This article is based on the recognition that any policy is associated with historical constructions and modes of operation specific to each reality, each state. Every policy is inserted in a general trajectory and is designed in an institutionality, which somehow conditions it and gives meaning to it ¹1. Baptista TWF, Mattos RA. Sobre política (ou o que achamos pertinente refletir para analisar políticas). In: Mattos RA, Baptista TWF, organizadores. Caminhos para análise das políticas de saúde. Porto Alegre: Rede UNIDA; 2015. p. 83-149.. When it comes to government policies, every policy is a government policy, formulated at a specific conjuncture, even though its formulators aim for it to continue beyond the government in which it was created. In turn, many policies include in their content new proposals for the design of institutions and practices, trying to reinforce or modify that institutional trajectory in which it is inserted. Over time, a sequence of policies and proposals for action, arising from different government situations, alongside other policies and proposals for action formulated outside government spaces, may constitute a new institutional trajectory. Examining the marks of these trajectories can help us to recognize, at a given conjuncture, possible attempts at inflections and ruptures.

Here, two trajectories of institutional construction are of particular interest: the Brazilian Unified National Health System (SUS), and the Food and Nutritional Security System (SISAN), guided by the recognition of everyone’s right to health and food. This article focuses on the governmental and institutional dimensions, without dealing with the intricacies of actors who dispute or build alliances around their projects at a certain conjuncture. First, it seeks to point out, albeit quickly, the main characteristics of these two institutional trajectories, and then to examine the two Brazilian national food and nutrition policies (PNAN) in their insertions in those institutional trajectories. The term plural policies is used here in the plural to highlight the great differences in the circumstances in which they were formulated: the first in the context of the State Reform proposed by the Fernando Henrique Cardoso government, and the second, in the context of the turn from the Luís Inácio Lula da Silva government to the Dilma Rousseff government, after the full institutional development of the food and nutritional security (FNS) area. It intends to offer elements to reflect on the radical ruptures with this long institutional trajectory of defense of those rights that seem to be underway in the current conjuncture.

The trajectory of SUS arises from the criticisms of the health movement to the arrangement of the health system implemented in the Ernesto Geisel government. In addition to excessive centralization and the absence of participation, that arrangement reinforced an old dichotomy between two institutional fields (with repercussions on service organizations and practices): public health, whose modus operandi would be the organization of actions aimed only at some problems of interest collective; and medical care, aimed at responding to the care demands of individuals. It was exactly against this dichotomy that SUS emerged, both in defending the unity of command (therefore only one institutional field) and in proposing the principle of comprehensiveness, which implies the continuous articulation of preventive and curative actions, individual and collective, required for each case at all SUS levels. The constitutional text largely reflected the ideas systematized in the VIII National Health Conference (CNS), although with losses suffered in the process of debate in the Constituent Assembly: a sharp reduction in the broader view of health, the recognition that health is open to the private initiative, and a weakness in the SUS financing scheme, for example.

The trajectory of SISAN is marked by the 1st National Conference on Food and Nutrition, strongly inspired by the debate of the VIII CNS. Starting from the thesis that access to adequate food is everyone’s right, and having included in its agenda the agrarian policy, agricultural policy, food supply and marketing policy, in addition to health actions (public health, to be precise) carried out by Brazilian National Institute of Food and Nutrition (INAN), it proposed the creation of an interministerial National Food and Nutrition Council. It would be responsible for formulating the PNAN and coordinating the SISAN, also intersectoral ²2. Instituto Nacional de Alimentação e Nutrição. Conferência Nacional de Alimentação e Nutrição. Brasília: Instituto Nacional de Alimentação e Nutrição; 1986.. Such a proposal did not have immediate consequences. It is good to remember that, unlike health, the topic of food was not included in the agenda of the Constituent Assembly.

The idea of a Brazilian National Council for Food Security (CONSEA) will appear in 1991 in a document prepared within the so-called parallel government of the Workers’ Party. CONSEA was thought of as an intersectoral institution, linked to the presidency by a Special Secretariat for Food Security, and would be chaired by the President of the Republic himself ³3. Freitas GC. Da fome à segurança alimentar e nutricional: análise da (re)criação do Conselho Nacional de Segurança Alimentar e Nutricional (CONSEA) no primeiro governo Lula [Dissertação de Mestrado]. Rio de Janeiro: Universidade do Estado do Rio de Janeiro; 2017.. In that conception, it would be up to CONSEA to formulate the National Food Security Policy.

