In his text SUS: o que e como fazer? (The SUS: what to do and how to do it?), Gastão, like any good architect of health, builds on a set of analyses and proposals synthesized in five theses concerning the formation/reform of Brazil’s Unified Health System (Sistema Único de Saúde - SUS).

To leave the reader in no doubt, he asserts that the paper amounts to “a text written in defense of the Unified Health System”. This assertion is fundamental in the current national conjuncture, characterized by a conservative offensive against social policy and, in particular, the SUS – the greatest social policy in the history of our country, despite unresolved problems that have arisen during its 30-year existence. In this respect, Gastão aptly emphasizes that these problems persist because “no government or party has assumed the funding and implementation of the SUS as a national priority”.

Yet, the problems of the SUS also persist because international players such as the World Bank have never accepted the universal and comprehensive nature of the Brazilian healthcare system. From time to time, they publish reports painting a negative picture of SUS and reaffirming the efficiency and effectiveness of the private sector. In actual fact, these players are agents of capital that seek to expand consumer markets, turning health into a good. For those without purchasing power, they defend selective healthcare under the responsibility of, but not necessarily provided by, the state, such as universal health coverage.

Commenting on the World Bank’s latest report, Gastão suggests that rather than closing small, supposedly “inefficient” hospitals, as recommended by the bank, they should be transformed into “mixed units, integrating family health teams, urgent and maternal care, and low-complexity surgical procedures into the same service”. With this, he proposes a break with the logic of economic calculation as a criterion for analyzing social policies and the introduction of criteria based on rationality of care, access, social inclusion and the expansion of coverage for such analyses.

On a national scale, mainstream media has been constantly biased against the SUS and in favor of the private sector, helping to form a negative image of the system, which has failed to win the hearts of workers, professionals and service users for its defense in these dark times. In this respect, the reinvigorated, enlarged and democratized health reform movement needs to innovate and incorporate modern means and technologies in order to engage with society, not only recognizing existing problems, but also, as Gastão recommends, elucidating them and proposing solutions with a view to developing a “health project for all Brazilians”.

It would appear to be necessary and timely to reexplore the original ideas and objectives of a health reform movement that articulated the right to health with democracy and the fight to reduce national inequalities. Both social rights and democracy are in decline at the beginning of this century, not only in Brazil but in various countries around the world. According to Streeck¹1. Streeck W. As crises do capitalismo democrático. Novos estud. - CEBRAP [online]. 2012. [acessado 2018 Jan 8]. (92). Disponível em: http://www. scielo.br/scielo.php?script=sci_arttext&pid=S0101-33002012 000100004&lng=en&nrm=iso
http://www. scielo.br/scielo.php?script=... , the post-war pact that combined democracy with capitalism is falling apart. The advance of financial capitalism and the growing concentration of economic power in mega-corporations that exert power over governments and nations imposes limits to democracies circumscribed by national spaces, putting an end to the historical experience of so-called “democratic capitalism”. In this context, the defense of democracy and universal social policies implies the defense of a project that envisions an egalitarian society, not only from a material point of view, but also a cultural, environmentally sustainable, and democratic standpoint, detached from the authoritarian assumptions embedded in the new offensive of neoliberalism that reveal the authoritarian direction taken by capitalism.

The defense of public spaces is essential, particularly because we are far from having an adequately funded, public SUS. The SUS accounts for a mere 46% of overall health expenditure, despite having to provide healthcare to 75% of the country’s population, meaning that this 75% have not “adhered politically and ideologically to the SUS”. As Gastão suggests, this data and the problem of underfunding needs to be widely disseminated and discussed with society by the defenders of the SUS.

From an institutional standpoint, the tension between centralization/decentralization and national/local level present since the creation of the SUS reflects a struggle for power within the federation that disregards the principles that guide the organizational structure of the system and the problem of regionalization. Gastão puts forward some proposals for addressing these problems, which, together with a unified SUS worker policy, could make a significant contribution towards reducing national healthcare disparities. However, the implementation of such proposals would require consensus even among the social actors committed to defending the SUS and the right to health.

Finally, another one of the numerous challenges facing the SUS in the short and medium-term is demographic transition and population aging. In 2016, the proportion of the population aged 60 years and over stood at 14.4%, while the number of people in this age group increased by 16% between 2012 and 2016, compared to only 6.7% in the 0 to 13 years age group, leading to significant widening of the country’s population pyramid at the top and narrowing at the bottom²2. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional por Amostra de Domicílios Contínua. [acessado 2018 Jan 8]. Disponível em: https://www.ibge.gov.br/estatisticas-novoportal/sociais/populacao/9127-pesquisa-nacional-por-amostra-de-domicilios.html
https://www.ibge.gov.br/estatisticas-nov... . This issue needs to assume a prominent position in the political agenda across all levels of government and, particularly, in the actions promoted by the SUS as a state policy. Partial hospitalization, fixed period hospitalization in short-term care facilities (one month per year) to allow carers to rest from their caring responsibilities, and Benefício de Prestação Continuada (Continuous Care Benefit) for family carers of dependent elderly relatives should be incorporated into policies directed at elderly people.

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