Long live SUS!

Image: Johannes Plenio


The Unified Health System expresses the desire of Brazilians to have the right to health as a prerequisite for well-being, freedom and democracy

On social media, everything is displayed, and it couldn't be any different with the vaccine against Covid-19. Whoever takes it, the child or relative or friend of the person who takes it, everyone wants to announce to the world the relief of soul caused by this experience that at the height of the disease took on an epiphanic air. Most of the posts follow the same pattern: so-and-so “vaccinated” (in keeping with the facts, the grotesque depronominalization of the verb is maintained), VIVA O SUS! (just like that, in big letters).

It is an unprecedented, unexpected and very welcome unanimity around our public health system, unfortunately crystallized at the cost of much suffering, almost twenty million patients and, above all, more than half a million deaths. That is why it is convenient, in fact it is absolutely necessary, to take advantage of the occasion to fight a narrow prejudice spread in certain parts of the Brazilian population: the Brazilian Unified Health System would have appeared out of nowhere and would be nothing more than something useless to jeopardize rivers of public money. Few opinions are so perverse and fatally misleading as this; it is perverse because it is often stated by those who neither know nor use the SUS, it is fatal because contempt for a system that cares for millions of lives kills. Anyone who, today, does not recognize the importance of the SUS, the vital help (literally speaking) that it has brought us and continues to bring in the fight against the pandemic, is either bad in the head or simply acting in bad faith.

Against ignorance and prejudice, we wanted here, instead of dwelling on the obvious, to speak and salute our Unified Health System as one of the most beautiful and ingenious inventions of the Brazilian “engine” (allow the reader to use poetic license). It is the result and realization of the commitment of generations in the fight for the right to universal, equal and free access to health; hence its greatness. An institution like the SUS is not limited to a physical structure: health posts, a body of employees, budgets, and so on. The most beautiful private hospital is not SUS, the meanest public health post is. The SUS is great because it is, first and foremost, an idea that unifies all of this and constitutes the spirit of all of this public infrastructure, common to all of us Brazilians and residents around here (it is important to note that the system makes no distinction, recognizing that every being human deserves the same respect to his health). The SUS is an expression of the history of the desire of Brazilians to have the right to health, and in this way it is faithful depositary of the most dignified expectations of a society that is not always so dignified.

First of all, it should be remembered, especially for younger people, that the right to health has not always existed in Brazil, much less a system responsible for guaranteeing it. Until the 1988 Federal Constitution, instead of being a right linked to citizenship itself, health differed little from other goods and services available to anyone who could pay; there was free care provided by the National Institute of Medical Assistance of Social Security (Inamps), but this was reserved for “taxpayers”, that is, formal workers, with a “signature card”, as they say. The “non-taxpayers” – self-employed, informal workers, the unemployed – who could not pay could only count on the assistance of charities, generally offered by holy houses linked to the Catholic Church and other philanthropic entities.

This being so, it is not surprising that most of the population lack access to healthcare, a condition that was fully reflected in the statistics. To mention just two basic indices when evaluating the health of a population, in the 1980s, when the country was re-democratized and the new Constitution was drafted, according to the IBGE, life expectancy for Brazilians at birth was 62,5 years, already the infant mortality rate was 69,1 per 1000 children up to one year old.[I]

Against this dramatic situation and seeking to transform it, there was never a lack of revolts, struggles, discussions, pressures, specific actions and others of greater scope. A crucial moment in this incessant struggle took place in the second half of the 1970s, when it focused on the movement known as the Brazilian Sanitary Reform (RSB); in the compass of opposition to the military dictatorship, the problem of the right to health brings together workers in the area, university students, unions and popular movements. Theoretically, the big news lies in the fact that, rather than simply seeking to improve the possibilities of care, the RSB promotes an intense debate around the very idea of ​​health and how to implement it through a health system.[ii] It is a profound and thought-provoking reflection. Instead of limiting oneself to understanding “health” negatively, as the mere absence of disease, a positive meaning is defended for the notion: comprehensive health as physical, mental and social well-being; guaranteed as a right for all, and not restricted to the privileged who could pay for it. As a result of this breadth of the concept, it was understood that, in addition to specific measures and to the taste of the rulers of the occasion, only an equally broad, unified system, with a structure and fixed sources of funding, would be able to ensure the health of Brazilians.

