The Brazilian unified national health system as an observatory for universal rights: a reflection based on the social sciences1
Paulo Roberto do NascimentoI,i; Fabiola ZioniII
IDepartment of Health Practices, Public Health Faculty, University of São Paulo (FSP/USP). Av Dr Arnaldo, 715. São Paulo, Brazil. 01246-904. firstname.lastname@example.org>
IIDepartment of Health Practices, FSP/USP.
The bibliography on the crisis of modernity is wide-ranging. One particular school of thought takes the view that various pillars of modern social life are under threat: among them the achievements represented by universal rights. The public health literature also points out that the Brazilian Unified National Health System (SUS) is a development going against the worldwide movement towards flexibilization of these rights. The principles of universality and comprehensiveness not only constitute an institutional, financial, political and social challenge, but also express society's decision to implement universal rights. We have used Souza Santos's theoretical instrument to characterize SUS as an observatory regarding effective application of these rights. Institutional remodeling and democratic deliberations for establishing a social contract emerge again as matters of importance.
Keywords: National Health System. Social contract. Human rights.
Limited resources and insufficient management are currently placed as hindering the health system development in the country. However, the crisis that goes with putting into effect the Brazilian Unified National Health System (SUS) allows identifying elements that go beyond difficulties in rationalizing the resources use, whether financial or management.
New sociabilities or a new society?
The modernity crisis is not a recent issue. The contract pillars upon which the contemporary western societies were built suffer nowadays from intense questioning arising from new forms of sociability pled by transnational finance capital. There are many authors who discuss about this new sociability, looking for evidences of its constituent elements, basically confronting them to sustainability forms that built the modern world.
Santos (1999) identifies the modernity crisis as a set of deep changes in the own inclusion/exclusion process which is characteristic of that critical way of living in society.
Living in modernity is a critic living in itself, a living that has a precarious balance, acquired by a double movement, which disseminates the inclusion possibility perception at the same time that excludes it. The social contract, preconized by the classics of Political Theory - Hobbes, Locke and Rousseau2 - that laid the groundwork for modern sociability, solidifies it on the possibility of individuals, social groups and entire societies emerge from the "state of nature" and integrate themselves into modernity. This possibility works as modernity legitimizing mechanism that is primarily settled on contractual mechanisms which operate in order to both include and exclude. From social struggles waged as a result of that tension emerges a whole set of institutionalities that complied with the concrete way of living in modern societies. Santos identifies three main large institutionalization groups that conform the modern living: institutions that socialize the economy, institutions that politicize the State and institutions that nationalize (a certain interactive configuration of space-time) the cultural identity. All modernity historical and social forms fit themselves into that institutional outline, as well as the various forms of social struggles, so that the latter - which most paradigmatic expression are the classes struggles between the founding antagonistic interests of capitalist societies - have neither questioned nor indicated a path to overcome modern contours. In a nutshell: modern social struggles have not showed overcoming ways of modernity to the same extent that sufficed in disputing alternative forms of modern institutionalities.
It turns out that, in the last half century, the tense conflictual balance of modernity came under increasingly intense turbulence exactly for the crumbling of the management operational basis of inclusion/exclusion process. In other words, the contractual form that defined what would be included and, thus, what would be excluded from the contract undergone such changes that the currently in effect outcome expanded the exclusion possibilities while limited inclusion mechanisms. To put it bluntly, the precarious balance under which modern societies got used to living has increased its precariousness and dares to dangle itself unwarned, on a tightrope, increasingly expelling previously included social segments (post-contractualism), hindering the entry of those who were out (pre-contractualism) and looking for a new meager oscillating way of balance on a "state of nature" increasingly supplied with human contingents and with natural elements.
