Abstract

Relations among democracy, citizenship and health have shaped the Unified Health System (SUS) over the past four decades. Until 2016, democracy was strengthened and social rights extended, despite structural difficulties, conflicts between projects, and unevenly over time. The SUS has allowed advances in access and improvements to health conditions. Between 2016 and 2022, there were significant reversals in economic, social, and health policies. Since 2020, the situation has been aggravated by the multidimensional crisis associated with the COVID-19 pandemic. The work of the SUS, universities and public scientific institutions was fundamental in tackling the crisis. From 2023 onwards, Brazil has faced enormous challenges in restoring a democratic national project focused on social welfare. Strengthening the SUS depends on the character of social policies and democracy, and on transforming relations among State, market and society, to overcome constraints that have persisted even during progressive governments. The SUS, a universal policy rooted in a broad concept of health and democratic values, is fundamental to establishing a pattern of development aimed at reducing inequalities and building a more just society.

Key words:
Democracy; Citizenship; Health; Health policy; Health system

Brazil’s health sector reform of the 1980s formed part of an unprecedented process of democratisation resulting from intense political mobilisation involving a wide range of social actors¹1 Escorel S. Reviravolta na saúde - origem e articulação do movimento sanitário. Rio de Janeiro: Editora Fiocruz; 1999.^,22 Paim JS. Reforma Sanitária Brasileira: contribuição e crítica. Salvador/Rio de Janeiro: EdUFBA/Fiocruz; 2008.. Promulgation of the 1988 Constitution, which expanded citizens’ rights and the State’s responsibilities, laid out a new terrain for the political struggles of subsequent years³3 Rodriguez Neto E. Saúde: promessas e limites da Constituição. Rio de Janeiro: Editora Fiocruz; 2003.. The recognition of health as a right and the founding of the public and universal Unified Health System (Sistema Único de Saúde, SUS) were achievements of society and set Brazil apart in Latin America, a region marred by structural inequalities and predominantly segmented and exclusionary social policies.

Relations among democracy, citizenship and health pervaded the shaping and trajectory of the SUS over the following three decades. At least until 2016 - although the process differed at times - democracy was strengthened both formally and substantively, citizens’ participation in political life increased and citizenship expanded. Civil, political and social rights gradually expanded - conditional on the historically structural peculiarities of the Brazilian case, as expressed in the persistence of inequalities in various dimensions - considering the categories proposed by Marshall⁴4 Marshall TH. Cidadania, classe social e status. Rio de Janeiro: Jorge Zahar Editor; 1967..

The definition of citizenship offered by Tilly⁵5 Tilly C, editor. Citizenship, identity and social history. Inter Rev Soc Hist 1995; 40(Suppl. 3):1-17. is useful in thinking about the changing relations between the State and society in the period, and how they overlapped with the expansion of rights, as it highlights their multifaceted character. To Tilly, as a category, citizenship “designates a set of actors - citizens - distinguished by their shared privileged position vis-a-vis some particular state”. Meanwhile, as a tie, citizenship “identifies an enforceable mutual relation between an actor and state agents”. Also, as a role, citizenship “includes all of an actor’s relations to others that depend on the actor’s relation to a particular state”. Lastly, “as an identity, citizenship can refer to the experience and public representation of category, tie or role”^{5, p.8}.

In contemporary capitalist societies, universal social policies are based on the assertion that certain actions and services are the State’s duty and everyone’s right, regardless of class, income, ethnicity/race, placement in the labour market or ability to pay. Universality is fundamental to counterbalancing market forces that generate inequalities and establishing full citizenship based on social equality. The comparative study by Esping-Andersen⁶6 Esping-Andersen G. As Três economias políticas do welfare state. Lua Nova 1991; 24:85-115. identified different welfare state regimes. The social democratic regime, strongly anchored in universal, comprehensive social policies, yielded better outcomes in expanding rights, “de-commodifying” service access and reducing the social stratification induced by capitalism. Esping-Andersen’s research, however, was based on high-income capitalist countries considered democracies. In structurally unequal societies, universal policies are even more essential and need to be associated with strategies to foster equity to reach historically excluded groups in situations of social vulnerability.

Some authors have explored the complex relations among democracy, social policies and inequalities in Latin America. In a historical, comparative study of Latin American countries that combined secondary data analysis and in-depth case studies, Huber and Stephens⁷7 Huber E, Stephens JD. Democracy and the left: social policy and inequality in Latin America. Chicago: University of Chicago Press; 2012. identified a positive relationship between the duration of democracy, the expansion of redistributive social policies and the reduction of social differences. They found that longer periods of democratic stability were necessary to enable, particularly historically excluded, social groups to access decision-making power and State institutions by representation, occupying posts or participating directly in power and decision-making arenas. This afforded greater influence on public and social policies to reinforce their redistributive nature and the possibility of reducing inequalities.

