When the Brazilian National Health Council called the 16th National Health Council in December 2017, the Council realized that the time was ripe for revisiting and updating the guidelines set out by the 8th Conference in 1986. The Council thus proposed to organize the debate along the lines that oriented the 8th Conference: Health as a Right, Reformulation of the National Health System, and Health System Financing, while adjusted to the current times, as expressed in the central theme: Democracy and Health: Health as a Right and Consolidation and Financing of the Unified National Health System¹1. Conselho Nacional de Saúde. Resolução nº 568, de 8 de dezembro de 2017. Diário Oficial da União 2018; 15 jan..

The Conference was convened with the motto “8th + 8”, urging participants to revisit the shaping of the Brazilian health system from the start of the “New Republic” in 1985: universalist initiatives in healthcare, developed either unilaterally by the Federal government or via agreements with states, municipalities, and charitable organizations; leadership of the National Health Reform Commission in the transition between the 8th Conference and the National Constitutional Assembly; the debates in the Constitutional Assembly running up to the enactment of the 1988 Constitution; and the set of legal and normative provisions introduced since then. In other words, a system governed by the principles set out in the Constitution: (i) the right to health guaranteed by the State, (ii) through social and economic policies, and (iii) with the guarantee of universal and equal access to actions and services.

However, the two Conferences took place in very different historical contexts. In 1986, Brazil was emerging from a dictatorship that had lasted 21 years, with scars that were still very recent from the resistance struggles to the regime, involving a broad political front around the only opposition party in existence until the return to the multiparty system, the Brazilian Democratic Movement (MDB); but also by the resurgence of the trade union movement and workers’ strikes; by the movements of the urban peripheries and favelas and the Basic Ecclesial Communities; by the emergence of a progressive intellectual class in such areas as economics, social sciences, education, health, housing, and others. The growing struggle to reclaim civil and political rights was associated with the struggle for progress in social and environmental rights as well.

The government coalition that launched the New Republic also reflected this broad political spectrum, in which the Center-Left of the time headed the Ministries of Social Security, Labor, and Culture, besides occupying important positions in the Ministry of Health. The municipal elections of 1985, the first in Brazil’s history in which illiterates were allowed to vote, gave an overwhelming majority to the successor of the former MDB, electing 19 of the 25 state capitals’ mayors. In the state elections of 1986, in the wake of the inflation control policy known as the Cruzado Plan, the party elected all the state governors except Sergipe. The year 1986 also witnessed the election of the representatives to the National Constitutional Assembly, resulting in a composition favorable to the introduction of social reforms and policies.

The period was characterized by economic stagnation and accelerated inflation, which the government attempted to harness by a series of stabilization plans. The failure of these initiatives led to an inflationary surge that was not contained until the following decade, at a cost that would prove high on the national economy.

At the international level, a major wave of protests and movements for rights had shaken the central capitalist countries in the late 1960s, adding new issues to the traditional demands related to struggles over the distribution of wealth and income. The social crisis was further aggravated by the incapacity of States, pressured by growing fiscal deficits, to meet the new demands. In the 1970s, participatory and community experiments at the local level and in the world of work, such as the factory councils, nurtured a promise of accelerating History by the expansion of participation by subaltern sectors and minorities ²2. Offe C. New social movements: challenging the boundaries of institutional politics. Soc Res (New York) 1985; 52:817-68..

In Brazil, the struggle for re-democratization and the emerging social movements awakened the expectations for expanding democracy, with the introduction of new forms of political participation. The historical dimension of the 8th National Health Conference thus rested on the convergence of a set of factors that transcended the Conference itself.

History took another direction at the turn of the 1980s, with the rise of Margaret Thatcher in the United Kingdom and Ronald Reagan in the United States. The neoliberal “solution” to the economic crisis was to postpone it by deregulating capital markets, expanding credit and private indebtedness, making economic policy practically independent of political oversight by national States ³3. Streeck W. Tempo comprado: a crise adiada do capitalismo democrático. Coimbra: Actual; 2013.. Paradoxically, the “new spirit” of neoliberal capitalism absorbed many elements from the self-management ideals of the previous decades ⁴4. Boltanski L, Chiapello E. O novo espírito do capitalismo. São Paulo: WMF Martins Fontes; 2009..

