity of the State, weakening instances of policy coordination and regulation. In this crisis of affirmation of the state culture, a principle of 'shared sovereignty' was imposed, in which the most diverse business sectors in the health area, increasingly linked to the international financial market, began to take ownership of the public budget. Part of this principle are efforts to challenge the expansion of public power facilities and initiatives aimed at commercial regulation. In this movement, the organization and execution of State services began to be claimed by market agents as an attribution that now belonged to them. In such an environment, the defense of a conception of democracy and expansion of rights that lacked a consistent defense of the State was formed.


Challenges of the contingent foundation of the SUS

In the scenario of institutional expansion of the SUS, the Sanitary Reform struggles became much more varied and branched out in the social fabric, it being natural that the many struggle fronts developed their own agendas and fragmented into resistance fronts within the public system. Currently, the challenge posed to the different fronts of struggle can be elucidated, for example, in the domain of the anti-asylum struggle of the Psychiatric Reform, which was able to promote the de-hospitalization of madness, but which is increasingly pressured by the growth of therapeutic communities; in turn, Social Control, which was able to create a new participatory paradigm within the Brazilian State, perceives the emptying of these arrangements in management control, demanding innovations in its condition of political and institutional influence; the various unions that represent health professionals followed the substantial expansion of jobs, structured, however, from precarious bonds and without any expectation of holding public tenders. Despite the differences, the profusion of OSSs, OSCIPs, SSAs and State Foundations, built depending on the municipal or state reality, weakened job stability in the public administration of health services, limiting the implementation of a nationally unified system.

In this vigorous constellation of social movements, the formulation of different theses and political practices aimed at overcoming the problems of the SUS also spread. This condition is explained by the growing distance between managers and organized health workers. Once companions on the same journey, it is now possible to identify the rooting of adversarial positions that were formed in the face of the claim for better wages and working conditions, increasingly perceived as corporate insensitivity to the urgent obligations of management. These political tensions are directly associated with the fragmentation of the program, which can also be seen in the controversies between scholars and policy makers in the Public Health departments. Quite often, opposing convictions were formed about the management model – be it through direct administration or based on partnerships consecrated by the new public management –, in which the centrality of this debate is even questioned. This condition is eloquent in clarifying how the projection of liberal thought on the design of the State – such as the Bresser Reform, in 1995, and the Fiscal Responsibility Law, in 2000 – established barriers that fractured important places in the identity and struggle for public health, highlighting the importance of demarcating a line of division with the dominant ideology.

The temporal permanence of these structures lateralized, for example, the proposal of a federal career for SUS workers, transforming the legitimate work demands of nurses, doctors, pharmacists, dentists, technicians, community health agents and other professionals into a thick labyrinth of political agendas and actions. A multidisciplinary career for the SUS has systemic implications: in political terms, it more clearly delineates the meaning of underfunding for public debate; reframes municipal responsibility with personnel policy; weakens the hiring of OSSs and re-dimensions the tensions between managers and workers. The proposal also has the potential to overcome the discontinuity of care and unify the struggle for better working conditions, creating a national negotiating table in the SUS. As the Mais Médicos Program made explicit when intervening on the expansion, distribution and restructuring of training and medical work in the national territory, the issue of work management in the SUS is directly associated with a federative pact aware of the regional imbalance. A SUS career even raises issues of regionalized and integrated planning of Primary Care health services, the expansion and public distribution of specialized care units, and the effective implementation of a hospital policy for the SUS. Alongside other scholars, the reflections of Professor Gastão Wagner have been illuminating this debate, showing that the complexity of this topic is not insurmountable.

In this countermovement of daring to overcome the bunkers that seek to reduce the optimism of the will to a condition of romantic thought, there is an effort to expand unity between the various political subjects of the Sanitary Reform - such as Abrasco, Cebes, Rede Unida, party instances that discuss health, union segments and user representation, parliamentary representations, movements for training and education in health, among others. In this domain, political cohesion depends directly on the understanding that political protagonism lies in the willingness to open up to encounters, in keeping an outstretched hand in dialogue, bringing expectations closer together. In an election year, the Frente Pela Vida, which was an institution that renewed the national struggle for the SUS in the context of the pandemic, can organize its activities in the states, forging 'spaces for the accreditation of public health candidates', effectively committed to a 100% public SUS program .

More than ever, this movement of unity within the field of health care needs to be linked to the class aspirations of the black movement and black women, feminist struggles, youth, LGBTQIA+ collectives, indigenous communities, quilombolas and riverside communities, recyclable pickers, homeless people, delivery workers, movements for land and housing. These segments suffer firsthand the absence of a health system that is not fully realized, and they are forces that have been marking a point of division with the perverse capitalist structure present in the Brazilian State. In their struggle processes, they update the republican understanding of the foundation and continuous expansion of freedom, they have a resistance that is an educator of public conscience, and today they are active political subjects of the various public policies of Brazilian democracy. They are renewed political nuclei of citizenship that play a leading role in the defeat of fascist denialism and must, therefore, compose the spaces of direction – integrating action, formulation and decision in a sanitary program that seeks to update itself historically. Certainly, the socialist universality pursued by the SUS will only be fully realized by incorporating these neglected citizenships.

In addition to the elitism of representing the humble in politics, the challenge of the democratization of the Brazilian State that forms the sanitary tradition requires an organic connection with the classes it intends to represent. The realization and institutional stability of a political program depend not only on the correlation of forces between vanguards and elites, but also on the formation of broad public consensus, since the constitutionalized solution to conflicts always requires public recognition in order to be preserved over time.


SUS: horizon of renewal of democracy  

The scorched earth work promoted by oligarchic power against democratic Brazil opens an important path to its own delegitimization, reminding us that authoritarian thinking demands more strength than consensus to make its program viable. This failure informs us of a window of opportunity to initiate the movement against the political fragmentation and marginalization of the transformation program that is structured around the SUS. The expansion of popular and middle-class sensibility in support of the SUS makes up the core of the important transformations that took place with the pandemic. Public health moved from a sectorial agenda to the center of the struggle for a democratic Brazilian State, illuminating the program of progressive tax reform, science and technology development policies, and the need to rebuild the national industry. This condition can be understood as an important political asset that forms critical awareness, as it opens up the possibility of overcoming the media common sense of treating the 'SUS as an unavoidable problem'.

This understanding of the situation forms important guidelines for a programmatic synthesis of public reaffirmation of a public health identity. In a healthcare composition at the front, the unity between the various worlds of the Reform will define our ability to dare once again in history, advancing in a second virtuous cycle of realization of the SUS.

*Ronaldo Teodoro, political scientist and professor at the Institute of Social Medicine at UERJ; researcher at CEE-Fiocruz and CERBRAS-UFMG.

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