Abstract

In this interview, the former Minister of Health, José Gomes Temporão, professor and retired tenured researcher from Fiocruz in Rio de Janeiro, outlines the trajectory and the challenges facing management in the Ministry of Health in the period from 2007 to 2010 when he held the post.

Brazil; Management; Public Health

1- Former Health Minister, Alcenir Guerra, stated in an interview (http://piaui.folha.uol.com.br/materia/o-tempo-de-temporao) that there are four phases you go through as the Minister of Health: hope, discouragement, because you do not see progress in your initiatives, demands and complaints from the population and the media and, finally, rejection. Have you experienced these phases?

R: This interview was published in Piauí magazine in 2007, it contrasted with the beginning of my mandate as Minister, when several measures of impact and visibility were launched (the compulsory licensing of an AIDS medication, the discussion of abortion as a public health issue, etc.). Alcenir Guerra’s words are typical of a professional politician who felt frustrated and unable to see advancements in Health. He also worked for a disastrous government.

The interview ended with a question: at the end of my time in government, would I feel the same as him? That is, would I also feel rejected as a Minister, be affected by a sort of curse that affects everyone who enters government? What I can say is that the journalist never came to me with this question at the end of my term! When you have been involved in the construction of the SUS [Brazilian Health Service] for many decades, as I have, you feel hope every day. There have always been complaints and demands from the media and the population and this is important too. But, feeling discouraged and rejected, no, I have never felt that. I have had a very different experience. Even now, as I walk the streets of the city where I live, I am still recognized, and people come to talk to me about those days. Some even joke: come back Temporão! I have dedicated all my professional life to public health. I have been in health for 40 years, 32 of which I worked as a lecturer and researcher at Ensp-Fiocruz and I also held public positions at the municipal, state and federal levels. Being a Minister was a pleasurable experience for me. Throughout my four years as Minister, I was very conscious that I represented the movement for health reform in Brazil, something I’ve believed in since I was at university doing medicine. This was very special time for me, albeit sometimes stressful and exhausting, but consistent with my political, professional and personal trajectory. I was also part of a government that was committed to social concerns.

2- Before becoming Minister of Health in 2007, you headed the Healthcare Secretariat (SAS) and before that the National Institute of Cancer (INCA), during a period of crisis. What were the biggest obstacles for you as Minister of Health? What did you know you would have to face, what did you expect would be a problem but wasn’t, and what obstacles did you not expect?

R: Working in INCA and SAS provided me with greater knowledge and experience on how the public bureaucracy operates at federal level. I would not say that there were surprises as such, but some periods of concern. One was when the government failed to approve the continuation of the CPMF [Provisional Contribution on Financial Transactions]. That was a significant defeat. It prevented us from implementing several programs and objectives. The various defeats suffered in attempting to approve Amendment 29 - which would have given us a new funding basis for the sector - was also frustrating. As were the initiatives that questioned the tax exemption and expenditure framework that, since the 1990s, had been a significant mechanism for expanding the health insurance sector. In some specific cases, the Minister of Health was practically alone in a government where the position of the economic area Ministries and the Ministry of Planning had always been skeptical, if not against, these proposals. Unfortunately, with regard to these issues, there was not much difference between our government and preceding governments. Another significant issue was the extremely tense relationship with the mainstream media, given their constant attacks on the Lula government. An example was the emergence of some yellow fever cases at the end of 2007 which were monstrously transformed by the media into an epidemic. This even led to a few deaths when some people vaccinated themselves against medical advice because they were induced to do so by the climate of hysteria created by the media. The relationship with the media has always been one of our greatest challenges. Another proposal that led to much debate and conflict, in particular with the health professional bodies, was the creation of a new public management model: The Public Foundations, public entities but regulated by private law. This model was implemented with some distortion, when the Brazilian Company of Hospital Services (EBSERH) was created, though it flourished in its original version in some states, such as in Bahia.

But there is another important aspect. I remember that in one of the first interviews that I gave to the Fiocruz site, just after I was appointed, a journalist asked me, what would make me most proud in terms of my contribution to SUS and Brazil’s public health at the end of my term. I replied that when I concluded my term, I wished that the Brazilian population would be proud of its healthcare system, and that more people would gradually come to use the SUS services. That is, I hoped that the Brazilian population would increasingly come to believe in the improvement and strengthening of SUS. An indirect way of knowing this, even if it only provides us with a partial insight into a very complex process, is through the surveys conducted by the National Confederation of Industry in partnership with Ibope (CNI-IBOPE surveys) on the population’s opinion of the government’s public policies. In December 2010, at the end of my term, the CNI-Ibope poll found that 42% of the population approved the Government’s health policies, 54% did not approve them and 5% did not know. In March 2015, only 13% approved the health sector’s performance.

