Abstract

Brazil has changed a lot since the enactment of the 1988 Federal Constitution. Although substantial advances have occurred in the health sector, old problems persist and new ones arise. The main goal of ensuring the universal right to health has not been achieved. The 16^th National Health Conference will be held in 2019, an opportune moment to analyze the history, the present moment and the announcing trends. This text seeks to contribute to this analysis based on the results of studies on the developing health conditions of the population and the Brazilian health system in the last 30 years. It identifies the strengthening of the private sector and capital in the health sector, to the detriment of the public interest and the SUS. Finally, it discusses the strategies of the struggle for the right to health necessary and possible in the current context.

Key words
Right to health; Unified health system; Health care; Health policy; Health reform

Introduction

The 16^th National Health Conference (16^th CNS) is held in 2019, 31 years into the creation of the Unified Health System (SUS). Throughout this period, the country changed its demographic, epidemiological, economic, political and educational situation, but it did not overcome social inequalities and environmental aggressions.

The National Health Council launched a Guiding Document to support the debates of the 16^th CNS, which resumes the central theme – Democracy and Health – of the historic 8^th Conference held in 1986. It should be emphasized that this document not only revives the themes, but is also denounces measures that adversely affect social policies, as is the case of the freezing of public resources for health for 20 years, as determined by Constitutional Amendment Nº 95 (EC-95) of 2016.

In the context of the economic, social and political crisis in Brazil, there is no doubt that the challenges of the fight for the right to health in the country are enormous. To face them, one must carefully analyze the history, the present moment and the announcing trends. This analytical effort must be undertaken in public and diversified debates that enrich social participation and understanding of reality to produce agreements and consensuses that contribute to the mobilization and strategic action of the social forces committed to advocating the human right to health and the SUS.

Therefore, this text aims to contribute to broadening the debate, resorting to the results of scientific research and academic reflections published in the periodicals Ciência & Saúde Coletiva, Cadernos de Saúde Pública and Saúde em Debate, which published sections or special numbers in 2018 regarding the 30 years of the SUS. As these publications attest, there is much to celebrate, but one must also recognize the persistence of old difficulties and the emergence of new ones. Fundamentally, it must be admitted that the objective of ensuring the universal right to health has not been achieved.

This paper shows the results of studies on the trend of health conditions of the population and the Brazilian health system. It identifies the strengthening of capital and the market, to the detriment of the public interest, and seeks to subsidize the discussion of the necessary and possible strategies of the struggle for the right to health.

The trend of people’s health conditions and health services

The 1990-2015 period witnessed significant reductions in mortality rates due to communicable and preventable diseases, mother and child morbimortality, and child malnutrition. In turn, the population’s life expectancy increased from 68.4 years in 1990 to 75.2 years in 2016. Overall age-standardized mortality rates fell by 34%¹1 Souza MFM, Malta DC, Franca EB, Barreto ML. Transição da saúde e da doença no Brasil e nas Unidades Federadas durante os 30 anos do Sistema Único de Saúde. Cien Saude Colet [periódico na Internet]. 2018 Jun. [acessado 2019 Jun 02];23(6):1737-1750. Disponível em: http://dx.doi.org/10.1590/1413-81232018236.04822018.
http://dx.doi.org/10.1590/1413-812320182... . The reduction of child mortality was driven by the Bolsa Família (Family Grant) and the Family Health Strategy²2 Aquino R, de Oliveira NF, Barreto ML. Impact of the family health program on infant mortality in Brazilian municipalities. Am J Public Health. [periódico na Internet]. 2009 Jan. [acessado 2019 Jun 02];99(1):87-93. Disponível em: https://doi.org/10.2105/AJPH.2007.127480
https://doi.org/10.2105/AJPH.2007.127480... ^,33 Rasella D, Aquino R, Santos CAT, Paes-Sousa R, Barreto ML. Effect of a conditional cash transfer programme on childhood mortality: a nationwide analysis of Brazilian municipalities. Lancet [periódico na Internet]. 2013 [acessado 2019 Jun 02]; 382 (9886):57-64. Disponível em: https://doi.org/10.1016/S0140-6736(13)60715-1
https://doi.org/10.1016/S0140-6736(13)60... . There has been marked progress in the North and Northeast, which has not eliminated but reduced regional inequalities. Finally, advances in the SUS and social policies, combined with economic improvements, have come together to improve the health of Brazilians.