Obviously, institutionalities built by modern social struggles lose their ability to regulate conflicts, since they do not legitimate themselves anymore as an institutional expression of struggles around the same contractual statute. When the contractual terms are other ones, even though uncertain, then one may ask: on what institutionalities would take place the new living in society? As a matter of fact, it is in these terms that is questioned on the citizenship conception that has been built in the last two hundred years, whose ultimate expression would be: The right to have rights. Or, in distinct terms: Is the universality of rights achievable?
Actually, the central point of discussion is on what will be the new contract terms. Hence the importance of Santos' (1999) initiative in, at the gates of the future, risking a proposition: as we are finally faced with an opportunity to discuss the social contract in counter-modern terms, or at least in non-modern terms, we take part in this moment handling a program: overcoming the social regulation and seeking emancipation. Searching alternative sociabilities is a requirement of these new times.
We take too serious risks due to the erosion of the social contract for sitting idly while facing them. Thus, it is necessary to look for sociability alternatives that neutralize or prevent those risks and open the way for new democratic possibilities. [...] In view of this, it should be broadly defined the terms of a cosmopolitan requirement that is able to interrupt the pre-contractualism and post-contractualism vicious cycle. In a general level, that requirement translates into the reconstruction or into the reinvention of a space-time that favors and promotes democratic deliberation. (Santos, 1999, p.109)
The author adds:
[...] I believe it is possible to define some of the cosmopolitan requirements dimensions of space-time reconstruction of democratic deliberation. The ultimate meaning of that requirement is the development of a new social contract. It is about a quite different contract from that one of modernity. Above all, it is a more inclusive contract because it must cover not only the human being and the social groups, but the nature as well. Secondly, it is more conflictual because the inclusion occurs both due to equality criteria and to difference criteria. Thirdly, taking for granted that the ultimate objective of the contract is to reconstruct the democratic deliberation time-space, this one, unlike what has happened in the modern social contract, cannot be confined to the State national space-time and must likewise include the local, regional and global space-time. At last, the new contract is not based on rigid distinctions between the State and the civil society, among economics, politics and culture, between the public and the private sectors. The democratic deliberation, as a cosmopolitan requirement, has neither its own headquarters nor a specific institutional materiality. (Santos, 1999, p.112)
The universal rights defense, here represented by SUS constitutive principles, is presented as an anachronistic theme in these terms both for those who believe that these are modern times, wherein was occurring just a reflux of the 'welfare state', associated to the Estado3 structural reforms, and for those who see a post-modern contemporaneousness, an argument according to which the modern social contract, which presupposed inclusion, fell apart.
In the same way, we add, the obstacles seem insurmountable to its fulfillment when we confront the subordinate insertion which is offered to developing countries in the globalized world, facing reduced financial capacity, low level of scientific and technological development, and reduced competency to manage complexity.
For any of the three perspectives, there are huge risks for SUS viability. Therefore, questioning opens up: What would be the possible strategy for safeguarding the universal rights?, Have SUS participatory and negotiation spaces contributed to ensure such rights or have they made them flexible, restricting the scope of rights?, Would there be a need for flexibility, dictated by the new times, understood as a way to ensure in the face of scarcity?, May equity be a concept referring to greater agility in order to meet the most pressing needs, without this meaning universality and integrality reduction?
SUS - universal rights observatory
It is appropriate to remind that the problem formulated by Santos, posed by modernity crisis, directly reaches the path taken in Brazil in the 1980s when the Social Security structure was finally constituted, within which we situate the Brazilian Unified National Health System (SUS). Let's take a look, in general terms, at the trajectory traced by SUS.
We can say that a strong tradition was built in the country to defend the population's health (Escorel, 1998; Draibe et al., 1990; Oliveira and Teixeira, 1986; Braga and Paula, 1981). Public policies, incited by the productive sector and oriented towards disease control, dated back the origin, in the late nineteenth century, of our concern in fighting, in a systemic way, against the harms that afflicted the workers' health and threatened the economic sectors gains - always the strongest of national economy. Until the 1960s, the health sector was substantially characterized by the preponderance of public preventive actions, guided by diseases and incited by potential and true harms to the national economy. The morbidity profile changed greatly in that period, notably because of the population's demographic profile changes and of the industrialization and urbanization processes deepening.
