Political and organizational challenges in the Brazilian Unified National Health System: twenty years of public policy
According to opinion polls published in the mainstream press, health care has overtaken violence and unemployment as the principal problem in Brazilian society. In the last Congress of the Brazilian Association of Public Health (ABRASCO), I contended that there is more than a "rock in the path" of the Unified National Health System (SUS) - there is an entire quarry. And I insist on the impasse: despite the growth of the SUS, there are clear indications that we are failing to meet a major share of the people's health needs. The first challenge is that the system has not become a priority for the Brazilian government (with a few counties and States as exceptions). These exceptions serve to demonstrate that it would be possible to build a real public health system in the country. But the system's current backseat status has prevented Brazil from tackling the political and organizational changes and issues with the healthcare model needed to consolidate it. No one can safely predict today whether we will have a single, unified health system in the future, or a limited public network for treating low-income populations with targeted programs.
We failed to realize that we opted for a system aligned with the European tradition of socialization of health. According to the dominant discourse in Brazil, the main social policy is economic growth, whereby the majority will gain access to goods and (with time) private health insurance. The first challenge is thus to reaffirm the construction of a public system for all.
A second challenge is to acknowledge that there is a crisis of legitimacy in the state and public health organizations, due to their low efficacy and efficiency. Private interests have hijacked the health budget: entrepreneurs, professional corporations, bureaucracy, and politicians. Michel Foucault recognized that there is no "art of government from socialism". I have worked for years with the concept of "reforming the reform": reinventing state systems based on shared management and clear negotiation of health responsibility on the part of professionals, teams, services, regional networks, and States and counties. In short, organizational reform of the SUS - funds, councils, and collegiate bodies, cost criteria - has proven insufficient to construct governance for the system. The history of patrimonialism in managing the public good in Brazil has aggravated this situation. How else can one explain the gross negligence with Federal, State, and municipal hospitals and services? Administrations come and go, and misgovernment remains (skeptics are advised to visit a SUS hospital in their home towns, for a firsthand look). And we have failed to honor the health tradition of public systems: although there is a "system" in the name, the SUS does not function as a population-based territorial network. The hospitals and specialized centers were not integrated into the system. Hence the long lines, hence the cancers that reach the system in advanced stages. The family health strategy is a false priority, a discourse with limited consistency, as revealed by insufficient funding and a careless human resources policy. I accuse the government administrations that have followed the populist tendency of various municipalities and invented a kind of degraded primary healthcare for the poor: the so-called First Aid Units, one of the social spaces on which we will look back with shame in the future, as a sign of human perversity.
Optimistic perspectives: the world needs national systems, while the market massacres families' bodies and assaults their pockets. There are pieces of the SUS that work, successful experiences. There is a social base for us to proceed with the reform: thousands of workers and millions of Brazilians that have awakened to the importance of the system. However, there are rocks in the path - there are rocks inside people and inside the system.
Gastão Wagner de Sousa Campos
Faculdade de Medicina, Universidade Estadual de Campinas, Campinas, Brasil. firstname.lastname@example.org