However, as of 2015, some indicators pointed to the existence of risks to the continuity of this positive trend of the health situation. Infant mortality rates increased between 2015 and 2016, reversing a historical declining trend⁴4 Abrasco. Especial Abrasco sobre o aumento da mortalidade infantil e materna no Brasil.[matéria na Internet]. 2018 Ago. 31 [acessado 2019 Jun 02]; [cerca de 6 p.] Disponível em: https://www.abrasco.org.br/site/outras-noticias/institucional/especial-abrasco-sobre-o-aumento-da-mortalidade-infantil-e-materna-no-brasil/36777/.
https://www.abrasco.org.br/site/outras-n... . Microsimulations have shown that the eventually reduced coverage of the Bolsa Família Program and the Family Health Strategy will increase the number of deaths of children up to five years of age⁵5 Rasella D, Basu S, Hone T, Paes-Sousa R, Ocké-Reis CO, Millett C. Child morbidity and mortality associated with alternative policy responses to the economic crisis in Brazil: A nationwide microsimulation study. PLoS Med. [periódico na Internet]. 2009 Maio. [acessado 2019 Jun 02];15(5):e1002570. Disponível em: https://doi.org/10.1371/journal.pmed.1002570
https://doi.org/10.1371/journal.pmed.100... and those up to 70 years of age⁶6 Rasella D, Hone T, Souza LE, Tasca R, Basu S, Millet C. Mortality associated with alternative primary healthcare policies: a nationwide microsimulation modelling study in Brazil. BMC Medicine [periódico na Internet]. 2019 [acessado 2019 Jun 02]; 17:82. Disponível em: https://doi.org/10.1186/s12916-019-1316-7
https://doi.org/10.1186/s12916-019-1316-... .

Regarding communicable diseases, the expanded surveillance, control and prevention actions reduced morbimortality, especially of vaccine-preventable diseases. However, dengue, Chikungunya and Zika, diseases for which effective control technologies are not available, have maintained a high prevalence of infectious diseases in Brazil⁷7 Teixeira MG, Costa MCN, Paixão ES, Carmo EH, Barreto FR, Penna GO. Conquistas do SUS no enfrentamento das doenças transmissíveis. Cien Saude Colet [periódico na Internet]. 2018 Jun. [acessado 2019 Jun 02]; 23(6):1819-1828. Disponível em: http://dx.doi.org/10.1590/1413-81232018236.08402018
http://dx.doi.org/10.1590/1413-812320182... . In the case of environmental risks, the socioeconomic development model adopted was not guided by the search for an ecologically balanced environment⁸8 Freitas CM, Rocha V, Silva EL, Alpino TMA, Silva MA, Mazoto. Conquistas, limites e obstáculos à redução de riscos ambientais à saúde nos 30 anos do Sistema Único de Saúde. Cien Saude Colet [periódico na Internet]. 2018 Jun. [acessado 2019 Jun 02]; 23(6):1981-1996. Disponível em: http://dx.doi.org/10.1590/1413-81232018236.04702018
http://dx.doi.org/10.1590/1413-812320182... .

Concerning health services, on the one hand, an expanded public network, mainly primary care facilities, was observed, increasing access to medical visits and curbing hospitalizations. While poor quality cases are frequent and often seen in media denunciations, some indicators point to the improved quality of SUS services. For example, a decline was observed in admissions due to primary care-sensitive causes, which fell from 120 to 66 per 10,000 inhabitants between 2001 and 2016⁹9 Pinto LF, Giovanella L. Do Programa à Estratégia Saúde da Família: expansão do acesso e redução das internações por condições sensíveis à atenção básica (ICSAB). Cien Saude Colet [periódico na Internet]. 2018 Jun. [acessado 2019 Jun 02];23(6):1903-1914. Disponível em: http://dx.doi.org/10.1590/1413-8123 2018236.05592018.
http://dx.doi.org/10.1590/1413-8123 2018... .

Concerning health protection, the performance of actions through the National Health Surveillance System has improved, although control problems persist for large corporations, including food, tobacco and agrochemicals, whose activities are linked to risk factors related to the epidemic of chronic diseases¹⁰10 Silva JAA, Costa EA, Lucchese G. SUS 30 anos: Vigilância Sanitária. Cien Saude Colet [periódico na Internet]. 2018 Jun. [acessado 2019 Jun 02]; 23(6):1953-1961. Disponível em: http://dx.doi.org/10.1590/1413-81232018236.04972018
http://dx.doi.org/10.1590/1413-812320182... .