CONSEA was created (at Lula’s suggestion) ⁴4. Conselho Nacional de Segurança Alimentar e Nutricional. I Conferência Nacional de Segurança Alimentar e Nutricional. Brasília: Conselho Nacional de Segurança Alimentar e Nutricional; 1995. under the Itamar Franco government, as an intersectoral and participatory body created to address FNS issues. However, it was extinguished at the dawn of the Fernando Henrique Cardoso government. This council was “replaced” by the Solidary Community Program, a proposal to mitigate poverty by local development processes and with some assistance actions. This did not mean abandoning the FNS topic completely, but a lowering of its centrality: FNS was not, at that moment, a strategic objective of the government. However, it was admitted that in different ways, by successive approximations, FNS is progressively “contaminating public policies in Brazil” ⁵5. Instituto de Pesquisa Econômica Aplicada. Cadernos Comunidade Solidária. Brasília: Instituto de Pesquisa Econômica Aplicada; 1996..

With the advent of the Lula government in 2003, the topic of hunger took center stage on the agenda, generating conditions for institutional advances in FNS: the development of the Zero Hunger Program, initially under the responsibility of the Extraordinary Ministry of Food Security (which had a short existence, being replaced by the Ministry of Social Development in 2004); the resumption of CONSEA, as a vigorous intersectoral and participatory institution (especially from 2004); the creation of SISAN in 2006; and the recognition in 2010 of food as a social right in the constitutional text.

How do the two PNANs fit into these trajectories? The formulation of the first PNAN took place in the vacuum left by the extinction of CONSEA, in the midst of the State Reform conducted by the Fernando Henrique Cardoso government, whose objective was to reduce the dimension of the State in activities considered non-essential, and included the extinction of public institutions considered inefficient or unnecessary. In this context, Fernando Henrique Cardoso extinguished in 1998, by an articulated and simultaneous set of decrees, the Brazilian National Supply Superintendence (SUNAB), the INAN, and the Center of Medicines (CEME), besides creating, in this same set of decrees, the Health Policy Secretariat (SPS) in the Brazilian Ministry of Health ⁶6. Alves KPS. Entre a transição institucional e a transição nutricional: descortinando a trajetória da nutrição em saúde pública à atenção nutricional no Sistema Único de Saúde [Tese de Doutorado]. Rio de Janeiro: Universidade do Estado do Rio de Janeiro; 2019.. SPS developed a methodology of formulating health policies, applied primarily in the creation of policies for medicines and for food and nutrition, exactly the areas of operation of the two institutions that were extinguished. The government’s idea was to replace the structures of those bodies, considered heavy, with a lighter institutional policy-making path. Therefore, the first PNAN was formulated in the SPS, created by the State Reform. The Technical Area of Food and Nutrition emerged at SPS, inheriting the management of the extinct INAN agreements.

Those who engaged in the process of formulating the first PNAN, using that SPS methodology, knew how to take advantage of the formulation space to make a defense of FNS, recognizing its intersectoral nature. In fact, a “sectorial intersectoriality”, since it was conceived from the health sector. But this was the possible space for such developments in that government, with a low possibility of taking effect beyond the limits of the Brazilian Ministry of Health. It is as if FNS had “infected” PNAN. However, little attention was paid to the links between that policy and SUS, especially to the transformation aspects underway at exactly that conjuncture, which would result in a major expansion of primary health care in the following years. During the administration of Minister José Serra, Brazilian Ministry of Health published te Ordinance n. 3,925/1998⁷7. Ministério da Saúde. Portaria nº 3.925, de 13 de novembro de 1998. Diário Oficial da União 1998; 17 nov., that said “the priority given to primary health care represents a major effort for the health system to become more efficient, consolidate links between services and the population, and contribute to universal access and to the guarantee of comprehensive care”. Concerned with defending the FNS perspective (but without defending the extinct CONSEA), the first PNAN did not echo this priority of the Brazilian Ministry of Health at that time.

It should be noted that since then (1998), primary health care has had a great expansion, with the dissemination of the family health teams model, responsible for the health of an enrolled population, carrying out actions both individually and collectively. Over nearly two decades, some organizational innovations have emerged in primary health care, such as the creation of the Family Health Support Centers (NASF), which have become places for interdisciplinary work by professionals, including nutritionists.

