SUS, health, and democracy: challenges for Brazil Manifesto of six former Health Ministers on the 16th National Health Conference

Humberto Sérgio Costa Lima José Saraiva Felipe José Agenor Alvarez da Silva José Gomes Temporão Alexandre Rocha Santos Padilha Ademar Arthur Chioro dos Reis About the authors


In the year of the XVI National Health Conference (CNS), thirty-three years into the VIII CNS, this manifesto resumes the theme of relationships between democracy and health and warns Brazilian society about the impending risks that threaten the Unified Health System (SUS), defending our universal system as an effective instrument of health production and citizenship building.

Key words
SUS; Health; Democracy; CNS; Challenges


Many efforts have been made to organize and operate the Unified Health System over the past three decades, based on its underpinning constitutional principles: universality, equity, and integrality. The SUS presupposes a society project that expresses itself in civilizing values such as equality, social justice, and democracy. In this context, health is a value that involves care, sustainability, and health production for citizenship, linking individual and community care to economic development and human rights.

The SUS is a state policy and not a government policy. It is the result of the construction of Brazilian society and has been tenaciously resisting severe political and economic attacks throughout its existence. Health as a solidary value, citizenship right, and state duty, however, has never been so threatened as it is now.

The advances in primary care embodied in the Family Health Strategy (ESF), the National Immunization Policy (PNI), in the significant reduction in child mortality, the Epidemiological and Health Surveillance, the Pharmaceutical Care policy, Organ Transplantation, SAMU, the AIDS/Hepatitis Policy, the Psychiatric Reform, Fighting Tobacco Use, the Blood Policy, among other successful public policies, are significant and internationally recognized.

The field of research and innovation was strengthened, as was the implementation of an industrial policy aimed at the national production of strategic technologies for the country, the policy of strengthening the Productive Health Complex, through partnerships between public laboratories and private companies11 Gadelha CAG, Temporão JG. Development, innovation and health: The theoretical and political perspective of the health economic-industrial complex. Cien Saude Colet 2018; 23(6):1891-1902..

This whole process allowed the country to build a broad health care network that today meets the needs of most of the Brazilian population, with an essential impact on raising expectations and improving living conditions and reducing inequities and inequalities.

The magnitude and relevance of these achievements would undoubtedly have been more significant, far-reaching and of more profound results, had it not been for the structural impasses that imposed along this path strong organizational and financial constraints that prevented the full realization of their foundations.

This is clearly expressed when analyzing the structure of health financing. We invest about 9% of GDP in health, but of this amount, only 46% corresponds to public spending, that is, most health spending burdens the budget of households and businesses. No universal system has an as low public investment as ours, and when we add a significant tax and fiscal waiver each year to this, the underfunding situation gets worse.

Constitutional Amendment EC 95 focuses on this aspect, by placing austerity as a constitutional principle, freezes spending for 20 years and subjugates the health needs of the population to fiscal goals, imposing the status of an unfinanced system on the SUS, endangering even its survival.

This policy of deep cuts in social spending, in a context of denial of rights and devaluation of universal policies, intensifies setbacks and threatens to disrupt the SUS. SUS weakening is coupled with the attack on several fundamental public policies in the health-disease process and the expanded concept of health that involves the simultaneously biological, subjective, and social nature of health problems22 Massuda A, Hone T, Leles FAG, Castro MC, Atun R. The Brazilian health system at crossroads: progress, crisis and resilience. BMJ Global Health 2018; 3(4):e000829..

This constitutive basis of health policies is being deconstructed by changes in policies that have a significant impact on health, without hearing from the Ministry of Health and the Parliament, including:

  • Setbacks in safety standards in the workplace and legislation regarding work accidents and occupational diseases;

  • Proposals related to traffic legislation that affect morbimortality due to motor vehicles’ accidents (road speed, driving norms, and rules, “children’s car seat”, number of points to have the license revoked);

  • Attacks on the Child and Adolescent Statute;

  • Restrictions on widespread access to education and information and weakening sexual and reproductive rights policies;

  • Repeated threats to the disarmament status;

  • Increased tax benefits for the soft drink industry, contrary to what is being done worldwide;

  • Attack on public education and the threat to national science with the drastic contingency of the sector budget;

  • Uncritical release of agrochemicals and pesticides and threats to health, the environment, and sustainability;

  • The new drug policy, which enables involuntary hospitalization of users, prioritizes therapeutic communities and abstinence as the goal of addiction treatment, rather than policies geared to drug users’ health treatment focusing harm-reduction;

  • The Ministry of Justice’s proposal to reduce the price of cigarettes that will weaken the successful tobacco prevention and control policy.

Similarly, increased attention is needed to the risks of weakening private-sector health regulation. Constant market initiatives aimed at easing coverage rules, introducing popular plans, and adjusting health plans should be tackled.

The hegemonic vision in government and parliament, based on a fallacy, is that health, rather than investment, is expenditure and that business-oriented management, even in a context of reduced spending, will allow more to be done with less, even if it compromises the quality of life and threatens the safety of citizens and families.

This also gives rise to the widespread view – and from which we diverge head-on – that the SUS cannot be universal because it “does not fit the budget” and should only be aimed at providing more uncomplicated care for the poor. This mistaken view is unaware, besides the direct benefits of SUS on population health, that activities related to the health sector – services, medicines, vaccines and equipment – account for about 8.5% of GDP and incorporate strategic innovation sectors – information technology, biotechnology, microelectronics, fine chemistry, nanotechnology, among others – with vast repercussions in all sectors of the economy, accounting for 10% of formal qualified jobs, employing around 9.5 million Brazilians in 2015.

The dissemination of the picture of a penurious SUS, hostage to partisan political exchanges, meeting private interests and unsustainable with public resources, erases from the public perception the significant advances obtained and weakens its social support.

The SUS must and can be improved, as it is a heritage of the Brazilian nation and social policy to be preserved and recognized as a valuable common good, as is the case of other countries with universal health systems, such as England, Canada, and Portugal, among others.

Thus, the reaffirmation of a free and universal health system is based, first, on civilizational and justice principles, but also on evidence of the cost-effectiveness of universal public systems compared to other models, based on the private sector, health plans and insurance.

More than ever, social participation in the formulation, monitoring, and oversight of health policies in all spheres of government must be strengthened and expanded. Respecting and implementing the decisions of conferences and health councils, improving and guaranteeing the democratization of the state and citizen participation is fundamental for the destiny of the SUS and the country.

SUS is an achievement of the Brazilian people. Its consolidation and improvement are fundamental axes for the survival of the Democratic Rule of Law and the affirmation of public social inclusion policies.

Since it is the real expression of these values, advocating for a modern public health, of quality and respected by society must be based on care ethics and political, economic and technological sustainability of the SUS, which requires the reaffirmation of the SUS – universal, fair, comprehensive and free – as the health system for all Brazilians.


  • 1
    Gadelha CAG, Temporão JG. Development, innovation and health: The theoretical and political perspective of the health economic-industrial complex. Cien Saude Colet 2018; 23(6):1891-1902.
  • 2
    Massuda A, Hone T, Leles FAG, Castro MC, Atun R. The Brazilian health system at crossroads: progress, crisis and resilience. BMJ Global Health 2018; 3(4):e000829.

Publication Dates

  • Publication in this collection
    26 Sept 2019
  • Date of issue
    Oct 2019


  • Received
    20 July 2019
  • Accepted
    05 Aug 2019
  • Published
    07 Aug 2019
ABRASCO - Associação Brasileira de Saúde Coletiva Rio de Janeiro - RJ - Brazil