On the other hand, the persistence of a shortage of health professionals¹¹11 Viacava F, Oliveira RAD, Carvalho, CC, Laguardia J, Bellido JG. SUS: oferta, acesso e utilização de serviços de saúde nos últimos 30 anos. Cien Saude Colet [periódico na Internet]. 2018 Jun. [acessado 2019 Jun 02]; 23(6):1751-1762. Disponível em: http://dx.doi.org/10.1590/1413-81232018236.06022018
http://dx.doi.org/10.1590/1413-812320182... , and regional disparities in the quality of care persisted, mainly revealing the influence of socioeconomic factors¹²12 Ribeiro JM, Moreira, MR, Ouverney AM, Pinto LF, Silva CMFP. Federalismo e políticas de saúde no Brasil: características institucionais e desigualdades regionais. Cien Saude Colet [periódico na Internet]. 2018 Jun. [acessado 2019 Jun 02];23(6):1777-1789. Disponível em: http://dx.doi.org/10.1590/1413-8123 2018236.07932018
http://dx.doi.org/10.1590/1413-8123 2018... , as shown by the comparison of the average income of the wealthiest segment of the population with that of the poorest segment: the wealthiest 20% have an income 17 times higher than the income of the poorest 20%¹³13 Marmot M. Brazil: rapid progress and the challenge of inequality. International Journal for Equity in Health [periódico na Internet]. 2016 [acessado 2019 Jun 02] 2016; 15:177. Disponível em: http://dx.doi.org/10.1186/s12939-016-0465-y
http://dx.doi.org/10.1186/s12939-016-046... .

If it is undeniable that health care’s supply and coverage increased, it is also true that it involved the public, nonprofit and private sectors heterogeneously, consolidating the segmentation of services among clients with different payment capacities.

Thus, Brazil does not have a truly unified health system, but only a fragmented set of services that compete for the same resources. Also, it is a service provision that reflects and reproduces social inequalities and compromises the integrality of care, since it prioritizes the diagnosis and treatment of diseases and illnesses, to the detriment of risk prevention and health promotion.

In short, it can be said that the country has a service roster that covers most of the population, but has inequalities in access and quality of care, disfavoring vulnerable groups of the population. At the same time, the hegemony of a model of care centered on specialized and hospital care services remains unevenly deployed within the national territory. Finally, this set of services is based on an iniquitous distribution of actions and procedures between the public and private sectors, which assures the latter a higher volume of material and symbolic resources¹⁴14 Bahia L. Trinta anos de Sistema Único de Saúde (SUS):uma transição necessária, mas insuficiente. Cad Saude Publica [periódico na Internet]. 2018 [acessado 2019 Jun 02] 2018; 34(7):e00067218. Disponível em: http://dx.doi.org/10.1590/0102-311X00067218
http://dx.doi.org/10.1590/0102-311X00067... .

Thirty years of struggle for the right to health: the conflicting projects

If the constitutional recognition of the right to health has produced positive results, as shown in the previous topic, ensuring the right to health is far from having been achieved in the daily life of citizens, with the persistence and emergence of health problems and gaps and failures of services, unacceptable in civilized societies.

This situation is the (always provisional) result of the disputes between different projects of society that, in the health sector, can be schematically grouped into two blocks: the popular-democratic project of the Brazilian Health Reform Movement and the liberal-conservative project to which private sector to health is linked.

The Brazilian Health Reform has achieved essential victories since the end of the military regime in 1985, triggering three strategic routes¹⁵15 Paim JS. Sistema Único de Saúde (SUS) aos 30 anos. Cien Saude Colet [periódico na Internet]. 2018 Jun. [acessado 2019 Jun 02]; 23(6):1723-1728. Disponível em: http://dx.doi.org/10.1590/1413-81232018236.09172018
http://dx.doi.org/10.1590/1413-812320182... . The parliamentary route enabled the inscription of the right to health in the Constitution and established the Unified Health System. The technical-institutional route paved the way to the implementation of a useful set of health policies and programs. The socio-communitarian route allowed the promotion of social participation that contributed to the advances through councils and health conferences.

However, the political and social forces that succeeded in developing these strategies lost influence in the process¹⁶16 Noronha JC. Maturidade e suficiência. Cad Saude Publica [periódico na Internet]. 2018 Jul. [acessado 2019 Jun 02]; 34(7):e00109718. Disponível em: http://dx.doi.org/10.1590/0102-311X00109718
http://dx.doi.org/10.1590/0102-311X00109... and failed to maintain the unity achieved in the constituent period, and gains achieved were not sufficient to ensure the right to health in a universal and egalitarian manner, as proposed in the Final Report of the 8^th National Health Conference.