Furthermore, during that interview, I expressed my wish that at the end of my term, I would have furthered the population’s understanding that SUS is essential for improving their living conditions and as part of the process of consolidation of our democracy. That is, I pointed to the need to collectively develop political awareness, in the meaning of Berlinguer’s concept of health awareness, in order to ensure the political sustainability of SUS. But how do we assess this? How do we actually measure if this has occurred?

3- How to make policies, negotiate and bring together proposals with representatives of different sectors, without falling into “politicking” - exchange of favors, personal interest, and corporativism?

R: To turn public health into an important pillar, around which everything turns, is a permanent challenge, given the profile of the national congress and the specificities of a system of coalitional presidentialism. I managed to appoint all my team, except for the director of FUNASA (National Health Foundation). Apart from this position, I was able to appoint a high-quality team, strongly committed to health in Brazil and I was able to draft a plan of action (Mais Saúde, launched in December 2007) which I consider to be considerably innovative. If you place the strengthening and the advancement of SUS above anything else, ensuring that this concept steers every single government action, it is possible to ward off what you called “politicking”.

4- As former Minister of Health, how do you see the programs and project implemented in SUS. Are they marked by stability or are then generally initiatives of specific administrations? Have the projects and programs implemented during your administration been given continuity?

This is a very important topic. Most ministers are concerned with leaving their own mark so that it can then be used as political capital in the following elections either for parliament or government. I remember that getting to end of my time, I gave an interview to a newspaper and said that I would like to be remembered in the future as a Minister that did not leave any marks, but who worked to strengthen SUS itself¹1. Paim JS. Reforma Sanitária Brasileira. Rio de Janeiro: Editora Fiocruz; 2008.. Nevertheless, if we look at the development of SUS from a historical perspective, there is considerable stability with regard to the continuity and consolidation of its main programs and policies, that tend to be maintained across various governments, headed by ministers holding different ideological views: be it in terms of the System’s operational norms and regulations (Nobs, Noas, Pacto pela Saúde), the framework of high complexity networks, or programs and policies such as family health, psychiatric reform, sexual and reproductive rights, access to medication or generic medication policy. In fact, on the whole, the main trajectory is one of continuity and strengthening of these policies and programs. This is an interesting topic for academic analysis. The exception is the current administration that seems to be particularly committed to undermining what has already been achieved. They argue that their main objective is to improve cost efficiency. This is nothing more than a way of concealing their total lack of commitment to SUS. As a Minister, I kept and gave continuity to many prior initiatives, for example, the health policies for men, for the black population, strengthening the industrial health sector, the emergency service centers (UPAS), the SUS Open University, the expansion of the Fiocruz network, the Health in Schools program and the inclusion of sex change operations into SUS practices. I continued to give priority to early childhood development, such as the Brasileirinhas e Brasileirinhos Saudáveis [healthy Brazilian boys and girls] Strategy. But of course, political vision and commitment can affect the position of individual ministers and lead to changes in terms of pace, priorities and focus. These changes can impact on the continuity of certain policies, for example the sexual and reproductive rights policy stopped being a priority and some policies can be even scrapped, as was the case with Farmácia Popular (People’s Pharmacy) in 2017.

5- How close is the relationship between a Health Minister and the President? When you were Minister did you have regular sessions and meetings with the then President Lula?

R: Health is something that deeply affects the dynamics and the daily routine of a government. I had permanent contact with President Lula, not only because of the political weight of my position and the complexity of health in general, but because, as a Minister, I never shirked my responsibilities and always ensured I had a direct dialogue with society and this, of course, had repercussions for the President. During my administration, there were some serious episodes, such as the H1N1 pandemic, the defeat of the CPMF bill in congress and the drafting of the Mais Saúde program. The PMDB put constant pressure for me to resign and there was also the whole episode with Zeca Pagodinho and beer advertising on TV. Through all this, I was constantly in contact with the President, sometimes it was a little tense (laughter). But there were moments when this relationship was even more difficult. For example, in the discussion on abortion as a public health issue, when the President was called to give his own opinion, after I had argued in support of women’s rights. This led to a Bishop from the northeast of Brazil threatening me with excommunication, which also coincided with the Pope’s visit. In general, in terms of drafting health policies, ours was a constructive relationship. For example, the President called a meeting with the Governors of the Northeast states to establish a pact to reduce child mortality in the region. This decision was very significant for the reduction of child mortality which fell by half between 2000 and 2012. We made a considerable number of trips together to open hospitals, UPAS, research centers, SAMU [Mobile Emergency Care Service] Units, Farmácia Popular partnerships, Brasil Sorridente [dental care units] and to launch new programs such as health in schools and the inclusion of contraceptive pills into the Farmácia Popular program. His joint presence in events such as the opening ceremonies of the Abrasco [Brazilian Association of Collective Health] Congress, in the 13th National Health Conference and the 1st National LGBT Conference, as well as the graduation of the first doctors funded by the PROUNI program were particularly significant. At international level, it is important to highlight the UNASUR meetings that led to the creation of the South American Health Council and ISAGS [South American Institute of Governance in Health], as well as the launch of an antiretroviral factory in Mozambique. It is also important to recall President Lula’s decision that resulted in Brazil establishing, for the first time, compulsory licensing of a strategic medication for Aids treatment. All this, together with regular official meetings and having to put out fires, both inside and outside the government, led to a very close relationship and mutual admiration that continued even after I left government.

