This study aimed to analyze the role of the National Health Council in the core of the decision-making process of health policy in the period 2014-2017. The analysis was based on the political disputed projects in the health policy sphere and on the government projects of former Presidents Dilma Rousseff and Michel Temer. Due to the government’s project change, in addition to the social and parliamentary channels, the Council started to act through the judicial channel as well, moving from critical alignment to outright opposition until its neutralization, with the Council’s participation boycott in the health policy agenda discussions in the period 2016-2017. Although it did not have enough power to change the balance of forces surrounding the deconstruction of the Brazilian National Health System (SUS), the Council was part of a political bloc of resistance and confrontation in defense of the constitutional SUS.
National Health Council; Health policy; Social participation; Political analysis in health
The National Health Council (CNS) is a privileged space for the articulation of actors, ideas, and proposals for the health sector. From the end of the 1990s11 Côrtes SMV. Uma síntese do debate sobre os mecanismos e as dinâmicas participativas no sistema único de saúde. In: Côrtes SMV, organizador. Participação e saúde no Brasil. Rio de Janeiro: Editora Fiocruz; 2009. p. 199-205. to the present time22 Paim JS. Sistema Único de Saúde (SUS) aos 30 anos. Cienc Saude Colet. 2018; 23(6):1723-8.
3 Silva BT, Lima IMSO. Análise política da composição do Conselho Nacional de Saúde (2015/2018). Physis. 2019; 29(1):1-25.-44 Silva BT, Lima IMSO. 15a Conferência Nacional de Saúde: um estudo de caso. Saude Soc. 2019; 28(3):97-114., this Collegiate has shown a significant activism, mobilizing entities, social movements, and representations of national scope. Nevertheless, there is a lack of studies55 Silva BT, Lima IMSO. Conselhos e conferências de saúde no Brasil: uma revisão integrativa. Cienc Saude Colet. 2021; 26(1):319-28. on the CNS. Furthermore, they focus on specific issues: health surveillance66 Lucena RCB. Articulação entre o Conselho Consultivo da Anvisa e o Conselho Nacional de Saúde: uma análise no período de 2000 a 2010. Physis. 2015; 25(2):381-99.; its composition and internal dynamics77 Côrtes SMV. Sistema Único de Saúde: espaços decisórios e a arena política de saúde. Cad Saude Publica. 2009; 25(7):1626-33.; its performance concerning the recommendations of international financial organizations88 Correia MVC. O Conselho Nacional de Saúde e os rumos da política de saúde brasileira: mecanismos de controle social frente às condicionalidades dos organismos financeiros internacionais [tese]. Recife: Universidade Federal de Pernambuco; 2005.; and the struggle for recognition of ethnic-racial differences in this political arena99 Morais DS. Diferenças étnico-raciais e políticas de reconhecimento: perspectivas a partir do Conselho Nacional de Saúde e do Conselho Nacional de Educação [tese]. São Carlos: Universidade Federal de São Carlos; 2016.. Thereby, there is little research on the performance of the CNS in the disputed space of the health policy decision-making process.
Given this lack, this study aimed to answer the following questions: How did the political action of the CNS take place in the core of the health policy decision-making process from 2014 to 2017? What health projects have been taken over by the actors who dispute the health policy? What strategies were adopted by the Council to dispute the direction of the health project adopted in Brazil? Hence, this article aims to analyze the political performance of the National Health Council at the core of the health policy decision-making process.
Fractions of the disputed projects in the health sector are taken over and interpreted by the kernel of the state-owned decision-making power - the Executive, Legislative and Judiciary powers - through a constant tension of the Government (the objective and government project), socio-state-owned (for example, the CNS), and market components, with varying skills to direct the vector of forces towards the disputed projects based on their concrete praxis. In this manner, the political analysis1010 Testa M. Pensamento estratégico e lógica de programação. O caso da saúde. São Paulo, Rio de Janeiro: Hucitec, Abrasco; 1995. of the CNS performance presumes to contemplate: the coherence of the Council, as a testian organization, in relation to the disputed projects in the health sector; and the tensions caused in the objectives and government project through which the construction of the health policy inevitably takes place. This analysis relies on Mário Testa’s strategic thinking, whose central category is power.