These limitations were due to the opposition of the private sector to an expanded and qualified SUS instead of weaknesses of the Health Reform Movement. With its stratagems, the private sector successfully competed for the financial, material and symbolic resources that Brazilian society assigns to health services. It should be noted that the private sector that opposed the creation of the SUS is not the same that, three decades later, competes for public resources. Currently, the private health sector is led by multi-sector financial corporations, which hold the capital not only from health plan operators, hospitals and diagnostic and therapy services, but also companies in other economic sectors¹⁷17 Sestelo JAF. Dominância financeira na assistência à saúde: a ação política do capital sem limites no século XXI. Cien Saude Colet [periódico na Internet]. 2018 Jun. [acessado 2019 Jun 02]; 23(6). Disponível em: http://dx.doi.org/10.1590/1413-81232018236.04682018
http://dx.doi.org/10.1590/1413-812320182... .

In short, the current configuration of health services in Brazil results not only from initiatives that are conscious of political agents but also from structural determinations that have not been overcome. Thus, the current health “system” can be understood as organic to an ancillary capitalist society, immersed in class struggles¹⁸18 Souza LEPF. 30 anos do SUS: a transição continua. Cad Saude Publica 2018; 34(7):e00109418.. It may be that political segments of the progressive field have not timely identified health financialization, underestimating the accumulated power of capital¹⁹19 Santos NR. SUS 30 anos: o início, a caminhada e o rumo. Ciên. Saúde Coletiva [periódico na Internet]. 2018 Jun. [acessado 2019 Jun 02]; 23(6):1729-1736. Disponível em: http://dx.doi.org/10.1590/1413-81232018236.06092018
http://dx.doi.org/10.1590/1413-812320182... , especially in the transition from the twentieth to the twenty-first century.

Financial dominance and attack on the constitutional political regime

Structurally, capitalism is experiencing a time of financial dominance. Financial or “paper” (currencies, debt securities, shares in stock exchanges, and the like) wealth multiplies relatively independently of the production and valuation of real assets, i.e., value-for-money goods and services for people²⁰20 Braga JC, Oliveira GC, Wolf PJW, Palludeto AWA, Deos SS. For a political economy of financialization: theory and evidence. Econ. soc. [periódico na Internet]. 2017 [acessado 2019 Jun 02]; 26(n.spec ) Dec. 2017. Disponível em: http://dx.doi.org/10.1590/1982-3533.2017v26n4art1
http://dx.doi.org/10.1590/1982-3533.2017... ^,2121 Roosevelt Institute. New Rules for the 21st Century, 2019. [documento da Internet]. [cerca de 50 p.]. [acessado 2019 Jun 02]. Disponível em: https://rooseveltinstitute.org/wp-content/uploads/2019/04/Roosevelt-Institute_2021-Report_Digital-copy.pdf
https://rooseveltinstitute.org/wp-conten... . This financial logic dominates the entire economy: even the productive industry and agriculture now earn a significant part of their profits from the specific financial activity.

The expansion of this rationale imposes a new role for the state that must reduce the provision of services to citizens to allocate increasingly more resources to the paper wealth multiplication process. As a consequence, the policies of direct money transfer to the poor that introduces them into the financial market are acceptable, but policies that require the provision of services by the state apparatus or strong participation of the public power, such as the SUS, become uninteresting in the perspective of high finance.

Analyzing the connections between the financialization process, the social protection system and the Brazilian tax system, the growing trade in private pension plans and health care in the 2000s stems not only from the entry into these markets of large multi-sector financialized companies but also of increased fiscal subsidies given to the buyers of these plans²²22 Domingues JM. Lavinas L. The takeover of social policy by financialization: the brazilian paradox. New York: Palgrave Macmillan; 2017..

Under these structural conditions, one can understand that the current configuration of health services entails primary care that serves less-favored segments of the population, promoting some relief from social tensions, and simultaneously expands the market for health supplies.

The private provision of specialized services, in turn, constitutes a market for companies in the sector, no longer dominated by medical service companies, such as group medicine in the 1980s, but by companies whose central business is financial income and not the production and marketing of the health goods or services they offer.