The second PNAN, on the other hand, was born from the need to account for both the institutional advances of FNS and the improvements of SUS during the Lula government. There was a shift in emphasis: this is a policy focused on SUS ⁶6. Alves KPS. Entre a transição institucional e a transição nutricional: descortinando a trajetória da nutrição em saúde pública à atenção nutricional no Sistema Único de Saúde [Tese de Doutorado]. Rio de Janeiro: Universidade do Estado do Rio de Janeiro; 2019.^,88. Santos CRB. Política Municipal de Alimentação e Nutrição da Cidade do Rio de Janeiro: uma narrativa sobre seu processo de formulação [Tese de Doutorado]. Rio de Janeiro: Universidade do Estado do Rio de Janeiro; 2014.. An innovative landmark was the notion of nutritional care in SUS, comprising the care related to food and nutrition aimed at health promotion and protection and prevention, diagnosis, and treatment of diseases (not just nutritional diseases), associated with other health care actions ⁹9. Secretaria de Atenção à Saúde, Ministério da Saúde. Política Nacional de Alimentação e Nutrição. Brasília: Ministério da Saúde; 2013.. This is, finally, a proposal to overcome, in the practices of nutritional care, the old dichotomy between the fields of public health (to which INAN belonged at the Geisel government) and assistance. Such sectorial policy did not neglect, however, the insertion in the intersectoral trajectory of FNS, since, outside of it, no food and nutrition policy would make sense.

The current conjuncture presents strong signs of a radical rupture in the institutional trajectories of right to health and food. With the beginning of the economic crisis in 2014 and the political crisis that culminated in the impeachment of Dilma Rousseff in 2016, fiscal austerity assumed a central position on the governmental agenda. Regarding FNS, there was a reduction of funds in the order of 68% between 2014 and 2016 ¹⁰10. Instituto de Pesquisa Econômica Aplicada. Políticas sociais: acompanhamento e análise. v. 1. Brasília: Instituto de Pesquisa Econômica Aplicada; 2000.. In a prospective scenario, the New Tax Regime instituted in the Temer government, with validity for twenty years, dramatically strangles all public policies, even compromising development goals signed by the Brazilian government ¹¹11. Souza LEPF, Barros RD, Barreto ML, Katikireddi SV, Hone TV, Sousa RP, et al. The potential impact of austerity on attainment of the Sustainable Development Goals in Brazil. BMJ Global Health 2019; 4:e001661..

Right at the beginning of the Bolsonaro government, CONSEA was extinguished again (this time, with the later endorsement by the legislative power). It was a severe blow to FNS, at a time when food insecurity in Brazilian households, after a decade of sharp decline, reached alarming levels, even higher than those in 2004 ¹²12. Instituto Brasileiro de Geografia e Estatística. Pesquisa de Orçamentos Familiares 2017-2018: análise da segurança alimentar no Brasil. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2020..

Right at the beginning of the Michel Temer government, changes in the National Primary Health Care Policy brought changes that were considered to be weakening SUS principles. The changes deepened in the Jair Bolsonaro government, changing their relations with the territory where they operate, and perhaps setting the stage for further privatization at this level of care ¹³13. Morosini MVGC, Fonseca AF, Baptista TWF. Previne Brasil, Agência de Desenvolvimento da Atenção Primária e Carteira de Serviços: radicalização da política de privatização da atenção básica? Cad Saúde Pública 2020; 36:e00040220.. This is the context in which we are reached by the coronavirus pandemic, which explains the political weaknesses of the Brazilian Ministry of Health in the current government. This set of elements is sufficient to conclude that the current conjuncture is of destruction and dismantling of the institutional trajectories analyzed here.

Defending the right of everyone to health and food, in this process of dismantling and threats to the institutional trajectories of SISAN and SUS, implies, on the one hand, insisting that a new food policy will only make sense in the context of a comprehensive FNS policy, built in an intersectoral and interdisciplinary perspective, with broad participation of civil society. On the other hand, it implies not neglecting nutritional care within SUS as one of its central topics, thus guaranteeing the constitutional principle of comprehensiveness in SUS. Fundamentally, it means resisting the setbacks in progress.

Acknowledgments

I thank Rosana Salles-Costa, Claudia Santos, Kelly Alves, and Gabriele Freitas for their criticism and contributions.

References

Publication Dates

History