The Brazilian government projects presented between 2014 and 2017 were carried out in the government program of the Brazilian President Dilma Rousseff, contemplated in the 2014 elections, and in the government project of the Brazilian President Michel Temer, presented in 2015 to political party leaders aligned with the Brazilian Democratic Movement Party (PMDB); therefore, when Mr. Temer was the Vice President of the country.
The foundations of the 2014 government program Mais Mudanças, Mais Futuro (“More Changes, More Future”) guided the balance between economic and social growth and stated the commitment to strengthening and improving the Brazilian National Health System (SUS), whereas the 2015 government program Uma Ponte para o Futuro (“A Bridge to the Future”), in force until the end of 2018, had as its central guideline the recovery of the Brazilian economy through the balance of public accounts; the expansion of concessions; the participation of the private sector; and the constitutional disconnection of spending on health and education.
In this political analysis, the health sector is seen not as a set of institutions, but rather as a social space of power struggle in constant reorganization, resulting from the relationship between social actors, members of both political society and civil society, when they develop sectorial action1010 Testa M. Pensamento estratégico e lógica de programação. O caso da saúde. São Paulo, Rio de Janeiro: Hucitec, Abrasco; 1995..
Within this sector, Paim1111 Paim JS. Reforma Sanitária Brasileira: avanços, limites e perspectivas. In: Matta GC, Lima JCF. Estado, sociedade e formação profissional em saúde: contradições e desafios em 20 anos de SUS. Rio de Janeiro: Editora Fiocruz; 2008. p. 91-122. identifies three disputed projects: the mercantilist project, which acknowledges health as a commodity and the market as the best option to meet individuals’ health demands and needs; the health reform project, mainly aimed at improving the living conditions of the Brazilian population, which can be reached through social reform based on the democratization of health, the State, and society, and which defends the constitutional SUS - one of its main concrete results; and the revisionist or rationalizing project, defended by those who prefer greater flexibility regarding SUS principles and guidelines, adjusting them to the economic, state, and hegemonic class interests.
In this light, the CNS acquires the characteristic of a testian organization1212 Testa M. Vida. Señas de Identidad (Miradas al Espejo). Salud Colect. 2005; 1(1):33-58., in which a group of diverse individuals gather to achieve a certain aim around which they generate actions based on majority decision, with at least a common purpose of interfering in health policy - understood here as an action or omission of the State, a social response to health problems and their determinants1313 Paim JS, Teixeira CF. Política, planejamento e gestão em saúde: balanço do estado da arte. Rev Saude Publica. 2006; 40 Esp:73-8..
The political performance of the CNS is projected in the space of the Brazilian State decision-making process, composed by the powers of the Republic, pressing governmental components to take over the health project adopted by the CNS. The direction pointed out by the political forces - that is, whether towards a mercantilist, revisionist, or the Brazilian Health Reform project - is the product of the synthesis of numerous struggles conducted by various actors at each historically determined moment.
A qualitative case study research1414 Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 13a ed. São Paulo: Hucitec; 2013. was carried out at the CNS, whose political performance was analyzed over a four-year period. The period 2014-2017 was a strategic choice, given that it corresponds to a year before both the political crisis triggered by the impeachment process of the Brazilian President Dilma Rousseff and that of her successor, Mr. Temer.
The interviews were conducted with 27 counselors, 22 of whom belonging to the 2015-2018 management period, and five to the 2012-2015 management period. They were identified by two categories: state representatives (government representatives) and societal representatives (market and social representatives). Government representatives of health management were classified as state actors; and those in the category of providers of goods and health services, as societal market actors. As for the societal social actors, they were named by the categories: workers’ entities and health professionals; workers from other areas; entities of People with Pathologies and People with Disabilities (PwD); gender and ethnic entities; community associations, social movements, and Non-Governmental Organizations (NGOs); and the category of religious representations1515 Côrtes SMV. Conselho Nacional de Saúde: histórico, papel institucional e atores estatais e societais. In: Côrtes SMV, organizador. Participação e saúde no Brasil. Rio de Janeiro: Editora Fiocruz; 2009. p. 41-71..