Finally, some ultra-specialized services, whose business models cause them to have very high prices, are provided by the public sector, ensuring, on the one hand, access of a sufficient number of people to guarantee economic scale to the service, and on the other, the realization of the capital of the equipment industry and the provision of affordable health insurance options by the middle classes.

It is worth noting that the SUS remains essential for this new private sector, as seen by the proposals for public-private integration²³23 Coalizão Saúde. Proposta para o sistema de saúde brasileiro. [documento da Internet]. [cerca de 28 p.]. Disponível em: http://icos.org.br/wp-content/uploads/2016/04/Coalizao_Brochura.pdf
http://icos.org.br/wp-content/uploads/20... , which translate, in practice, into broader access to public resources and more considerable influence in the definition of official policies.

Under the aegis of financialization, the interest of the capital in the situation of the last two decades has been apparent: the financial sphere securing increasingly more significant portions of socially produced resources. Looking at business opportunities, in the case of Brazil, nothing is more attractive to them than social security, given the enormous volume of transacted resources. With fewer, but not insignificant resources, health and education also come under the watch of investors and rentiers.

The financial system’s uptake of these funds, however, is hampered by the constitutional framework of 1988. Hence, the capital under financial dominance yearns for the cancellation of public pensions based on distribution, ending the linkage of health and education expenditures, and reducing the number of public servants.

The changes sought by the capitalists are of such magnitude that they can be characterized as a frontal assault to the political regime provided for by the 1988 Constitution. In order to facilitate the attack, the political and business leaders aligned did not hesitate to promote President Dilma’s impeachment in 2016, imprison the favorite contender for the 2018 presidential election and support an unprepared candidate with no commitment to democratic order. Having attained the leadership of the Federal Executive Power and a broad parliamentary base, these political forces try to bring the final blow to the regime established by the Constitution.

The current challenges of the struggle for the right to health in Brazil

First, the struggle for the right to health in Brazil in 2019 requires facing the challenge of building a national development project. In order to be consistent with the idea of health as a human right, development must be sovereign, socially inclusive and sustainable. It requires investments in policies that promote full employment and combat income inequalities, housing, sanitation and public transportation; in the innovation of the productive and technological structure; in the sustainable management of natural resources; in universal access to quality services in the areas of Education, Social Security and Food Security.

There is no doubt that a project like this is antagonistic to the interests of the capital, well represented by economic ultra-liberalism that proposes the privatization of the state patrimony, promoting subjugation, divestment in science and technology, social exclusion and environmental devastation.

The construction of a democratic-popular project demands more than the timely opposition to each ultraliberal initiative. It requires a strategy of overcoming the financialized economy and valuing productive activities. It is about establishing benchmarks and imposing limits on the permissiveness of financial markets, securitization and derivative schemes, and high levels of leverage.

Also, adequate treatment of the public debt issue is essential, with mechanisms to define interest rates that meet the interests of national development, and reforms in favor of tax justice, aiming to overcome the regressive Brazilian system.

Therefore, the Health Reform Movement must revitalize the social control collegiate²⁴24 Teixeira CFS, Paim JS. A crise mundial de 2008 e o golpe do capital na política de saúde no Brasil. Saúde Debate [periódico na Internet]. 2018 Out [acessado 2019 Jun 02]. 2018; 42(n. espc 2):11-21. Disponível em: http://dx.doi.org/10.1590/0103-11042018S201
http://dx.doi.org/10.1590/0103-11042018S... , articulating with other social movements, especially those linked to strategic sectors of the economy, in the formulation of this new development project. In particular, it is essential to fight for the preservation of state-owned enterprises, under democratic control, and to strengthen the national system of science, technology and innovation. Essentially, it is about reinvigorating the state’s ability to subordinate particular economic interests to the interests of national development.

Secondly, it is necessary to preserve democracy. There is no doubt that the juridical-parliamentary coup in 2016 weakened Brazilian democracy. The inauguration of the new government in 2019 aggravated the situation with the intensification of attacks on social, political and civil rights. In this context, it is impossible to promote the right to health without defending all rights.

In the year in which the 16^th CNS is held, among the many attacks on rights, the proposal for a social security reform is highlighted, realized in the Proposed Constitutional Amendment – PEC No. 06/2019, which, without combating privileges, penalizes workers. This proposal removes the constitutional guarantee, destroys the concept of Social Security and proposes a capitalization system that benefits the financial system to the detriment of future retirees.