6- What was your relationship with the democratic participation/social control arenas? Did your experience have an impact on some of these mechanisms?

R: I have many years’ experience in this subject. Before the Nova República (during the military regime), when I was Secretary for Planning at INAMPS (Social Security National Institute for Health Care), part of Hésio Cordeiro’s team, I was able to draft and implement the AISs [Integrated Health Actions]. These already included mechanisms for social participation at the municipal and state levels. Under Eleutério Rodrigues Neto’s coordination, I was part of the drafting of legislation that established the SUS and was involved in the discussions on social participation forums. As a Minister, my relations with the National Health Council (CNS) were influenced by the debates on State foundations. There was a clear conflict. The 13th CNS conference took place during my term and it was sad to see that my position on abortion was defeated. I think these conferences and councils need to be reviewed. We need to return to conferences where we can debate concepts and theses, as was the case with the 8th conference. In relation to the Councils, I think we need to rethink the issue of professional councilors and the fact that the introduction of social control within the structure of the State inevitably led to their loss of power and autonomy. But I do not have a ready-made answer.

7- The increase in the judicialization of health is an issue that drives discussions on the limits of the comprehensiveness of SUS. How to steer these discussions towards strengthening SUS within a context in which it is claimed that there is no budget for it? Is there an impasse in terms of discussions on comprehensiveness?

There are three ways of looking at judicialization: from the point of view of rights - when a citizen or an organization goes to court to demand access to a particular technology or procedure that, for some reason, they have been denied, but which may be seen as a demand within a conception of health as a right guaranteed by the Constitution; as a need already established in directives, protocols or official policies but which, for whatever reason, was not available at the time or in time and; and desire, when strategies of the health industries use the judicial route to try to incorporate a certain technology of their interest in the SUS protocols. That is why I created the Commission for the Incorporation of Technologies (CITEC) at the Ministry of Health. This was the first SUS body geared towards the management of health technologies. It was further improved in 2011 with the approval of law 12.401 which established CONITEC (National Commission for the Incorporation of Technologies). There must be criteria for this process of incorporation, which also involves public-private partnerships. It is important to take this discussion to the health insurance sector and strengthen the participation of patient representatives. Comprehensiveness is a fundamental SUS principle. It cannot be ‘softened’ or downgraded, otherwise we will undermine one of the main foundations of care, understood here as an ontological vision which goes beyond technical intervention.

8- In an article published in the Folha de S. Paulo newspaper in October, you discuss the need to conceive abortion as a public health issue. Ten years ago, as Minister of Health, you were involved in controversies for supporting the right of women to have an abortion. In your opinion, do you see less favorable conditions today for this discussion compared to when you were a Minister?

R: There is no doubt that there have been setbacks in relation to abortion worldwide. Even in countries where women can decide to terminate their pregnancy, access to abortion is gradually becoming a significant limiting factor as, for example, in the United States, India and South Africa. At the same time, recently, we have seen progress in South America, in Uruguay, Colombia and Chile. In Brazil, the religious lobby in the chamber of deputies has 197 members. They argue for a total ban of all terminations, even in cases where the current backward legislation allows it. The fact is that abortion is legal for women who can pay for it. They go to private illegal clinics. While poor women put themselves at risk and die and this has a significant impact on maternal mortality rates in Brazil. It is important to reflect on the “right to life” these people tend to talk about. Which life? Whose lives? Women’s lives are never considered! Often these “women” are teenagers without access to information and living in places where there is a lack of policies that could support them with their sexual and reproductive rights. These policies need to be in schools, part of young people’s education. They must be taught, together with the importance and responsibility, the place/role of fathers and mothers, or whatever format a family takes, to look after their children, as well as their impact on personal development and society. Schools would be a great opportunity for communicating this, creating an environment that promotes life, in face of so many difficulties. But this is not done because of prejudice and hypocritical views on “what young people should know” about themselves and their personal relationships with others. Even in cases where the legislation allows access to termination services, as when the pregnancy was a result of rape, this is a difficult and painful process for women.