There were selected counselors from all categories and who, according to the record in the CNS meeting minutes, played a prominent role in the Collegiate body. Therefore, the following counselors from the 2015-2018 management period were interviewed: 1 market representative; 2 government officials; and 7 social actors from the categories of health professionals and health workers, being one of them the President of the Council, 3 social actors from the segment of workers from other areas, 4 from the segment of pathology patients, 4 from the category of community associations, and 1 representative from the ethnic and gender category. As for the interviewees of the 2012-2015 management period, the following were selected: the President of the Council, and 2 representatives of the Ministry of Health (MH), being one of them the Minister of Health himself, a member of the Forum of National Health Workers Entities (FENTAS), and a member of the User Forum.
Semi-structured interviews were guided by two scripts: one designed for interviewing government representatives, and another for the other counselors. The interview questions addressed to state actors were related to the Ministry of Health’s project, designed and conducted for the health sector; its analysis of the Council’s performance; and its relationship with it in the 2014-2017 Brazilian context. The questions addressed to the societal representatives concerned the understanding of these actors about the CNS performance in the period analyzed.
Data were also collected from two sources: news produced by the Council and published on their website between 2014 and 2017; and 49 minutes of the ordinary and extraordinary meetings conducted in the same period. Moreover, data were organized into two matrices: one for news and another for information from the minutes. Data were gathered between September 2017 and January 2018.
After reading the interviews, minutes and news collected, excerpts referring to the political activities of the CNS were extracted and gathered in Excel matrices, composing the corpus of analysis from which, after several readings, the registration units were extracted1616 Bardin L. Análise de conteúdo. São Paulo: Edições 70; 2011.. The analysis of this material enabled us to gather the speech extracts that expressed the core of understanding of the text around the analytical categories adopted in the theoretical framework of this study (Disputed Projects in the Health Sector - mercantilist, revisionist, and constitutional SUS; Government Projects – Mr. Rousseff’s and Mr. Temer’s government programs; and The Relation with the Powers of the Republic - decision-making nucleus). In this way, a political analysis of the National Council’s performance in the construction of the Brazilian health policy was conducted.
The research project was submitted to the Research Ethics Committee and obtained approval under opinion number 2,235,550, complying with all the ethical aspects provided for in Resolution 466/2012 of the CNS.
The year 2014 (the end of President Dilma Rousseff’s first term)
The final year of President Dilma Rousseff’s first term and the beginning of Arthur Chioro’s term at the Ministry of Health (MH) was marked by the relative alignment of positions between the CNS and the MH. On various occasions, the CNS requested explanations and made recommendations to the MH, the Secretariat of Planning and Budget (SPO), and the Presidency of the Republic on the budgetary and financial execution presented in the Quarterly Accountability Reports (QAR). Despite the commitment and liquidation of public investment in health continued unevenly - including for public health actions and services -, and in spite of the contingency of budget resources, the 2013, 2014 and 2015 Annual Management Reports (AMR) referring to the MH management in the analyzed period of the President Dilma Rousseff’s government were, even in the face of strong tensions, approved by the plenary of the Council with reservations (CNS, minutes 258, June 2014; minutes 260, August 2014; minutes 263, November 2014; minutes 275, November 2015; minutes 283, July 2016). The Collegiate’s trust in the government’s political coalition contributed to the Council taking a tolerant political position in the face of the government’s omission regarding the constant underfunding of the SUS.
[...] It was another political moment of the National Council, which thought that if we were inside the government, it was ours, and we were in lukewarm social control. We were still leaving... Many setbacks that had now intensified started a long time ago, in previous governments. Away back, the Annual Management Reports were approved with reservations because it was thought that this was the most appropriate way. We are not going to oppose the government because it’s our government. And look what happened?(Interviewee No. 6 - Social Societal Representative)
The CNS performance on the public health financing agenda extrapolated the relationship with the MH, to the extent that the Collegiate entities, together with other social movements, led the project “Health + 10,” which predicted that 10% of the Union’s Gross Current Revenues would be directed to the health sector. In this way, the popular mobilization mechanism would be activated, and the Legislative tensioned with the Popular Initiative Law Project 321/13. This proposal was powerful in unifying the interests of government representatives with the Council’s social entities. The speech extracts below illustrate this dynamic:
[...] In this period, the position of the CNS is strongly directed towards the Popular Initiative Law Project, which was the culmination of the Council’s performance, the collection of signatures, their handling to the President of the Chamber, and the monitoring of this process [...] So, the issue of financing heavily influenced the CNS performance at that time.(Interviewee No. 10 - Social Societal Representative)
In the Chamber of Deputies and Federal Senate spheres, the healthcare project with a stronger policy for the Brazilian society had become increasingly prominent in the positions taken by the Federal Legislature. In April of that year, the Chamber of Deputies, under the presidency of Henrique Eduardo Alves, of the PMDB party, resumed the debate on health public financing. In the National Congress, the CNS, other national entities, and social movements involved in the “Health + 10” movement required that the Popular Initiative Law Project 321/13 be detached. In other words, it was claimed that it should be separated from other projects, becoming independent and thus gaining an urgent character in the legal process.