The participants of the 16^th CNS and the members of the Health Reform have, therefore, the responsibility to protect Social Security by engaging in the movement against the Social Security Reform and specifying in the agenda of this movement the protection of the Unified Health System and the Unified Social Assistance System.

The preservation of Brazilian democracy also requires the articulation of the rights-advocacy movements²⁵25 Campos GWS. SUS: o que e como fazer? Cien Saude Colet [periódico na Internet]. 2018 Jun. [acessado 2019 Jun 02]. Disponível em: http://dx.doi.org/10.1590/1413-81232018236.05582018
http://dx.doi.org/10.1590/1413-812320182... , including homeless people struggling for housing, landless people for agrarian reform and ecological agriculture, indigenous people and their right to the territory and a dignified existence, blacks and the fight against all forms of racism, women seeking equality, the LGBT population in their struggle for the right to be what they are, young people for autonomy, public education and decent work.

The joint action of social movements is necessary to combat initiatives that seek to weaken social participation such as decrees that extinguish participatory councils or create difficulties for the financing of trade unions.

The 16^th CNS should also highlight the democratization of the mass media as necessary to strengthen the Brazilian democracy. Finally, democracy protection necessarily includes the demand for the release of Lula and the fight against the politicization of the police apparatus, the Public Ministry and the Judiciary.

Besides measures related to development and democracy, the struggle for the right to health requires the adoption of specific strategies and tactics to improve the SUS. Within the scope of health policies, the first challenge is to reorient the health care model. The SUS must overcome the dominant biomedical and mercantilist model, strengthening health promotion practices, with the articulation of intersectoral actions directed at the social determinants of health, while extending coverage and improving the quality of prevention, diagnosis and treatment of diseases and injuries.

The establishment of health care networks is probably the best strategy to coordinate the set of services necessary for the operationalization of comprehensive care²⁶26 Mendes EV. As redes de atenção à saúde. Cien Saude Colet [periódico na Internet]. 2018 Jun. [acessado 2019 Jun 02]. Disponível em: http://dx.doi.org/10.1590/S1413-81232010000500005
http://dx.doi.org/10.1590/S1413-81232010... . We should add that the setup of networks can benefit from new technological resources – remote diagnosis, surgical robotization, teleconsultations, and the like – which facilitate people’s access to a wide range of services.

The network integration of the set of health services, however, is not enough to change the care model. It is also necessary to modify the economic dynamics that underpin the biomedical model. More precisely, it is necessary to ensure the primacy of health policy over commercial interests, putting the productive health complex at the service of the SUS.

To this end, it is necessary to promote policies for industrial development and health science, technology and innovation, which, combined, stimulate national production²⁷27 Gadelha CAG, Temporão JG. Desenvolvimento, Inovação e Saúde: a perspectiva teórica e política do Complexo Econômico-Industrial da Saúde. Cien Saude Colet [periódico na Internet]. 2018 Jun. [acessado 2019 Jun 02]; 23(6):1891-1902. Disponível em: http://dx.doi.org/10.1590/1413-81232018236.06482018
http://dx.doi.org/10.1590/1413-812320182... , at costs that society can afford, of the indispensable supplies to meet the health needs of Brazilians.

Thus, the 16^th CNS should reiterate the principle of integrality, recommending the implementation of health care networks, from the community level and primary care units to the specialized and hospital levels. It should also recommend the strengthening of the productive health complex, urging public managers to increase investments in innovative arrangements for the production of health goods.

Indeed, the reiteration of these positions will find, on the one hand, a multifaceted resistance, especially that of managers who have advocated, for example, primary care centered on medical clinics, individual accountability for AIDS prevention or even approaches without scientific rationality such as the religious treatment of chemical dependence and the hospitalization of people with mental disorder as a priority therapy. On the other hand, this reiteration will gather people and social movements that, mobilized by specific issues, are fragile because they are dispersed.

The second challenge related to the strengthening of the SUS refers to its improved efficiency. At this point, three issues stand out: the professionalization and publicity of management, health regionalization and personnel policy.

SUS management professionalization requires valuing public careers and adopting performance criteria to evaluate health work, rewarding efficiency. Also, the management of health care facilities should be empowered, giving greater autonomy to local managers and, at the same time, making them accountable for results achieved rather than compliance with administrative rules. In this line, management positions should be occupied, primarily, by career technical officers.

Professionalization must accompany the reinforcement of the publicity of administrative acts. The publicity of the state administration must be ensured through the mechanisms that give transparency to the management, including those provided by the Law of Access to Information.