In Brazil, between 1988 and 2016, changing relations between the State and society associated with growing democracy and expanding citizenship permitted increasing social participation, and expansion and innovations in various social policies, including health policies. These changes, however, were not enough to shift the power asymmetries between social groups, nor to reduce the glaring structural inequalities expressed in multiple dimensions (class, race, gender, territory), which in turn determine access to power, resources and the possibility of actually exercising citizenship rights. Throughout the period, conflicts were observed between different plans for Brazilian society, which were expressed in constraints on the expansion and stabilisation of redistributive policies, such as health and education policies, whose universal nature is stipulated by the 1988 Constitution.

Economic and social policies’ orientation differed between moments and governments. The 1990s, notable for political democratisation and economic liberalisation⁸8 Sallum Jr B. Crise, democratização e liberalização no Brasil. In: Sallum Jr B, organizador. Brasil e Argentina hoje: política e economia. Bauru: EDUSC; 2004. p. 47-77., saw policies introduced to combat poverty and increase access to public services and social participation. In education, primary and lower secondary education became universal. In health care, the first ten years of implementation of the SUS saw measures, mainly in primary care, expanded at the national level. Meanwhile, universal policies were designed (e.g., the HIV/AIDS control policy) and came to stand as global examples, changes were introduced to the model of health care (in mental health, for example) and inter-managerial health commissions and councils were set up, with social participation, at the three levels of government. However, economic and State reform policies curbed any expansion of the spending, services and human resources necessary to support stronger universal policies and reduce social and health inequalities⁹9 Machado CV, Lima LD, Baptista TWF. Políticas de Saúde no Brasil em tempos contraditórios: caminhos e tropeços na construção de um sistema universal. Cad Saude Publica 2017; 33(Supl. 2):e00129616..

Later, during the Lula and Dilma governments (2003-2010 and 2011-May 2016, respectively), redistributive policies grew and produced impacts in reducing poverty and on some indicators of inequalities. Increases in the national minimum wage improved workers’ incomes, labour rights (of domestic workers, for example) were advanced, programmes to combat hunger and transfer income were expanded (most notably the Bolsa Família family allowance programme) and public universities grew and multiplied. Affirmative actions favoured the presence of black and low-income students in higher education. Health programmes and measures implemented to improve public access to the SUS included the acceleration of the Family Health Strategy, the launch of the Smile Brazil dental care programme, multiprofessional Family Health Support Teams, the More Doctors Programme and emergency care services (emergency mobile care ambulance services and emergency care clinics), among others.

To summarise, from its inception in the 1988 Constitution until 2016, in a democratic context, the SUS permitted important advances to be made in public access to health care and to positive health outcomes¹⁰10 Machado CV, Silva GA. Political struggles for a universal health system in Brazil: successes and limits in the reduction of inequalities. Glob Health 2019; 15(Suppl. 1):77.. As a universal policy, it was an important vector in asserting rights and promoting social equality. However, implementation of the SUS vigorously reflected disputes and contradictions between political projects, expressed, for example, as insufficient public funding, a growing private health care industry (national and international companies offering health plans and insurance, diagnostic support services and provision) with State incentives, constraints on engagement and appropriate pay and training for health personnel to staff expanding services and operate a recast model of care, difficulties in expanding national capacity to innovate and produce technologies and strategic inputs to meet the needs of the SUS⁹9 Machado CV, Lima LD, Baptista TWF. Políticas de Saúde no Brasil em tempos contraditórios: caminhos e tropeços na construção de um sistema universal. Cad Saude Publica 2017; 33(Supl. 2):e00129616..

The impeachment of President Dilma Rousseff in 2016, following a period of political crisis, represented a setback in Brazilian democracy and in incremental political and social advances, whatever their difficulties. Described as a “parliamentary coup”¹¹11 Santos WG. A democracia impedida. Rio de Janeiro: Editora FGV; 2017., this interruption of a democratically elected government on spurious grounds is regarded as differing from previous coups (such as that of 1964), because it sought support in institutional mechanisms. Other countries are reported to have experienced the erosion of democratic regimes without “tanks in the streets” and apparently within legal bounds¹²12 Levitsky S, Ziblatt D. Como as democracias morrem. Rio de Janeiro: Zahar; 2018.. It should be added that, in relatively recent democracies, such as Brazil’s, the risk that democratisation processes will be reversed is greater than in established democracies¹³13 Avritzer L, Rennó L. The pandemic and the crisis of democracy in Brazil. J Politics Latin America 2021; 13(3):442-457..