The urban workers masses brought to the State a new configuration of their concerns, generating a whole set of labor and social security rights, reflecting what was happening around the industrializing world which competed in the service and products market. Needs related to diseases cure, rather than to their prevention, emerged registering themselves in pension and retirement plans regulated by the State. Notwithstanding, prevention was the overruling character of public actions. The end of the Second World War changed definitely that scenario landing in the country, as synonyms of health, the medicinal and therapeutic medical acts associated with hospitals and market-oriented.
The first group medical initiatives in the country date back to the sixties. That time coexists with the much desired unification of institutions and retirement and pension funds reunited in the National Institute of Social Security - INPS during the military regime (Malloy, 1985). Under the legitimate argument of providing social security rights to the largest possible share of the population, composed by all workers, it was also reached the State capitalizing goal by means of social security contributions in order to finance works necessary to the economic development. Nevertheless, the huge size of the generated public apparatus, coupled with the lack of resources public control and of its participation in the policies and priorities formulation - made possible by the absence of political participation and of active citizenship pled by the exception regime - soon produced an endless diversity of fraud forms and misrepresentations of public purpose of the social security system. A not derisive additional aspect to understand the situation was given by the health care medical-hospital character imbedded in rights and in social security benefits.
The second largest Brazilian budget in the 1960s proceeded from the social security system. The scenario was that of a large amount of resources, managed far away from the population's sight, directed at national economic development projects substantiated on the market and feeding the medical-hospital attention. That took place in a world that, enchanted with the technological development, learned to revere miraculous solutions for its health problems: the medicine, the diagnostics device, the therapeutic practices in general, and the hospital. A new consciousness, a new knowledge involved the population who more and more placed the health problems solution in those small exogenous devices, external to its body or environment.
The health system problems, in turn, produced a whole wave of programatic devices, public policies rationalizers of resources and systemizers of State participation in the population health protection. Resulted from the seventies and eighties: the National Health System - SNS, the Program of Internalization of Health and Sanitary Actions - PIASS, the National Program of Basic Health Care Services - Prev-saúde, the Integrated Health Actions - AIS and the Social Security Medical and Hospital Assistance System - SAMHPS, the last two initiatives arisen from the Health Care Restructuring Program, developed within the framework of the Consultant Council of Administration of Social Security Health - CONASP - and the Unified and Decentralized Health System - SUDS (Almeida , Chioro, Zion, 2001; Cohn, s / d; NEPP, 1986). The National Health System - SUS is the historical result of those experiences, where there were mistakes and rightness. But not only, as much of its emergence still owes to the redemocratization process of the country, conquered by the society forces and movements fighting against dictatorship.
In 1986, the social forces summoned at the VIII National Health Conference defined the health state of a population as the outcome of the whole set of different sectoral policies: economic, wage, educational, environmental, housing, food and nutrition, transport, cultural, health, among other policies. In other words, health is not only a result of the health sector achievements.
The sanitary movement efforts, associated with redemocratization movements of the country, of which that one participated, registered SUS principles in the 1988 Constitution. Health, as a universal right, required public actions directed at prevention, promotion, cure and rehabilitation (TCU, 1999).
Regarding the limited coverage for the population provided by the social security system, the Movement for Sanitary Reform reacted proposing universal coverage, according to the social security system of the constitutional text. As for the traditional separation between curative and preventive care levels, respectively operated by the medical-hospital social security system and by the actions of public health of the Health Sector, the Movement reacted with the wholeness principle of care. From the striking difference in care among different social security sectors and between the social security population and the excluded population of any health care emerges the distributive principle of equality. The exclusion of workers and users from the health system decision makers, heightened by the bureaucratic-authoritarian regime period, led the Movement provide the system control guideline by means of community participation. At last, in response to the strong deciding centralization that marked completely the set of health care instances, but as a doctrinal principle of belief in the civil and political society from where it should emanate the system determinants as well, it began to appear the decentralization policy as the most important of the instruments guiding the system organization. (Nascimento, 2002, p.18)
It is noteworthy that the central countries discussed the reflux of the Social Welfare State when we established the concept of Social Security in the 1988 Constitution.