Paradoxically, the political coalition that formed the Legislative Houses found political viability as of 2013 to remarkably streamline the project of the imposing budget. It was proposed in 2000 and turned into the Constitutional Amendment Proposal (PEC) 358/2013, which provided for the transfer of 1.2% of the Union’s Net Current Revenues (NCR) to parliamentary amendments, of which 50% should be applied in the health area and deducted from the federal budget for the MH. This project gained an amendment, even of greater impact for the sector, as it also established that 15% of the Union’s NCR should be directed to the health area in a phased basis over a four-year period. In practice, the approval of the tax budget amendment represented a cutback in funding for the SUS, as it placed the Union’s obligations at levels lower than those established by Law 141/2012, in force in the country.
Three political strategies were adopted by the CNS in 2014 to interfere in health policy: negotiation with the Executive power on public health financing; and participation in a Judiciary hearing, defending both universal and free access to the SUS; and monitoring of health-related projects in legal process in the plenary and in the commissions of the National Congress. From the concrete analysis of the scenario of the Legislative Houses, the CNS identified that some decisions were taken in spaces that different from those formally instituted, such as thematic commissions and the plenary sessions of the Federal Chamber. Agreements between parliamentarians from the health caucus and pacts between political party leaders started to demand more improved tactics from counselors, ranging from those related to taking part in public hearings, establishing dialogue with committees, requesting clarifications, to those referring to participating in committee meetings, negotiating, holding demonstrations to strengthen popular pressure, and analyzing the vectors of power at each specific time (CNS, minutes 254, February 2014).
The mercantilist health project was clearly strengthened with the dominance of the Economic Power over the Executive and Legislative Powers through corporate financing of the 2014 election campaign. After all, nearly R$55 million were donated by health insurance companies to candidates from different parties and of all positions sought, including to the Presidency of the Republic. The re-elected Brazilian President, Dilma Rousseff, received R$11 million from the health insurance companies Amil and Qualicorp. As for the other candidates for the same position - Aécio Neves, from the Brazilian Social Democracy Party (PSDB), and Marina Silva, from the Brazilian Socialist Party (PSB) -, they also received donations from health insurance companies. Other influential politicians, such as Eduardo Cunha, who would later become president of the Chamber of Deputies, received R$250,000 from the health insurance company Bradesco Saúde. Furthermore, political parties that had a prominent position concerning the number of health-related projects were also benefited by the health market1717 Scheffer M, Bahia L. A saúde nos programas de go¬verno dos candidatos a Presidente da República do Brasil nas eleições de 2014: notas preliminares para o debate [Internet]. 2014 [citado 3 Maio 2016]. Disponível em: http://cebes.org.br/site/wp-content/uploads/2014/07/proposta-sa%C3%BAde-presidenciaves-2014.pdf
The year 2015
Still during the electoral period, the Executive Power presented to the Chamber of Deputies the Provisional Measure 656/2014, which addressed tax incentives for the areas of information technology, civil construction, and investments in wind power. To that extent, other articles were added by the National Congress, including one allowing the entry of foreign investors in the Brazilian healthcare market. In the beginning of the subsequent year, this Provisional Measure was converted into the Brazilian Federal Law 13.097/2015, allowing the participation of companies and foreign investment in the Brazilian health care and actions, without the restrictions provided for in the Organic Health Law (OHL), as well as eliminating the obligation of international entities to be subject to the authorization and control of the MH to conduct their activities1818 Brasil. Presidência da República. Lei nº 13.097, de 19 de Janeiro de 2015. Dispõe sobre a entrada de capital estrangeiro no setor saúde. Diário Oficial da União. 20 Jan 2015..