Santos¹¹11 Santos WG. A democracia impedida. Rio de Janeiro: Editora FGV; 2017. argued that, in Brazil, the 2016 coup plotters shared a “common denominator” with those of the 1960s in their “rejection of the economic and social progress of the vulnerable classes”¹¹11 Santos WG. A democracia impedida. Rio de Janeiro: Editora FGV; 2017., p. 42. In that light, Fortes¹⁴14 Fortes A. Brazil's neoconservative offensive. NACLA Report Americas 2016; 48(3):217-220. explored the neoconservative offensive that removed the elected president, Dilma Rousseff, interrupting a historical cycle that had begun in the mid-1980s, marked by a commitment to extending universal social rights and active social participation in policy making, albeit amid constraints imposed by the need to accommodate traditional political forces and difficulties in breaking with neoliberal economic policies.

The Temer (2016-2018) and Bolsonaro (2019-2022) governments brought significant setbacks in economic and social policies. Austerity measures, restrictions on public spending (aggravated by Constitutional Amendment 95/2016, which capped public spending) and incentives for privatisation were intensified. Reforms restricted social security, labour and other rights, increasing the vulnerability of lower-income groups. Obstacles were imposed on universal social (health and education) policies and social assistance¹⁵15 Abrucio FL, Rodrigues RV, Milanello TRS, Melo YM. Ascensão e crise do Sistema de Assistência Social (SUAS) no federalismo brasileiro. Katal 2023; 26(2):243-254., weakening numerous programmes and worsening social indicators. Investments in science and technology fell abruptly, adversely affecting universities, research institutions, innovation capacity, knowledge and technology production in Brazil. Channels for social participation in public policies were also undermined and, during the Bolsonaro government, military personnel became an increasingly significant presence in positions in several federal ministries.

From 2020 onwards, the situation was aggravated by the multidimensional crisis associated with the COVID-19 pandemic, which had strong impact on Brazil in social repercussions and high mortality from the disease. The denialist president delayed the adoption of economic and social protection measures to address the crisis and weakened the Ministry of Health’s ability to coordinate responses to the health emergency. The situation was not worse thanks to the existence of the SUS, universities and public scientific institutions (such as Fiocruz and the Butantan Institute), which mobilised strongly to control COVID-19. This included efforts in research, training, vaccine development and production, and public communication to circulate reliable information. It took outstanding commitment on the part of researchers, health personnel, social and community movements, some SUS managers, government officials and parliamentarians to counter government omissions and policy guidelines at odds with technical and scientific recommendations for dealing with the emergency¹⁶16 Freitas CM, Pereira AMM, Machado CV. A resposta do Brasil à pandemia de Covid-19 em um contexto de crise e desigualdades. In: Machado CV, Pereira AMM, Freitas CM, organizadores. Políticas de saúde em tempos de pandemia: nove países, muitas lições. Rio de Janeiro: Editora Fiocruz; 2022. p. 295-322..

In 2023, marking a historical watershed for Brazil, Lula was returned to the Presidency of the Republic for a third term after a disputed electoral process, in which he received 50.9% of valid votes (against 49.1% for outgoing President Bolsonaro). During the transition, the winning coalition presented a broad diagnosis of the public policy situation in Brazil¹⁷17 Gabinete de Transic¸a~o Governamental. Relato´rio final - dezembro de 2022 [Internet]. 2022. [acessado 2024 maio 25]. Disponível em: https://www.cartacapital.com.br/politica/relatorio-da-transicao-detalha-retrocessos-sob-o-governo-bolsonaro-leia-a-integra/
https://www.cartacapital.com.br/politica... and a government platform designed to transform the pattern of national development in more inclusive and democratic directions and committed itself to introduce policies to reduce structural inequalities and to reposition Brazil on the world stage.

The government that took office faced numerous political challenges, including its lack of a parliamentary majority and extreme social polarisation. On January 8, 2023, one week after the presidential inauguration, public buildings in Brasília (including the presidential palace, the national congress and federal supreme court) were invaded, signalling the persistence of coup movements and resulting in criminal investigations.

Despite the difficulties, the first eight months of the government gave signs of important changes in several areas. The composition of ministries and senior government officials shifted to improve representation of women, black and indigenous people (although still insufficiently and under pressure from groups in Congress for access to positions of power). A series of policies that had been discontinued or weakened were reinstated and equity-oriented policies were expanded. There was now an explicit commitment to inter-sector policies, an emphasis on intergovernmental dialogue and stronger cooperative relations in the federation and a promotion of participatory policymaking bodies. Brazil’s foreign policy was reoriented towards geopolitical realignment by strengthening integration and cooperation with other countries of the Global South. However, tensions persist - as expressed in the debates surrounding the new fiscal framework approved in 2023, which removed the cap on public spending - between the imperatives of a balanced budget and the need to expand public spending to meet enormous social needs.

