Over the years, I have become more and more convinced that the Brazilian National Health System (SUS) as foreseen by the constitution is better and more generous than Brazil.

Without doubt, this is a paradoxical deduction, in so much as the SUS was idealized and is being implemented in the same contradictory, old and eternal country of the future, which, apparently, has never reinvented itself. So much so that, despite the fact that much has been accomplished and the positive impact of the SUS on the health and life expectancy of the Brazilian people, the concrete SUS – the “actually existing” system – still has a long way to go before being able to uphold the universal right to health and comprehensive health care based on individual and collective health needs.

While progress has undoubtedly been made, the SUS that is currently taking shape increasingly resembles the precarious living conditions of the 70% of the Brazilian population that use it on a regular basis. In the SUS, as in deprived areas, there is neglect with the ambiance, with the efficiency of public service delivery and, most serious of all, with the people that use and work in the system. The SUS is gradually becoming yet another space dominated by the rationality of the age-old traditional promiscuity of Brazilian politics. In short, the SUS has shaped its ethics, aesthetics and operational standards in line with the way of life of the majority; in many respects and situations, confirming a pattern of disrespect for human dignity.

There is deep-rooted economic, social and political inequality in Brazil. It is as if there were two worlds coexisting in the same territory. Despite significant progress in reducing poverty in recent years, two-thirds of the population earn less than two minimum salaries. There are also deep inequalities when it comes to power. The composition of the National Congress confirms the imbalances in political representation, being made up mostly of businessmen, men and whites. Machismo is the dominant culture, while in public and private organizations the terror and arbitrariness of managerialism prevails. Cities are split in two, with gaping differences in basic sanitation, transport, housing, urbanization, leisure, and public security. We only need to look at the Map of Violence to realize that there are two Brazils. Governments have concerned themselves more with economic growth and maintaining the power of the elites than social and human development strategies.

“For whom is it intended”, the SUS? – Caetano Veloso would ask. Is the concrete SUS really a system that “belongs to all of us and is for all of us”?

Defending the SUS involves combatting inequality, promoting a shift in current economic and social policy, and imposing public interventions aimed at promoting equality and well-being.

The phrase I tend to use, “We are hope... and the others”, is a metaphor that expresses certainty that defending the SUS, democracy and social rights, particularly in present times, depends more on civil society than on the State and career politicians. It depends on revitalizing the health movement and promoting political articulation across broad sectors of society – civil rights movements, such as those that struggle for the rights women, the elderly, indigenous groups and black people, disease-specific groups, religious groups, and unions; ultimately we need to give voice to a project that seeks to build an inclusive society that upholds the right to health.

To a large extent, the SUS is the concrete manifestation of the history of struggles to protect the right to health. It is necessary to talk about the SUS, comment on this utopia and dream with the concrete possibility that it is realizable, something that depends not only on defending what has been built, but also on implementing changes to overcome the countless impasses that separate the SUS on paper from the real day-to-day SUS.

Outlined below are just some of the strategies that may reinforce our ability to resist the raving folly of the country’s ruling elite.

1 - Promote symbolic practical actions to strengthen the SUS as a system that belongs to all of us and is for all of us. The flight of the wealthiest one-third of the population to private insurance plans is yet another symptom of building one country for the rich and powerful and another for the people.

To this end, we need to develop a national campaign to create a law that prohibits the utilization of public funds to pay private health plans for civil servants, state employees, parliamentarians, and members of the judicial and executive branch, etc.

We need to organize a movement to create a law that ends income tax exemption for taxpayers who use private health services.

We need to promote a shift in the culture and policy of workers’ unions towards actions in defense of the SUS, particularly in the regions where their members live, and the reallocation of company spending on employee health plans to workers’ salaries and benefits.

2 - Achieving adequate funding for the SUS requires changes to the prevailing economic framework and the adoption of actions to promote economic growth, or “new developmentalism”, where public resources are used not for tax relief – a measure known by the nickname of bolsa empresário (the business grant) –, but rather for investing in social policies and infrastructure, including basic sanitation, urban reform, public transport, housing, health, education, public security, and social promotion.

The most pressing challenge at the moment is the repeal of the Constitutional Amendment 95 (which imposes a ceiling on public spending for the next 20 years), given that, in the short term, it will promote brutal spending cuts that are set to affect social policies, infrastructure, and health, thus leading to thousands of avoidable deaths.

I also defend that requests for increased health funding should be accompanied by a project setting out how resources will be allocated, the elaboration of a map showing gaps in access to medium and high complexity care services by health region, the formulation of a SUS staff policy, and widening the coverage of arbovirus control policies through actions that tackle the social determinants of epidemics such as urban decay.

3 - State reform and SUS management reform is also needed, aimed at drastically reducing system fragmentation and SUS dependence on partisan politics and the executive branch. Despite containing the term “unified” in its name, it is impossible to ignore the challenges facing the planning, set up, management and evaluation of service delivery, and the rational use of resources in the SUS. A feasible way to improve integration between federated entities across all levels of health care (primary care and medium and high complexity care services, urgent care services, and health surveillance) is through strengthening the health regions.

I believe that health regions should assume a widened role, becoming partially responsible for the operational management of the network (medium and high complexity care), regulation, urgent care services (the Mobile Emergency Care Service – SAMU, acronym in Portuguese), and health surveillance. To this end, health regions should benefit from regional health funds with their own specific budget according to the respective demand for care services, in addition to contributions from federal and state governments. As provided by current legislation, each health region is governed by Comissões Intergestoras Regionais (regional intermanagement commissions), which shall appoint an appropriately qualified and experienced regional health secretary. Municipalities, apart from participating in the management of health regions, are responsible for managing the services and programs that fall within their remit.

To achieve relative autonomy within the SUS, it is important to fight for a law that replaces cargos de confiança (political appointments made on the basis of trust) for management positions within the SUS with merit-based appointments made through a competitive, transparent and unbiased selection process.

4 - A unified staff policy for the SUS

There is a multiplicity of policies and approaches to personnel management in the SUS. Each type of service provider, be it the federal, municipal or state government, social organizations, health foundations, philanthropic organizations, and contracted private service providers, have its own rules and mechanisms for the recruitment and payment of health workers. Budget constraints and legal and management problems related to human resource management in Brazil have led to the development of a very ad hoc approach to personnel management within public health services and precarious working relationships.

The emergence of a new type of health professional depends on the creation of a unified staff policy for the SUS that takes into account the diverse nature of health professions and specialties, health care and Brazil’s various regions.

We need to break with the tradition of organizing careers into professional categories and move towards an approach based on the main areas of the health care system: primary care; medium and high complexity care (secondary and tertiary system – outpatient clinics, referral centers, home care services, and hospitals); the urgent and emergency care network; health surveillance; and operational support (administrative, maintenance, and financial).

This new policy would be jointly implemented across the federal, state and local governments by a tripartite commission, with the creation of a public agency (an autonomous body or public foundation) and personnel policy fund.

5 - The SUS needs to be recognized as a public space. The experiences of public universal systems show that this alternative is incompatible with the market system. Should progress be made with the redefinition of the role and organization of health regions and the creation of a unified staff policy for the SUS, there will be no need to outsource the management of the SUS to social organizations. These organizations could be totally replaced by the reshaped public health network, thus providing the necessary conditions for effective service delivery according to the principles and guidelines laid down in the relevant legislation.

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