In the Council’s plenary, this agenda intensified the disputes between the segments. While the representatives of the Ministry of Health defended the measure, arguing that it referred to regulate an existing practice in the country and to regulate and provide conditions of competition to Brazilian companies, the market representatives, consistent with the proposal, advocated that this could improve health care in the country, as it would increase health-related resources. The other segments were against the proposal because, besides the fact that the measure was unconstitutional, foreign investment would strengthen the health market, rather than health as a right. This position prevailed in the Collegiate, being explained in the recommendation deliberated by the plenary with criticism and warnings against the proposal (CNS, minutes 265, January 2015; minutes 267, March 2015 - http://conselho.saude.gov.br/ultimas_noticias/2014/12dez18_Nota_medida_prpvisoria_656_2014_4cnstt.html). The speech extract below points out the plenary’s dispute around this proposal:
[...] My attitude of honoring, valuing, respecting the CNS didn’t make the Council any nicer, taking it easy on me. Quite the opposite, its position was very tough, with many questions made to me or to the decisions of [President] Dilma [Rousseff] - for instance, not to veto that article on international capital. I had to go to the Council and argue. [It was] a tough discussion, but I took a stand on behalf of the Government.(Interviewee No. 4 - Government State-owned Representative)
In this perspective, although the government program Mais Mudanças, Mais Futuro points out the direction of the health policy for strengthening the SUS, the Executive became restrained by market pressures, also exposed in the measures adopted by the National Congress that favored the private sector.
In 2015, besides the mobilization for the 15th National Health Conference44 Silva BT, Lima IMSO. 15a Conferência Nacional de Saúde: um estudo de caso. Saude Soc. 2019; 28(3):97-114., one of the main CNS banners continued to be the fight for more funding for the SUS. To gather political forces around this agenda, the Front in Defense of the SUS (abraSUS) was launched at the CNS, bringing together social, governmental, and parliamentary entities. The abraSUS manifesto pointed towards a set of alternatives to increase revenues for health policy. Notwithstanding, their proposals distanced themselves from those that really prospered in the powers of the Republic.
The Constitutional Amendment Proposal (PEC) 87/2015 of the Federal Government expected to extend to 2023 the Untying of Federal Revenue (DRU) that would be in force until the end of 2015. Nevertheless, to this proposal were added others from the Senate (PEC 143/2015) and the Chamber (PEC 4/2015), with a percentage increase from 20% to 30% of federal taxes that would be decoupled from the social security budget for arbitrary use by the Government. Moreover, this provision was created for the Brazilian states, municipalities, and the Federal District. Considering the COFIN (Budget Financing Commission)/CNS estimate of withdrawing the total amount of R$44.6 billion from the SUS - if the referred DRU/ PEC had been in force in 2016 -, the CNS plenary approved a motion to repudiate this proposal and sent it to the Senate. The measure was approved in line with the government program Uma Ponte para o Futuro of the interim President Michel Temer, which anticipated the constitutional untying of spending on health and education (CNS, minutes 281, May 2016; http:/ /www.conselho.saude.gov.br/ultimas_noticias/2016/04abr27_Conselho_alerta_Senado_PEC143.html).
Post impeachment of President Dilma Rousseff
In the counselors’ perception, the change of government impacted the health sector, in terms of accelerating a process that was already ongoing in the country. According to the interviewees’ statements, besides the lower permeability of the new governing coalition to the participation of society, the historic underfunding of SUS worsened, better exposing the face of the health project assumed by the Government. In the scenario of democratic instability, the CNS held a public act at the Ministry of Health to alert its members to the essentiality of democracy for the SUS.
[...] for me it’s like a continuum: [It’s happening] the same setback in the destruction of the SUS. I think the coup sped up. [...] But I think that, anyway, before we had space for dialogue [...] But not with the coup; there’s no conversation. What is defined there is defined [...], without the possibility of dialogue.(Interviewee No. 5 - Social Societal Representative)
In the interim government, the federal executive submitted to the Congress the PEC 241/2016, establishing federal public spending limits for primary spending, which includes social security over a twenty-year period. Deliberately, this PEC sets no spending limits on public debt. In fact, this measure freezes the Union’s public financing until 2036, including that for health, based on the minimum spending applied in 2016, ensuring that there are more resources to pay off the debt.