Throughout the 1980s, marked by the gradual departure of the military dictatorship, the return of direct elections and, above all, the drafting of a Constitution that would live up to the times, this militant meditation concentrated on the RSB gained formidable resonance; the health problem, rather than a technical and statistical issue, was inextricably combined with the yearnings for a democratic life. Democracy is health, health is democracy – more or less how the public health physician Sérgio Arouca (1941-2003), one of the fundamental names in the struggle for health in Brazil, expressed himself when he proposed a reflection on the terms “health”, “disease” and the relationship between them, at the 8th National Health Conference, in 1986. Health, he explains, “is a social well-being that can mean that people have something more than simply not being sick: that they have the right to a home , work, living wages, water, clothing, education, information on how to dominate the world and transform it. That they have the right to an environment that is not aggressive to them, and that, on the contrary, allows a dignified and decent life.”[iii]

It is clear that a movement and reflection of this magnitude do not come out of nowhere; on the contrary, much depends on considering other experiences and learning from their successes and difficulties. If there is a place where originality matters less than the effective accumulation of forces, it is the field of social struggles and public policies.

Thus, the words of Sérgio Arouca presented themselves as a reading of the founding documents of the World Health Organization (WHO). At the end of the Second World War, in the midst of efforts to rebuild a shattered world and within the framework of the then newly founded United Nations (UN), the WHO was created in 1948, which acted as a driving force behind the idea of ​​right to health and today is an important global agent in the fight against the pandemic, centralizing information and research results, guiding countries and coordinating the program Covax Facility, which aims to provide immunizers to all countries in the world, including and above all the poorest.

In terms of implementing that conception of health, the most immediate inspiration came from the British health system, which also had its roots in a crucial innovation in the field of ideas. In the middle of the war and with the United Kingdom cornered, the economist and politician William Beveridge (1879-1963) was asked to chair a commission charged with studying the reorganization of the government's social policies. In 1942, he presents the document that became known as the “Beveridge report” (in the original Social Insurance and Allied Services[iv]), containing a plan of reforms whose seminal principle was the following: “freeing oneself from needs is one of the essential freedoms of humanity”. The defense of freedom was not new, but redefining the concept by linking it to its material conditions. Instead of being restricted to a negative meaning (I am not obliged to do this or that, the State cannot intervene here or there), the idea of ​​freedom gains a positive and concrete content that can only be achieved and preserved through a broad social support program: education, minimum income, health, retirement, unemployment insurance. The whole idea of ​​social well-being as it was configured in post-war Europe (the so-called welfare state or welfare state) was influenced by the “Beveridge report”. Now, one of its most immediate effects was the creation in 1948 of the NHS (National Health Service, National Health Service), a public service system for the entire population, still active today in the United Kingdom and which gained worldwide visibility during the pandemic, British Prime Minister Boris Johnson always spoke from a pulpit with the inscription “Stay home, protect the NHS” (stay at home, protect the NHS).

The struggles and debates around the right to health, the aspirations of generations of Brazilians condemned to suffer and die for lack of health care, the impetus of the most basic human desire that is a healthy life, all this flowed into the National Assembly Constituent Assembly, installed in 1986, and finally in the text of the new Constitution enacted in 1988.

There, in a conventional way, since Article 6, health was listed as a social right alongside others (education, leisure, social security, etc.). The unprecedented step came only in the chapter “On social security”, in a brief section entitled “On health”, which decisively affected Brazilian constitutional history by enshrining health as a right of all citizens. The core of this small revolution is in Article 196: “Health is everyone’s right and the duty of the State, guaranteed through social and economic policies aimed at reducing the risk of disease and other injuries and universal and equal access to actions and services for its promotion, protection and recovery.” To ensure the effectiveness of this right, article 198, which is equally fundamental, provided for the following: “Public health actions and services are part of a regionalized and hierarchical network and constitute a single system (…). The unified health system will be financed (…) with resources from the social security budget, the Union, the States, the Federal District and the Municipalities, in addition to other sources.”

It was the act of birth of the SUS, which not by chance took place from the firm combination of the notions of right to health e health system.