Thus, the 16^th CNS should reaffirm the importance of public careers, practices to stimulate work efficiency and empower local managers. Also, it should denounce attempts to restrict management transparency and urge health counselors to persevere in monitoring the performance of health institutions.

As far as regionalization is concerned, the experience of the SUS has already shown that municipalities alone are unable to provide all the necessary health services. The previous experience, on the other hand, has already shown that the centralization of management at the federal or even state level generates inefficiency. The organization of regions, according to territorial identities and with adequate population scales, is the best strategy to promote the coordination of public policies in a federated country²⁸28 Viana ALDA, Bousquat A, Melo GA, DeNegri-Filho A, Medina MG. Regionalização e Redes de Saúde. [periódico na Internet]. 2018 Jun. [acessado 2019 Jun 02]; 23(6):1791-1798. Disponível em: http://dx.doi.org/10.1590/1413-81232018236.05502018
http://dx.doi.org/10.1590/1413-812320182... . It should be added that the increased use of information and communication technologies can contribute to an efficient configuration of health regions.

One must recognize, however, that it is not easy to regionalize health care. The difficulties stem from multiple factors, such as SUS underfunding, undue interference of business and political-party interests, and the Brazilian federal structure itself, which grants autonomy to the municipalities and encourages their multiplication. Therefore, regions can only be realized by promoting institutional innovations and experiencing higher levels of shared power between the municipalities, its state and the Union, and also the representations of social control.

It is therefore up to the 16^th CNS to renew support for the implementation of the health regions, guiding managers to improve federal coordination mechanisms and increase investments in SUS infrastructure, including multidisciplinary health teams.

Strengthening these teams and ensuring decent work conditions for all SUS professionals and workers requires an effective personnel policy, consistent with the proposals for changing the care model and for integrating services. Concerning personnel training, this policy should aim to increase the number of professionals, adapt their profiles to the health needs of the population and improve the quality of teaching-learning processes. To that end, the entire health services network should become a training space and every practicing professional should have responsibilities with the training of future colleagues. With regard to learning processes, teaching practices should support the development of technical, ethical and social skills that contribute to overcome the differential quality of health care, which makes the services used by the poor, black and indigenous people, women, LGBT, disabled and older adults of lower technical and human quality. In order to promote equity, the personnel policy should also include the distribution of training institutions throughout the country and the creation of careers based on national guidelines that ensure stability and the possibility of functional progression. Finally, it should ensure appropriate working conditions, with the definition of careers, positions and salaries, perhaps not by professions, but by levels of health care, such as primary care and hospital care²⁵25 Campos GWS. SUS: o que e como fazer? Cien Saude Colet [periódico na Internet]. 2018 Jun. [acessado 2019 Jun 02]. Disponível em: http://dx.doi.org/10.1590/1413-81232018236.05582018
http://dx.doi.org/10.1590/1413-812320182... .

The third and final question regarding the challenge of strengthening the SUS refers to its financing. Knowledge derived from the experiences of managers and health advisers, as well as comparisons between countries or, in Brazil, between SUS and health insurance plans and insurance, leaves no doubt about the insufficient resources for the public health system. In order to overcome underfunding structurally, the fundamental strategy is to consolidate the Social Security budget, which currently requires facing two significant threats. The first is PEC 06/2019 of the Social Security Reform, especially regarding the proposition of the capitalization regime that eliminates the primary source of income of Social Security. The second, just as severe as or more so, is the proposal to terminate the constitutional linkage of health resources, announced by the Minister of Economy, which will not lead to the freezing of health spending, as EC-95/2016 does, but to the absolute reduction of SUS funds.

Addressing these threats requires a broad social mobilization, to which the participants of the 16^th CNS must adhere, associating advocacy for the SUS with the fight against PEC 06/2019. This mobilization should counteract these threats concerning the definition of stable sources of income for Social Security, such as (a) the increased Social Contribution Tax rate on Net Income for financial institutions; (b) the creation of a General Tax on Financial Transactions; (c) taxation of remittances of profits and dividends of multinational companies; and (d) the establishment of the Contribution on Large Wealth²⁹29 Mendes AN. Uma história de impasses do financiamento. Revista Conasems 2013; (48):34-35.. The allocation of funds from the pre-salt oil exploration to the SUS and the end of the unlinking of Government revenues and tax relief measures that withdraw funds from Social Security must be added to this list.