The PEC 241/2016 turned into the Constitutional Amendment (CA) 95/2016 later that year. It must not be forgotten that the proposal made in this CA was provided for in Mr. Temer’s government program Uma Ponte para o Futuro. At the CNS ordinary meeting, the basis of the argument given by the Ministry of Finance in the debate on the subject was that it would be necessary to control public expenditure to hold the economic crisis (CNS, minutes 287, November 2016). This attack by the Brazilian Executive on the withdrawal of funding to the SUS, besides its historical underfunding, points towards a change in the health project assumed and carried out explicitly by the MH, which started to be aligned with market interests.
Giving priority to fiscal balance at the expense of investment in the social area was pointed out in the interviewees’ speeches statements. The counselors also mentioned that it was about the implementation of the government program of the political coalition ahead of the Brazilian State. They evaluated that this new legislation was harmful to the public health sector.
[...] Temer and Meireles approve the even more radicalized [...] policy called austerity that is by no means austere. Instead, they are quite generous policies concerning financial capital, the remuneration of interest on public debt loans, but which are highly unfavorable to social policies in general, including the health policies. Amendment 95 of the public spending limit will be the death of SUS [...] If they don’t change this policy, we’ll be witnessing the end of SUS as a universal system project.(Interviewee No. 10 - Social Societal Representative)
[...] he is carrying out a government program that was not approved at the polls [...]. The coup was given to change the government plan. That’s why this parliamentary coup existed [...](Interviewee No. 8 - Social Societal Representative)
After the Constitutional Amendment 95/2016 approval, besides the fight strategies adopted in previous years, the CNS resorted to the health policy judicialization. According to COFIN/CNS estimates, this Amendment approval represents a loss of over R$430 billion for the health sector until 2036. As a result, the CNS’s entities filled as amici curiae for a Direct Action of Unconstitutionality (ADI 5.658) in the Federal Supreme Court (FSC) to block the implementation of this Amendment. Furthermore, they also mobilized several entities; made demonstrations with thousands of people to defend the SUS; sought alliances with the parliamentarians who voted against the CA 95/2016; participated in National Congress debates, showing the impact of this measure for the health sector; and pressured the Legislative House with a public act of vigil on the voting days of this agenda.
Both the CNS and the SUS Defense Front also adopted a strategy to mobilize society to support a manifesto, which aims to collect millions of signatures to strengthen society’s position against CA 95/2016 in the judgment of the Direct Action of Unconstitutionality in legal process in the FSC. The speech extract below highlights this process:
[...] there are male and female friends of the cause, which is a document that will be sent to the FSC. So, we need 3 million signatures for a document that can stop the CA 95/2016 that freezes investments [...] until 2036. They are investments in healthcare, education, and social assistance.(Interviewee No. 16 - Social Societal Representative)
Faced with the prominence of the Brazilian Legislative and Executive Powers around the deconstruction of SUS, the Council began to employ greater political activism and adopt a position of resistance and confrontation. According to the interviewees, this process is tied to the government change, as shown in the speech extract below:
[...] what happened was that it became quite politicized, even because of the truculent manner of our Minister of Health. He is not an easy guy to deal with(Interviewee No. 1 - Market Societal Representative)
In 2016, the Health Communication Conference was hold and two additional thematic Conferences were summoned: the Women’s Health Conference and the Health Surveillance Conference. Along with the political activism of the CNS through the social route, the Collegiate confronted decisions by the Parliament, the Federal Executive, and the Ministry of Health itself in defense of the constitutional SUS. On the other hand, other issues strongly marked the health policy in Brazil, such as the Parliamentary Coup D’état; the proposal of the MH to create individual/private health plans with a restricted package of supposedly low-cost services, which would directly benefit health insurance companies; the setback of specific health policies, such as the National Primary Health Care Policy (PNAB), which started to financially induce the creation of health teams without a medical professional, in addition to excluding the Community Health Agents (ACS) from the full coverage of the non-vulnerable population1919 Brasil. Ministério da Saúde. Portaria nº 2.436, de 21 de Setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde. Diário Oficial da União. 22 Set 2017.; the decision taken by the Tripartite Inter-Management Committee (CIT) to interrupt federal funding of the Brazil Popular Pharmacy Program’s own network, among other challenges for the health sector (http://conselho.saude.gov.br/ultimas_noticias/2017/04abr18_Presidente_CNS_manifesta_Fim_rede_propria_farmacia_popular.html).