In social life, there are things that an individual may or may not have according to his or her possessions: going to a certain place, purchasing a device, using air transport, etc.; there are others whose usufruct is guaranteed by means of a right. What it foresees is neither a privilege (as before 1988, health was the privilege of those who could pay) nor the satisfaction of needs (until 1988, those who could not pay were left with charity); the law is universal, it ensures a good to all citizens of a State, in such a way that the very idea of ​​citizenship would be crippled if the law were not respected. Thus, by establishing that health is a right, our Constitution states that all Brazilians must have equal access to it just because they are citizens, and that this right must be guaranteed by the Brazilian State as one of its basic attributions; otherwise, the State would be denying the idea of ​​citizenship and, therefore, delegitimizing itself. Citizenship and rights are inextricably linked.

It is understandable, therefore, that in the tradition of democratic political thought the theme of rights occupies a leading position: they express, as it were, the soul of republican power and of freedom itself. For democracy, as important as the rule of law (correctly seen as an obstacle to authoritarian excesses) is the state of rights (what are they? are they respected? how to expand them?). If, on the one hand, the legal form of the unusual, private property, unequivocally exists; rights, on the other hand, are what comes closest to a legal form of the common, that is, that whose essence is not in exclusivity, but in being universal and egalitarian, benefiting all. Hence the creation of rights, within a society, generally implies the expansion and strengthening of the sphere of what is common to all citizens, the res publica (Let us remember that the word “republic” derives from this Latin expression that precisely means public or common thing). This is all the more true and relevant when the object of a right is health, the basic condition of any life and, therefore, also of a happy and free life. Although health is not a guarantee of freedom and happiness, without it the possibility of these is necessarily precarious.

Now, no matter how good an idea is, it is necessary to implement it so that it demonstrates its effectiveness in reality. The institution of a single system was the way to implement the right to health advocated by the Constitution, in line with the proposals of the RSB, and its gradual structuring followed two guidelines that proved to be decisive: decentralization and comprehensive care.

SUS is a single but decentralized system; all levels of government (municipal, state and federal) are responsible for health promotion and financing, including autonomy for local actions. In the pandemic, this institutional architecture demonstrated its vigorous success after the Federal Supreme Court (STF) decided that mayors and governors could take health measures in default of federal inaction; that is to say, even if one sphere of government proves to be flawed, the SUS is capable of functioning through its branches spread across every corner of the country. The uniqueness of the system does not mean that it is a monolith that can be autocratically directed this way and that.

In addition, SUS is not limited to taking care of diseases. It was implemented to contemplate health in its fullness: from basic to complex care, from prevention to planning, passing through scientific investigation. In some respects, it has even gone further than its counterparts in the world; remarkable fact taking into account the continental dimensions of Brazil. For example, we were among the first countries to include in the health system the free provision of cocktails against AIDS, even in the worst years of the disease; Likewise, the National Immunization Program (PNI), born in 1973 and later incorporated into the SUS, became one of the largest and most effective public and free vaccination programs in the world, responsible for controlling diseases such as measles, for polio eradication, and today it is a crucial part of vaccination against Covid.[v]

The effects of the creation of the SUS were enormous and reconfigured the health scenario in Brazil, something that we usually do not even realize. In just over three decades of operation, access to care has become universal and prevention works; charity ceased to exist because the procedures performed are reimbursed; all health numbers improved. Returning to the two indexes mentioned above, in 2018, just over three decades after the new Constitution, the life expectancy of Brazilians jumped to 76,3 years and infant mortality dropped to 12,4. And a very important detail: thanks to the universal and free service, the improvements also reached the most underprivileged segments of the population, in some cases bringing them closer statistically (more than in education, for example) to the national average.[vi]

Even Brazilians who have never set foot in a health center benefit from the SUS. There is no lack of examples and it is worth mentioning them to dispel the prejudiced impression that public health is something that only interests the underserved: the SUS organizes organ donation and performs more than 90% of transplants; the vaccine protection provided by the PNI is essentially collective, as it only works when everyone is immunized; the SUS is crucial for statistics on crime, and therefore the formulation of public security policies, through the Mortality Information System (SIM) allocated in the IT department of the agency (the DataSUS); most of Brazilian scientific research in the area of ​​health is produced in institutions linked to the SUS or through its programs.

Of course, this does not mean that the system is unaware of very serious problems. They are many and the biggest one is funding.[vii] although the expense per capita with health in Brazil is reasonable in comparison with other countries, it turns out that investment in health act, that is, with the SUS, it is still low compared, for example, with the British NHS. In addition, being unique, which is its greatest virtue, obliges the system to deal with the perverse effects of structural inequality in Brazilian society: the network has to be prepared to deal with diseases typical of very poor countries, whose prevention would involve universalization from access to the water and sewage network, to highly complex cases prevalent in developed nations.