The struggle for more funds for the SUS cannot ignore, however, that Brazilian society does not poorly invest in health, considering total public and private spending: in terms of GDP, the proportion exceeds 11%. Thus, increased funding of the SUS must coincide with the inversion of the proportions between public and private expenditures. No country with a universal health system has been close to matching the share of Brazilian private spending, which accounts for 66% of total health expenditure.

Moreover, what is more serious is that most of the private expenditure does not refer to health insurance, but people’s out-of-pocket expenditure³⁰30 World Health Organization (WHO). Global Health Expenditure Database. [documento na Internet]. [acessado 2019 Abr 03]. [cerca de 6 p.]. Disponível em: https://apps.who.int/nha/database/Select/Indicators/en
https://apps.who.int/nha/database/Select... . In 20% of households, health expenses represent more than 10% of total expenses. These catastrophic expenses disproportionately affect the poorest segments of the population, who have direct health expenditures five times higher than the general population³¹31 Boing AC, Bertoldi AD, Barros AJ, Posenato LG, Peres KG. Socioeconomic inequality in catastrophic health expenditure in Brazil. Rev Saude Publica [periódico na Internet]. 2014 [acessado 2019 Jun 02]; 48(4):632-641. Disponível em: http://dx.doi.org/10.1590/S0034-8910.2014048005111
http://dx.doi.org/10.1590/S0034-8910.201... compared to their household expenses. Thus, it is necessary to reduce the direct expenses of households with medicines, medical and dental examinations and visits, and the like, which requires the increased access and improved quality of SUS services. A strategy to increase public spending, without increasing total health expenditure, is to end public subsidy to health plans, estimated at R$ 12.5 billion in 2015 alone, representing a tax expense of 32.3% of the Ministry of Health budget in that year³²32 Ocké-Reis CO. Sustentabilidade do SUS e renúncia de arrecadação fiscal em saúde. Cien Saude Colet [periódico na Internet]. 2018 Jun. [acessado 2019 Jun 02]; 23(6):2035-2042. Disponível em: http://dx.doi.org/10.1590/1413-81232018236.05992018
http://dx.doi.org/10.1590/1413-812320182... . This strategy also has the advantage of contributing to the equity of health financing, since the subsidy to health plans means the transfer of resources that belong to everyone to the most privileged segment of the population.

In this perspective, the 16^th CNS should not only demand increased resources for the SUS, but also the end of subsidies and tax incentives, either through tax exemptions or non-reimbursement to the SUS of the use of public services by private plans’ carriers, or by low-interest loans to health plan operators, the health supplies industry, and nonprofit hospitals for non-exclusive healthcare services to the SUS.

Also, delegates of the 16^th CNS should reaffirm the need for effective regulation of health plan operators and private providers, questioning the performance of the National Supplementary Health Agency.

Lastly, regarding health financing, the participants of the 16^th CNS cannot forget that SUS financial and economic feasibility, in the long term, depends on overcoming the mercantilist health care model, which stimulates the uncritical incorporation of technologies, catering more to commercial interests than health needs.

As a conclusion: how to implement this agenda?

The formulation of a sovereign, inclusive, sustainable and democratic development project, while capable of gathering broad sectors of society, has powerful opponents. Overcoming them requires the establishment of a critical mass of people and organizations capable of formulating such a project.

Indeed, the 16^th CNS is a privileged space for the debate required for the elaboration of this project and the maturation of the strategies to strengthen the SUS, establishing new individual and collective subjects. Perhaps one of the most relevant results of the 16^th CNS will be the understanding of the urgency of setting a broad democratic and popular historical block for the sovereignty of the country, social equity, sustainable development, Social Security and the SUS.

Besides entities and social movements already represented at the Conference, the leaders of the struggle for the right to health must seek to strengthen their articulations with all democratic forces working in favor of citizenship rights. It is the opportunity to articulate a mass movement to protect Social Security, combating PEC 06/2019 and the proposal of unlinking the resources of the SUS and protecting the Citizen Constitution, with the preservation of the guarantees concerning social security, health and social assistance.

Finally, it is necessary to fight for democracy at all levels and spaces, in work and educational settings, in socially interactive spaces, in the daily life of people and institutions. It is necessary to radically broaden the public debate, denouncing the country’s risks of a civilizational setback, evidencing links between Health and Democracy and reacting to the advance of fascism, cultural conservatism and political authoritarianism that threaten the democratic achievements achieved with much struggle over the last 40 years.

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