Looking at this question as a public health issue can help us develop a perspective that is more respectful of women’s rights.

9- The media’s coverage of public health and the SUS can both help foster health awareness or undermine the political struggles for the right to health and the Brazilian health system. What is the role of the press with regard to the functions of the Minister of Health?

R: Building political awareness of collective health, within an understanding of health as a social and political phenomenon, is essential for strengthening SUS. In societies where health systems are seen as a legacy, built by many generations, that must be safeguarded and improved have managed to imbue political sustainability into the system. From this point of view, in Brazil, the role of the mainstream media is clearly both contradictory and negative. It is true that there are forums for providing information, guidance and supporting the mobilization of society in important themes that cannot be ignored. These paradoxes become clear when looking at the economic interests associated to the health insurance sector, the large drug advertisers, the contradictions between programs that reach the population on healthy life styles and the massive advertising of soft drinks, fast foods and ultra-processed foods. The press can also act as the Minister’s persecutor (for example, in Alcenir Guerra’s case) or even support him in specific situations (with campaigns on dengue and sexually transmitted diseases), reproducing positive debates. But in Brazil, we have a very interesting phenomenon. This is the transmigration of charity and philanthropy into SUS, in the sense that the media permanently blurs the issue of the right to health which is downgraded by claims that SUS is indeed important, but only for the poor population. We live in a country where our Constitution states that health is a universal right. But we see all the time initiatives such as “criança esperança” [child hope], the Luciano Huck program, campaigns for funding treatments abroad, via the internet. Unfortunately, behind all this, is a view that these would be an alternative to what they believe to be a bankrupt system. Please understand one thing, I have nothing against solidarity campaigns and civil society initiatives that clearly support situations that have been identified in common, so long as these are conducted in dialogue with SUS and its principles.

I believe that the press has a very important role in monitoring and following up health policies, contributing to the greater transparency and better management of the system.

10- Thinking about future strategies for Brazilian public health, the “Brasil Saúde Amanhã [Brazil Tomorrow’s Health] project identifies three scenarios, these are: optimistic and possible, pessimistic and plausible, and no change and probable. In face of these potential scenarios and considering that there are elections in 2018, what are your visions for the future of the Brazilian health system?

R: Well, this exercise in immensely challenging! But, if we take a timeline starting in the year 1500, when Brazil joined the 16th century globalization process, we see that throughout its 517 years history, 64% of the time Brazil was a Portuguese colony, 13% a monarchy, 8% an oligarchic republic, 7.6 % a dictatorship and only a little more than 2% a democracy. That is, we are still a very fragile and young democracy. Therefore, organizing and structuring social and health policies within this context is also a relatively recent initiative.

Carlos Gentile de Melo, one of CEBES [Brazilian Centre for Health Studies] founders, described those committed to public health as inveterate optimists. We cannot deny the huge advances that took place in access and coverage in the last 30 years. But recent defeats put everything we have achieved so far at risk. Amendment 95 that froze all public expenditure for 20 years, the proposals for popular health plans, the undermining of the Family Health Strategy (creation of the doctors on duty, reducing the importance of the community health workers, the risk of focusing only on the most vulnerable) reinforce a limited view in which SUS is simply a healthcare plan for the poor. The fact is, we are at the beginning of a long process full of contradictions and the current state of affairs makes us more pessimistic, but we cannot fall into this trap and disregard the advances and, as it’s already been said, there is no light without shadow, no progress without setbacks.

11- After you left the Ministry of Health, you took up other positions, such executive director of ISAGS. You have focused on research, participated in various events and been a critic of certain aspects of the current state of affairs. Can you tell us a little about life after being Minister of Health?

R: It is, without a doubt, a lot calmer! (laughter). To be a Minister for four years, being committed fulltime to the health of the population, having to give up my personal life, and the lack of the privacy that comes with being a public person has had a very significant impact on my life and that of my family. But I continue to work, I have travelled the country giving lectures, developing ISAGS, which is an international organization with headquarters in Rio de Janeiro. It is linked to UNASUR. I was its director for five years. I did some consultancy work for the government of China, reviewing its health policy. I re-established my links with Fiocruz. In other words, I am not short of things to do! The experience I have gained could be used to produce a practical guide on how to be a Minister! There’s an idea!!! (laughter).

I can say that today I am in the same position I have been for decades: helping to build a legacy for the Brazilian society, that is, SUS.

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