Important changes were seen in the health field from the early months of the government. One of these was that, for the first time in history, a woman - sociologist and researcher, Nísia Trindade Lima - was appointed Minister of Health. As president of the Fiocruz from 2017 to 2022, she had led the institution in tackling the COVID-19 pandemic, in a perspective committed to strengthening the SUS and to reducing social inequalities. Other senior positions at the Ministry of Health were filled with managers whose profile is technical and political and who have worked in the SUS. The government advocates restoring the Ministry of Health to its strategic role in conducting national health policy, by reinstating mechanisms for federative coordination and social participation. Several policies and programmes that had been interrupted or weakened have been reactivated, including those directed to Primary Health Care and health surveillance, management of health work and education, the health economic and industrial complex, with an emphasis on scientific and technological development and local production of inputs for the SUS, and others. Also worth highlighting is the emphasis placed on new agendas, such as digital health and the promotion of equity, including the restoration, jointly with other areas of government, of policies for the black and indigenous population and other groups in situations of social vulnerability.

The challenges, however, are immense. The repercussions of the COVID-19 pandemic, whose social and health impacts went well beyond disease-related morbidity and mortality have aggravated the scenario, already characterized by low investments and setbacks in public policies. Worsening conditions of life and the effects of overload on SUS care for other health conditions may have unforeseeable medium- and long-term effects. Moreover, the Brazilian health system’s structural problems predate the 2016 political breakdown and the COVID-19 crisis. These include insufficient public funding and the dynamism of the private health industry in Brazil (which benefits from state incentives and subsidies) and have persisted since implementation of the SUS began, and worsened with the financialisation of health¹⁸18 Mattos LV, Carvalho EMCL, Barbosa DVS, Bahia L. Financeirização, acumulação e mudanças patrimoniais em empresas e grupos econômicos do setor saúde no Brasil. Cad Saude Publica 2022; 38(Supl. 2):e00175820..

These and other constraints placed on establishing a universal, public health system in Brazil expressed distributional conflicts that remained unresolved, even under progressive, democratic governments. Establishing a universal health system and reducing health inequalities depend not only on restoring past policies that had suffered reversals and introducing incremental innovations, but on structural changes conditional on directions set by political agendas, government capacity and conditions of governability, all amidst disputes between different national and international projects and interests.

Strengthening the SUS thus depends on what place universal social policies occupy in the country’s development model, which involves wide-ranging changes in relations among State, market and society. The severity of the crisis attendant on the pandemic - combating which highlighted the need for public policies coordinated across different areas - prompted debate as to a possible “return of the State”, that is, increasing state intervention in economic and social matters¹⁹19 Carvalho L. Curto-circuito - o vírus e a volta do Estado. São Paulo: Todavia; 2020.. After thirty years of neoliberal disasters, the pandemic made it clear that “we all depend, for our individual and collective survival, on the attitudes and actions of others and the collective structure of care” ²⁰20 Gerbaudo P. O grande recuo - a política pós-populismo e pós pandemia. São Paulo: Todavia; 2023..

Also strategic to reconfiguring the State is increased public investment in education, science and technology, because of their importance to addressing inequalities and positioning a sovereign nation on the world stage²¹21 Arbix G. Ciência e tecnologia em um mundo de ponta-cabeça. Estud Av 2020; 34(99):65-76.. Meanwhile a stronger national health economic and industrial complex, with State incentives and regulation, by contributing to modernisation of the SUS, generation of better-quality jobs and access to healthcare, offers the possibility of virtuous interrelations between the economic and social dimensions²²22 Gadelha CAG, Gimenez DM, Cajueiro JPM, Moreira JDD. O Complexo Econômico-Industrial da Saúde (CEIS) como espaço estratégico para a modernização do SUS e para a geração dos empregos do futuro. Cien Saude Colet 2023; 28(10):2833-28432023..

However, reshaping the State is a matter for dispute in many countries, including Brazil. Moreover, the direction of State action depends on the correlation of forces surrounding public policy purposes and the nature of democracy in its various dimensions. As a universal social policy anchored in a broad conception of health and well-being and democratic values, the SUS is fundamental to establishing a pattern of development designed to reduce inequalities and build a more just society.

Acknowledgements

The author holds a research productivity scholarship from Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) and is a Scientist of Our State, supported by Fundação Carlos Chagas de Amparo à Pesquisa do Estado do Rio de Janeiro, FAPERJ).

References

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