Never has Brazil’s Unified Health System (Sistema Único de Saúde – SUS) been so big, yet so fragile. This paraphrase of Gastão Wagner is reminiscent of the underlying thesis of Brazilian health reform: that the exercise and expansion of democracy is an inexorable premise for the effective realization and strengthening of the SUS. The historical veracity of this argument is attested by its flagrant contrast with present times.

Based on the argument of historical inevitability, private commercial rationale has subordinated social well-being to fiscal austerity, guaranteed by the autonomy of constitutional bodies. This oligarchization of powerwillfully ignores democratic traditions manifested in the continuous public participation from which the SUS was born. This problem is corrosive to the realization of health as res pública and is at the root of the neoliberal counterrevolution that is terrorizing the welfare system, labor and education.

Under the auspices of neoliberalism, the lines of thinking of the privatization movement has gained considerable momentum in Brazil and it is important to understand the driving forces behind this process. In a recent World Bank report (2017), the ideology of fiscal adjustment is used to justify the spending ceiling defined by Constitutional Amendment 95/16 and prescribe the creation of new revenue streams via private sector fundraising and staff outsourcing. Through the inversion of values, this type of economic policy turns the universality and gratuity of services into historical remnants of “regressivity” and privileges and evokes partnership with the private sector as superior arrangements to direct government administration. The echoes of this narrative assume their own temporality in national centers such as the Institute of Economic Policy Studies (Instituto de Estudos de Política Econômica/Casa das Garças).

To constitute a political bloc capable of resisting this “powerful political and cultural movement”, as Gastão Wagner puts it, we should not only be aware of the lines of thinking of the privatization movement, but also operate upon the places that assign it public legitimacy. In this respect, it seems imperative to: (i) investigate the meanings of public communication in relation to the SUS, (ii) and clarify the linkages between organized labor, the commodification of healthcare, and the fight for healthcare reform. The political concern that unifies these agendas is the need to develop and sustain a social base of support for the SUS.

The first agenda concerns the silencing of evidence of the “superiority of public systems over private systems” imposed by nondemocratic media. In this respect, opinion polls reveal a curious fact: the positive perception of direct SUS users is counterposed by major rejection among those who stated they had never used the system¹1. Schiavinatto F. Sistema de indicadores de percepção social (SIPS). Brasília: Ipea; 2011.. These results suggest that in the absence of tangible contact with public health services the media, which paints a predominantly negative picture of the SUS, plays an essential role in the formation of public opinion.

The SUS is not impervious to the political role played by the media in democracies. Traditional media claims to be independent from the world of politics, yet in practice represents interests by disseminating the perspectives of specific groups, which, in the case of health, may be best characterized as a veritable lobby for the privatization movement²2. Lima VA. Informação e Saúde Pública: a incapacidade do estado. In: Lima VA. Regulação das Comunicações. História, poder e direitos. São Paulo: Paulus; 2011. p. 173-204.. The political meaning of the SUS will not be formed by propaganda pieces or access to healthcare databases, but rather by engaging with active citizens’ movements.

The second dimension, which demonstrates a shift in the social base of support for the SUS, is revealed in the corporate culture of rights present in labor relations. Employee health plans account for 76% of the private health insurance market. This economic-corporate rationale is fueled by a general lack of knowledge of the breadth of occupational health services provided by the SUS and lack of integration of Workers’ Health Referral Centers (Centros de Referência em Saúde do Trabalhador – CERESTS) with primary and medium and high complexity care services. The lack of dialogue between the health reform movement and trade union leaders produces numerous externalities. It is therefore essential to raise political awareness in order to deconstruct this historical disjunction if the health reform movement is to reassume its position at the center of Brazilian democratic life.

Conclusion

This debate seeks to organize reflections made by Gastão Wagner and create ways of reaffirming the public nature of health policies. By highlighting the meanings of this socially regressive dynamic, which has launched a vicious attack on “nonmarket spaces within capitalist economies”, we seek to debate possible ways of fully integrating the ideals and principles of the health reform movement into the center of the political identity of Brazilian citizens. Viewed as a synthesis of a political direction, this debate opens a new chapter in the fight to defend Brazil’s Unified Health System.

References

Publication Dates