There are multiple possible perspectives to evaluate the SUS. In view of the moment we are living, we think it appropriate to highlight it here as a idea. To some, it may seem derisive, and for that reason we take leave to conclude by reiterating the capital point. The SUS is not limited to a set of hospitals and health posts, ministerial and governing sections, agreements, employees, statistics; the system does not exist without this structure, but it does not exhaust it. It is the conception of the right to integral health for citizens as a duty of society through the State that unifies, systematizes and gives a civic sense to this material and human infrastructure. Debates around the SUS are inseparable from those about the type of society we intend to be and the functions we assign to the State, the way we conceive well-being and how much of this condition is individually or collectively conquered. Can I be happy while someone else suffers from lack of basic medical care? The answer to a question like this is at the base of what we think or fail to think about the SUS.

One day the pandemic will end, and perhaps we will become aware of how much our former way of life has been seriously shaken: apart from the lives that were lost, many small businesses we frequented have closed their doors, the fear of physical contact that should persist for a good Over time, certain changes in work and study are here to stay. So, if a more lucid assessment is possible, hopefully we will notice that one of the few things that has been strengthened throughout the health crisis is our Unified Health System. Multiplying its energies, overcoming its shortcomings, facing the disease as much as its sickly detractors, the SUS proved worthy of the expectations that Brazilians place on it.

It is doubtful that, from now on, anyone will be willing to squander a public, free and universal healthcare system that was and is the only thing left to us during the pandemic emergency. This will only happen when we forget the loss of hundreds of thousands of lives, the pain of those who survived the disease and live with sequelae, the epiphany of immunization through vaccines produced mostly in public institutions (the Oswaldo Cruz Foundation and the Butantan Institute); when we forgive the actions and inaction, equally harmful, of those who wanted and want to destroy our health system and, by extension, our health; the day we finally lose sight of the fact that this institution, forged through the commitment and struggles of generations, constitutes the most complete expression of the desire of Brazilians to have the right to health as a prerequisite for well-being, freedom and democracy.

As it is greeted on social media, with good reason, VIVA O SUS![viii]

* Homer Santiago He is a professor in the Department of Philosophy at USP.

Originally published in the magazine Humanitas, São Paulo, August 2021.


[I] Cf. IBGE Agency: https://agenciadenoticias.ibge.gov.br/agencia-sala-de-imprensa/2013-agencia-de-noticias/releases/26104-em-2018-expectativa-de-vida-era-de-76-3-anos

[ii] In general, see Health and democracy: history and perspective of SUS, org. by Nísia Trindade Lima, Silvia Gerschman, Flavio Coelho Edler and Julio Manuel Suárez, Rio de Janeiro, Fiocruz, 2005.

[iii] See “Health is democracy” (with the link to the video of the conference by Sérgio Arouca), portal Think SUS: https://pensesus.fiocruz.br/saúde-é-democracia

[iv] There is a translation into Portuguese: The Beveridge Plan, Lisbon, Editora Século, sd

[v] See VV.AA., “Vaccine production, issue of national sovereignty”, portal the earth is round, 16/06/2021: https://aterraeredonda.com.br/producao-de-vacinas-questao-de-soberania-nacional/

[vi] Cf. “With SUS, blacks and browns reach whites in terms of longevity in 22 states”, Folha de S. Paul, 11/07/2021.

[vii] For an analysis of the problem, see Carlos Octávio Ocké-Reis, SUS: the challenge of being unique, Rio de Janeiro, Fiocruz, 2012.

[viii] Today, all Brazilians know Fiocruz and understand the relevance of its work. It is good to know that, in addition to producing vaccines, Fiocruz has a wide range of activities and is also an active publisher – a keen understanding, in the spirit of Sérgio Arouca, that health cannot be achieved without books. For those who want to know the history of the SUS, here's a tip to read the work (to which we owe a lot) by Jairnilson Silva Paim, What is SUS. It is a rich digital book in which the text is accompanied by images, interviews, videos. Access, as it should be in a public institution, is free: https://portal.fiocruz.br/livro/o-que-e-o-sus-e-book-interativo


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