Against this trend - which in the central countries resulted in the contraction of social protection policies and stimulus for full employment -, the Brazilian Constitution of 1988 promoted a historically unprecedented expansion of civil rights, the main conquest of which was the universal extension of the right to health for all citizens through a national public system.

The legal framework of the Brazilian Unified National Health System (SUS) extensively incorporated the participatory ideals spawned during re-democratization. “Community participation” became a Constitutional principle, and the legislation established the periodic holding of Health Conferences at the municipal, state, and national levels, with the responsibility of setting guidelines for health sector policy at the corresponding levels. In addition, the decentralization of resources and management responsibilities in the new system was conditioned on the creation of Health Councils at the state and municipal levels. Health was the pioneering area in the formalization of mechanisms of “social control”, expressed in Law n. 8,142/1990.

In 2003 the Presidency of Brazil was won by the Workers’ Party, heavily identified with the “participatory” theses, giving strong impetus to the attempts to speed up democracy through the creation of forums and advisory and decision-making bodies as alternatives to the devices for choice and representation via universal suffrage. The councils and conferences in traditional areas such as health, education, and social assistance were joined by others related to more specific policies or focused on vulnerable segments of the population ⁵5. Lopez FG, Pires RRC. Instituições participativas e políticas públicas no Brasil: características e evolução nas últimas duas décadas. In: Brasil em desenvolvimento: Estado, planejamento e políticas públicas. Brasília: Instituto de Pesquisa Econômica Aplicada; 2010. p. 564-87..

Thus, it was the State itself that assumed the task of organizing participation by “society”, through advisory or decision-making bodies with official approval, but in which “participation” actually occur via mediation of organized sectors of “civil society”, that is, “representatives” prepared to voice interests in the public sphere. Due to their fragmentation and “specialization”, such bodies exhibit weaknesses that became evident in the more recent period.

Important transformations occurred at the international level since the late 1980s. The fall of the Berlin Wall in 1989 and dissolution of the Soviet Union shortly thereafter heralded the final triumph of the liberal democracies of the North Atlantic, but the global financial crisis that struck in 2008 - the consequence of financial deregulation with credit expansion and private indebtedness in the previous period ³3. Streeck W. Tempo comprado: a crise adiada do capitalismo democrático. Coimbra: Actual; 2013. - marked a decisive turning point. A decade later, the responses to the crisis have proven largely insufficient: the monetary flexibilization that injected trillions of dollars into the global economy had a limited impact on growth; fiscal containment deepened the stagnation, inhibiting anticyclic measures, to the advantage of a handful of mega-corporations and a tiny minority of profit-seekers that command increasingly exorbitant shares of the global wealth ⁶6. Dowbor L. A era do capital improdutivo. São Paulo: Autonomia Literária; 2017..

The “Brexit” referendum, which voted for the United Kingdom’s withdrawal from the European Union, and Donald Trump’s election to U.S. President in 2016, ushered in the “crisis of democracy” as an extremely new diagnosis for the time. The encroachment of the xenophobic extreme right in the European Union had already sounded the alarm. Failures in the political systems’ filters, checks, and balances help understand the crisis, but its roots run far deeper: the erosion of a cornerstone of polyarchic democracy, “control of the agenda”, that is, the political community’s capacity to actually set the elected governments’ agenda ⁷7. Dahl RA. A democracia e seus críticos. São Paulo: WMF Martins Fontes; 2012.. The dogma of austerity and various economic constraints in recent decades has reduced the maneuvering room of elected officials to a residual minimum on economic matters and social policy, generating disbelief in democracy and its institutions ³3. Streeck W. Tempo comprado: a crise adiada do capitalismo democrático. Coimbra: Actual; 2013..

There is also evidence of the growing use of digital platforms to extract private data and spread targeted propaganda for commercial purposes, but also to interfere in electoral processes and destabilize governments, as shown in the documentary The Great Hack, in Brexit and in the U.S. Presidential elections ⁸8. Amer K, Noujaim J. Privacidade hackeada [filme]. Los Gatos: Netflix; 2019. Color, 113 min..