Considering these aspects, the relationship between government representatives and social counselors in the Council’s plenary became more conflicting. The former started to criticize the Collegiate’s strategy, calling it combative, risky, and not much resolute, and attributing the adoption of this tactic mostly to the government change, given that there were setbacks in the previous government and the CNS continued to have a negotiating attitude, as reported by the interviewees.
[...] I question some of the positions of the CNS itself, and I tell the president: “Be careful with the strategy you’re using to not throw the baby out with the bathwater, because this can lead to the strengthening of the idea of ‘to be against everything’. Adding this up, it leads to a gradual destruction of the SUS. Soon we’ll lose the ability to react.”(Interviewee No. 2 - Government State-owned Representative)
[...] the political discussion has radicalized a lot with the rise of these new people who are in the government with an adverse position to that of the Council [...]. This has greatly weakened our relationship.(Interviewee No. 2 - Government State-owned Representative)
[...] It’s like this: “I’m against such a thing because it was the Minister who ordered it to be done [...].” I won’t discuss the basics questions because I stand against everything. I think this is a serious problem that doesn’t give a solution for the country’s basic health problems.(Interviewee No. 1 - Market Societal Representative)
[...] People think that presenting a rejection note or giving a recommendation will build something [...]. And then, when you see the PEC of the National Budget Freeze, [you realize that] it’s a serious threat to the healthcare. So, how are we going to face this? Do you think we’ll be able to win this [battle] with just a brief repudiation note?(Interviewee No. 3 - Government State-owned Representative)
The inherent tension of the dispute of conflicting projects between the CNS and the MH in the Council’s plenary at that time was worsened by the withdrawal of the state and municipal managers’ representatives. Compelled by the financing difficulty, burdened with responsibilities for the health care of the population of their territories, and attracted by the possibility of having a more complacent attitude in the implementation of the constitutional SUS after the reformulation of the PNAB 2017, these representatives circumstantially backed down in defense of the project of the constitutional SUS.
The Ministry’s representatives on the Council adopted a discourse more focused on flexibilization of the SUS’s principles in the face of the MH’s offensive to weaken the public health system and strengthen the market. Thereby, the Ministry’s mercantilist project acquires a milder form in the Council due to the inflexibility of social actors to the Government’s agendas for health. The following speech extract from a Government State-owned Representative denotes an attempt to adjust the CNS’s deliberations to the State interests.
[...] There are resolutions approved by the CNS here, but when they got there, the Minister said: I will not approve them! And I replied: Minister, what can we agree on? And I brought them back to them, and then I said: “Look, we can have the MH’s approval if we change this part. Do you think it is possible? That’s the negotiation. We managed to make several changes, but there are others that we couldn’t change either in the Council or in the Ministry, and which until today are still without approval.(Interviewee No. 3 - Government State-owned Representative)
The CNS was characterized as a space for articulation of allied entities around the resistance to the SUS’s deconstruction in the analyzed period. If, on the one hand, the adoption of a coping attitude worked as an obstacle to a broader implementation of the mercantilist project in the health sector, on the other, it led the CNS performance to become innocuous in the political game. The interviewees’ speech extracts below indicate the narrow limit for the Council’s political action to affect health policy.
