In 2018, Brazil’s Unified National Health System (SUS) is celebrating 30 years since it was implemented following promulgation of the 1988 Federal Constitution. To highlight the date’s importance, the July issue of CSP features a Debate section with expert authors on the subject.

In three decades, the SUS has made strides in numerous health policies, several of which have been acknowledged by the World Health Organization as successful experiences that can be shared with other countries.

The Family Health Program was initially limited to a few municipalities of Brazil but has since expanded nationwide, covering 60% of the country’s population, with positive results like the reduction of infant mortality ¹1. Macinko J, Guanais FC, Souza MFM. Evaluation of the impact of the Family Health Program on infant mortality in Brazil, 1990-2002. J Epidemiol Community Health 2006; 60:13-9. and cardiovascular diseases ²2. Rasella D, O'Harhay M, Pamponet ML, Aquino R, Barreto ML. Impact of primary health care on mortality from heart and cerebrovascular diseases in Brazil: a nationwide analysis of longitudinal data. BMJ 2014; 348:g4014.. The National Immunization Program, dating to the 1970s ³3. Temporão JG. O Programa Nacional de Imunizações (PNI): origens e desenvolvimento. Hist Ciênc Saúde-Manguinhos 2003; 10 Suppl 2:601-17., has expanded vaccination coverage in infants (under one year) and incorporated new vaccines targeted to specific population groups, such as the HPV (human papilloma virus) vaccine for adolescents and the influenza vaccine for the elderly. HIV/AIDS prevention and treatment has seen improved access to antiretroviral therapy, resulting in increased survival of persons living with HIV and AIDS ⁴4. Marins JPR, Jamal LF, Chen SY, Barros MB, Hudes ES, Barbosa AA, et al. Dramatic improvement in survival among adult Brazilian AIDS patients. AIDS 2003; 17:1675-82., as well as a decrease in incidence thanks to the extremely low viral load in individuals with the virus who receive treatment.

Studies have also documented the scope and effectiveness of Brazil’s tobacco control policy ⁵5. GBD 2015 Tobacco Collaborators. Smoking prevalence and attributable disease burden in 195 countries and territories, 1990-2015: a systematic analysis from the Global Burden of Disease Study 2015. Lancet 2017; 389:1885-906., which reduced the proportion of smokers from 29% to 12% in men and from 19% to 8% in women from 1990 to 2015. More recently, the country’s active surveillance system allowed detecting an increase in the number of cases of microcephaly, raising the hypothesis of a causal association with congenital Zika virus infection, with important spinoffs for the deployment of a coordinated strategy to control the epidemic at the international and national levels ⁶6. Garcia LP. Epidemia do vírus Zika e microcefalia no Brasil: emergência, evolução e enfrentamento. Brasília: Instituto de Pesquisa Econômica Aplicada; 2018. (Texto para Discussão, 2368)..

In these and other successful cases, the SUS has helped establish a technical and institutional base for key health polices, anchored mainly in groups and organizations from the health sector, within the country’s constitutional framework (guaranteeing the right to health) and in specific legislation, in public funding (although insufficient), and in the expansion of inputs, actions, and services. Still, these strides have been offset by difficulties in ensuring the political, social, and economic changes that are needed to effectively reduce inequalities and guarantee social justice and the materialization of the universal right to health.

As explanatory factors, analyses of health policies from 1990 to 2016 emphasize the diversity of conditioning factors that limit these needed changes ⁷7. Machado CV, Lima LD, Baptista TWF. Políticas de saúde no Brasil em tempos contraditórios: caminhos e tropeços na construção de um sistema universal. Cad Saúde Pública 2017; 33 Suppl 2:e00129616.: conflicting interests and agendas, failure by successive elected government administrations to prioritize the consolidation of a universal health system, the duality of government action (fomenting the public system, but mainly favoring private health care providers through various tax incentives), marked social stratification, and the nature of relations between the state and the market in Brazilian capitalism and in health.

Brazil’s current context of political crisis and serious threats to dismantle the state and the social rights conquered in the 1988 Constitution call for reflection on the urgency of building alternative proposals to fight the inequalities in their multiple dimensions and causes. The defense of the SUS requires revising the political pact permeating the relations between state and society, thereby building progressive alliances and debates that result in a socially inclusive and environmentally sustainable development project for the country. Among others, the promotion of redistribution and de-concentration of income and wealth, fair taxation, safety in the workplace and in other areas of life, and de-commodification and adequate provision of social services in the cities and countryside are central elements in this process.

In this sense, the strengthening of inter-sector and interdisciplinary dialogue in thinking and scientific production in the field of Collective Health are essential. CSP intends to contribute to this process as a vehicle for the dissemination of ideas, analyses, and proposals from a science committed to democracy, social rights, and the improvement of populations’ health conditions.

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