The Brazilian context reflects these same issues, with particularly perverse ingredients. We are reaching the third decade of the 21st century without having completed basic civilizational tasks: a predatory and environmentally disastrous development model in the countryside, based on the latifundia or gargantuan landholdings and the disorganized expansion of the agricultural frontier; a huge mass of “structurally excluded” workers, concentrated on the outskirts and favelas of Brazil’s large cities, with no prospects for incorporation into the economy’s dynamic sectors; likewise, failure in the “Weberian task” of ensuring the State’s monopoly over the legitimate use of force, that is, the effective expropriation of private means of violence.

The global political and economic configuration has reached a new threshold, which appears in the United States’ new “national security strategy”. The United States has explicitly abandoned the idea of building a peaceful world order around “universal values” and assumes the pursuit of its national interests from a position of force ⁹9. Fiori JL. Geopolítica internacional: a nova estratégia imperial dos Estados Unidos. Saúde Debate 2018; 42 (n.esp 3):10-7..

As for South America and Brazil, the changes in U.S. policy appeared since the discovery of the Pre-Salt oil reserves, with the redeployment of the Fourth Fleet in 2008 and “hybrid wars” triggered in countries of the subcontinent, aimed at their political and economic destabilization ¹⁰10. Fiori JL. Onde estamos e para onde vamos? Uma "potência acorrentada". http://www.ihu.unisinos.br/78-noticias/590645-onde-estamos-e-para-onde-vamos-uma-potencia-acorrentada (acessado em 05/Jul/2019).
http://www.ihu.unisinos.br/78-noticias/5... .

The Brazilian economy has suffered for years from a loss of complexity in its industrial base and was heavily shaken by the political crisis soon after the Presidential succession in 2014, launching a recession that led to a downturn in the GDP of 3.8% in 2015 and 3.6% in 2016. The orthodox view blames the State’s fiscal weakness, but predictably, the “therapy” of fiscal restriction merely aggravated the situation, and recovery has proven extremely slow.

In Brazil, Constitutional rules and safeguards are being undermined with the complicity of government authorities whose duty is to watch over them. The purposes are political intimidation and undercutting of leaders, including the impeachment of the President in 2016, coincidingly finalized with the election of a government that pursues unconditional alignment with the United States.

The coalition that took office after the 2018 elections, elected according to Constitutional procedures but in a controversial process, does not appear interested in putting an end to the turmoil that began four years before. Since its inauguration, the new Administration has pushed a restrictive economic policy with the liquidation of social policies, cutbacks in public investments, attacks on human, civil, and environmental rights, and renunciation of national sovereignty.

Contrary to the 8th Conference in 1986, the 16th National Health Conference was held in a context of retraction in political and social mobilization. The objective of building a universal and “single” health system was not reached, and it remains distant to this day. Some determinant factors for this outcome were: (i) the establishment, during the dictatorship, of a private corporate-medical complex with significant installed capacity, largely built with public financing; (ii) the existence of an enormous unserved population contingent, excluded from the social security medical system prevailing at the time, and who were subsequently covered by the new system, greatly expanding the demand for services; (iii) lack of provision of consistent funding sources, generating a situation of chronic underfinancing, aggravated by the failure to earmark social security resources in the subsequent period. The consequence was lack of adherence to the SUS by important segments: middle-class liberal professionals and intellectuals, public employees, and workers in the most dynamic and organized sectors of industry and services (see Costa et al. ¹¹11. Costa AM, Noronha JC, Noronha GS. Barreiras ao universalismo do sistema de saúde brasileiro. In: Tetelboin C, Laurell AC, editores. Por el derecho universal a la salud: una agenda latinoamericana de análisis y lucha. Buenos Aires: Consejo Latinoamericano de Ciencias Sociales; 2015. p. 17-39.).

The participatory bodies can have a positive influence on resolution of obstacles to policymaking, but they prove fragile as a source of alternative legitimation to the representation derived from universal suffrage and do not replace political networking, especially in moments of crisis like the present.

The significant victory expressed in the conclusion of all the stages in the 16th Conference, with the reaffirmation of commitments and the struggle for democracy and health and its extensive health sector agenda, will only be able to move forward successfully if it is combined with the awakening of mobilizations around a broader agenda that interrupts the cycle of setbacks, regroups, and promotes the pact that was celebrated in the 1988 Constitution.

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