The problem would not be so relevant if that reflux was not inserted in the historical movement of the modernity crisis. The rupture of the universal rights safeguard, the State size and functions reduction, the functioning flexibilization of State institutions, a new relationship form between public and private spaces and the questioning of traditionally accepted democratic forms of conflicts political management are some of the modern contract crisis manifestations. They are all present in the international organisms formulation of conflict management in the 1980s4.
Thus, what would be more crisis confrontational than an institutionality that defended universal rights to a full state care? The national State space-time revealed at that moment a certain degree of independence regarding the sense that the crisis took on at an international level. Put in confrontation terms SUS, whether intentional or not, has a certain resistance character to the exclusion movement, even though we have arrived late at the future. In any case, it is a resistance which, far from being anecdotic, may constitute an experience of creating the new sociability that Santos tells us, given that his thesis main argument lies in optimism: If it is to be done, who will do it? "We can not sit idly..." In this manner, it is better we look at the universalizing attempts, less as a way of resistance and, more appropriately, as emancipation projects to be tested in a modernity crisis, since, as we infer, the crisis establishes a period of attempts and possibilities until the new sociability is formed, however unstable and exclusionary it may be.
It also worthwhile to remember, still according to Santos, the role to be performed by "democratic deliberations." Democracy5, so uncharacterized and despised, when compared with the strength of economic institutionalities, or exactly arising out of the action of multilateral organisms, strangely assumes in its analysis a central role in the coming unfolding. It is about bringing populations and individuals to the social, economic and political scenario, maybe as the last provision of forces to be revitalized, in order to affect the new contract: Finally, to take part or not to take part in drafting the terms of the new contract? Strengthening the mechanisms and widening the spaces for exercising democracy are essential for establishing a new agreement.
Therefore, what turns SUS a reality, rather than an experiment, for observing the possibilities of universal rights preservation, that is to say, of questioning the bases that will constitute the society which is currently created. Recognizing the importance of initiatives to constitute observatories that monitor sector policies, in the drive to lead them for meeting the population's needs, it must also be considered the preservation and realization possibilities of its constitutive principles and, when that does not happen, if the flexibilization they went through indicates building institutionalities that either make flexible or not the universal principles. From this perspective, it should be encouraged debate on management and funding, overcoming the limits imposed by questioning the rationalization or optimization of available resources.
Paulo Roberto do Nascimento and Fabiola Zioni participated in all stages of writing this paper, elaborated based on Nascimento's Doctoral Thesis under Zioni's guidance.
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1 Adapted from the introductory discussion to the Doctoral Thesis (Nascimento, 2006). Project submitted to the approval of the Ethics Committee in Health Research.
2 For a comparative discussion of the three classics on social contract, see Santos (2000), page 129 and the following pages.
3 In this respect we recommend reading Almeida (1997), when he situates the theoretical justifications for health systems reforms, in the eighties, as substantiated on the same basis that attempted to "decree" the end of the 'welfare state' (p.181). As for the State reforms, we refer to the retraction Â neoliberal procedure of the Keynesian intervention of the State in the economy,Â Â Â promoting the system deregulation and the state sector privatization (Ugá, 1997).
4 Particularly informative on the international agencies role in redefining the national states social agendas is Costa's text (1998), especially chapter five: The World Bank and the Social Policy in the 90s: the agenda for the health sector reformÂ in Brazil.
5 See Santos and Avritzer, 2002.
i Address: Av. Dr. Arnaldo, 715. São Paulo, SP, Brasil. 01.246-904.