[...] the CNS plays an important role, particularly in this confrontation [...]. If it weren’t for the CNS, everything would be easier for those who think as an anti-SUS. The CNS manages to impose some limits on these attempts to strongly modify the SUS, and this is the Council’s merit [...]. If it acted with a little more political judgment, it might have more strength. However, it does it in a way that it loses the battle alone, it loses the allies.(Interviewee No. 2 - Government State-owned Representative)
[...] Beyond doubt, social control was and still is an important part in the construction of SUS [...]; and especially now, at this extremely adverse moment in the system’s defense process. I’d say today is the biggest point of resistance that we have on the Esplanade, in the country, given everything that is happening in Brazil.(Interviewee No. 18 - Social Societal Representative)
According to the political principle, keeping a certain degree of opacity around the possibility of winning or losing is a necessary reserve for the permanence of both actors in the game, since remaining outside or indifferent in disputes is a strategic measure in case of unfeasibility to win1010 Testa M. Pensamento estratégico e lógica de programação. O caso da saúde. São Paulo, Rio de Janeiro: Hucitec, Abrasco; 1995.. In this perspective, the performance of the CNS in the construction of the health policy started to be disregarded by the MH because of the following factors: the social actors’ deliberate action to assume the Collegiate’s direction, occupying strategic spaces in the Council’s activities so that the deliberations of the CNS would be consonant with the positioning of these actors33 Silva BT, Lima IMSO. Análise política da composição do Conselho Nacional de Saúde (2015/2018). Physis. 2019; 29(1):1-25.; the CNS having assumed an intolerant political posture in defense of the constitutional SUS; and the Federal Executive of Health having assumed a management model that is not very prone to the participation of society. Cortes’s research11 Côrtes SMV. Uma síntese do debate sobre os mecanismos e as dinâmicas participativas no sistema único de saúde. In: Côrtes SMV, organizador. Participação e saúde no Brasil. Rio de Janeiro: Editora Fiocruz; 2009. p. 199-205., which was conducted at the CNS in the context of 2005, revealed that the taking of power in the Council by social actors may have contributed to the Collegiate’s power reduction in the decision-making process.
The boycott of the CNS’s participation by the MH in discussions on agendas impacting health policy in the 2016-2017 period did not hinder the Collegiate from continuing to work in health policy through social, judicial, and parliamentary channels. Undoubtedly, without the support of Collegiate managers - who are the health policy executors, spread throughout Brazil through the health secretaries -, and with the MH efficiently adopting and executing the project change in the health sector, which was focused on the market interests, it became even more remote the possibility of the CNS getting at least fragments of its health project to be taken over and translated by the Brazilian State.
The analysis of the political performance of the CNS in the scope of the Executive (the MH), Legislative (the National Congress), and Judiciary Powers allows us to make some statements. The National Council accumulated political forces and played a counter-hegemonic role within the kernel of the decision-making process, embracing the health project that defends the constitutional SUS. In this way, from its activism through various action fronts, the Council comprehended a political bloc of steady resistance and confrontation within and outside the State, becoming a relevant and fundamental barrier in the national scenario to the process of deconstruction of SUS, despite not having enough power to change the correlation of forces whose vector pointed towards the mercantilist health project.
The Council’s main political action strategy to influence the health policy construction was to mobilize different power resources to expand its power in the kernel of the health policy’s decision-making process. Through the social route, the Council mobilized society with petitions, as well as summoned health Councils, entities, social movements, and national representations to conduct public acts. Through the parliamentary route, in turn, the CNS identified allies and opponents of the SUS and built alliances within the National Congress to gather political power.
The performance of the Collegiate body before the Judiciary and Executive Powers underwent changes in the analyzed government periods. During the President Dilma Rousseff’s government (2014-2015), the CNS did not judicialize the health policy. The possible negotiation was directly made with the Federal Executive, although the health project materialized by the Ministry of Health differed from that defended by the Council. Afterwards, when the Federal Government and the Ministry of Health openly accepted the mercantilist health project for the sector, the Council changed its political approach. Therefore, besides acting in the mobilization and building of alliances, the Council activated the Judiciary, moving from critical alignment to complete opposition, until reaching its neutralization, in the face of the Ministry of Health’s boycott regarding the CNS participation in health policy agendas discussions in the period 2016-2017.
In the face of the strategic position of the CNS in the political arena of health in Brazil, it is imperative to conduct further studies of political analysis that can show the performance of both the CNS and collective social actors who dispute the direction of health policy in the sphere of the Republic Powers, particularly with regard to the current busy situation, marked by the rapid succession of facts and political clashes, which can give rise to significant changes in the health sector.
- Temoteo-da-Silva B, Lima IMSO. Political analysis of the National Health Council's performance in the construction of health policy in Brazil in the period 2014-2017. Interface (Botucatu). 2022; 26: e210582 https://doi.org/10.1590/interface.210582
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- Publication in this collection
18 Feb 2022
- Date of issue
26 Aug 2021
01 Oct 2021