This study aims to reflect about the current situation in the Brazilian Unified Health System (SUS - Sistema Único de Saúde), mainly in view of international determinations set by the World Bank (WB). To this end, it should be noted that the neoliberal direction taken by Brazilian politicians has gained momentum, mainly in the 1990s, due to a series of measures focused on opening the country’s borders to the international capital by offering tax exemptions to multinationals, as well as on privatizing state companies, on encouraging the indiscriminate use of imports as price control mechanism and on giving priority to the economic sphere at the expense of social policies. This process was named “counter-reform” by Behring (2003BEHRING, E. R. Brasil em Contra-reforma: desestruturação do Estado e perda de direitos. São Paulo: Cortez, 2003.), and it went against the philosophy guiding the 1988 Brazilian Federal Constitution (FC).

The 1989 Washington Consensus was the formal starting point for the Brazilian insertion in the neoliberal dynamics, which linked Brazil’s international relationships to guidelines of financial organizations such as the WB and the International Monetary Fund (IMF). According to Correia (2005CORREIA, M. V. C. 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 (Doutorado em Serviço Social) - Universidade Federal de Pernambuco, Recife, 2005.), these guidelines significantly affected SUS, since they ruled the health systems of backward capitalist countries according to protocols set by the neoliberal order. Two documents have significantly marked the beginning of this process in Brazil: Brasil, novo desafio à saúde do adulto/Brazil, a new challenge for adult health (BANCO MUNDIAL, 1991), which presented fiscal concerns with the public health proposal addressed in the 1988 Federal Constitution, and Relatório sobre o Desenvolvimento Mundial de 1993: investindo em saúde/1993 World Development Report: Investing in Health (BANCO MUNDIAL, 1993), which emphasized the so-called “cost-effectiveness logic” and advocated for a health system capable of offering some essential services for the poorest population and of providing the remaining services in partnership with the private sector.

These guidelines have taken SUS implementation away from its original proposal in several points. One of the main bottlenecks resulting from this dynamics lied on underfinancing the system due to legislative-judicial conflicts about the provision of specific resources to health, and to investment levels that were always lower than the original claim, which was supposed to reach 10% of the Gross Domestic Product (GDP). It is well known that the mechanism underfinancing public social policies, mainly social security (health, social insurance and social assistance), has been subjected to the untying of revenues allocated to primary surplus and, consequently, to the payment of interest on the Brazilian public debt (SALVADOR, 2008SALVADOR, E. Fundo público no Brasil: Financiamento e destino dos recursos da seguridade social (2000 a 2007). Tese (Doutorado em Serviço Social) - Instituto de Ciências Humanas Universidade de Brasília, Brasília, 2008.; MENDES, 2013MENDES, A. The long battle for SUS funding. Saúde Soc, v. 22, n. 4, p. 987-993, 2013.). This mechanism results from a historical dependent capitalism formation process that, together with other elements, marks a long history of social policies that were relegated to a second level.

This counter-reform process gains momentum in the current context again and, as it never ceased to be, this process develops under the leadership of the World Bank, which prevaricated in the report discussed in Congress, in April 2019 (BANCO MUNDIAL, 2019), when it attributed the core of some real issues faced by SUS to the technical inefficiency of its management. By doing so, this report perpetuated the discourse in place since the aforementioned documents from the 1990s. SUS certainly presents management issues that make some actions poorly efficient; however, the core of such issues lies on the neoliberal guidelines that have de-characterized the original SUS concept. This de-characterization is expressed in many ways; among them, one finds the weakening/bureaucratization of social control, the deficient and/or neglected training of new managers focused on SUS logic and, mainly, the underfunding issue. The World Bank conceals (or does not problematize) the fact that many issues faced by SUS (including management inefficiency) result from the neoliberal process, in which the Bank itself plays a leading role in formulating guidelines.

The aforementioned report is an insult to the history of SUS, which involves organization and collective efforts undertaken since the Sanitary Reform Movement. In addition, the report has several theoretical shortcomings that go against and/or that deliberately ignore SUS’s theoretical-methodological framework. For example:

1. 1) It addresses universality as if it was just a universal coverage. However, expanding the universal coverage does not necessarily mean assuring the effective access to healthcare in a resolved, equal and integral way, whenever necessary. Coverage can be restricted to a minimum package of services that can be provided in partnership with the private sector, based on mechanisms that favor such sector (GIOVANELLA et al., 2018GIOVANELLA, L. et al. Universal health system and universal health coverage: assumptions and strategies. Ciênc saúde coletiva, v. 23, n. 6, p. 1763-1776, 2018.).

2. 2) It deepens the defense of basic healthcare in order to implement primary care, and it does not even differentiate one from the other. This perspective “refers to a basic package of essential services and medicines, which are defined in each country and correspond to a selective approach designed to achieve basic universalism in developing countries” (GIOVANELLA et al., 2018GIOVANELLA, L. et al. Universal health system and universal health coverage: assumptions and strategies. Ciênc saúde coletiva, v. 23, n. 6, p. 1763-1776, 2018., p. 1766-1767). This item is articulated to the previous one: universal system x universal coverage. Based on the universal system, primary care should adopt a broad perspective focused on health promotion rather than a biological perspective; it should also be the gateway for users to have access to the most complex healthcare levels, in a structured and resolute way.

3. 3) It ignores the meaning of the Sanitary Reform carried out in the 1980s, which advocated for the transformation of both Brazilian health system and society; in its turn, this process implied greater articulation with other social complexes, mainly with the concept of social security.

4. 4) It broadens the private logic space. According to a study conducted by the World Bank in 2017, relatively well-paid health professionals are not very productive; this statement reinforces typical mechanisms adopted by the productivist / private logic to control the work force. In addition, the study advocates for the adoption of new management models based on Social Organizations, as well as for greater articulation between the public and private sectors (WORLD BANK, 2017). It is noteworthy that this logic is functional to the universal health coverage dynamics, thus ratifying a character contrary to the Brazilian Health Reform proposition.

5. 5) It ignores mechanisms focused on untying social security revenues that have historically fed the Brazilian public debt. It does so to enable the accelerated reproduction of capital, which is nourished by the conversion of public fund resources into financial capital. This process feeds back speculations and accelerates capital rotation in its different forms, in the constant struggle to mitigate the contradictions and crises inherent to capitalism.

6. 6) It ignores social participation in health, because it takes the population away from the process and because its results do not take into consideration the important role played by this principle in the system management process.

What is underway is even more offensive if one takes into account that the report is under discussion in the Brazilian parliament in the very same year when the country addresses the course to be taken by SUS at the 16^th National Health Conference (CNS - Conferência Nacional de Saúde), based on the 8^th CNS, which resulted in the systematized SUS proposal. Notwithstanding the important differences, nowadays, the country has been experiencing so many historical setbacks in social rights and policies (labor reform, unrestricted outsourcing, possible welfare reform, financial asphyxia in public education) that the consolidation of the right to health is endangered by similarities between the current and the former struggle agenda.

A historical digression is necessary to help better understanding the size of the challenge faced by the ones willing to defend SUS and its heterogeneous composition, which comprises internal elements and, above all, international leaders. Given the herein addressed prospect of dismantling, one must clearly understand the meaning of SUS and its ideopolitical foundations, as well as the position taken by the capitalist rules adopted by Brazilian policy-makers before the international hierarchical division, in order to face this process in an assertive and organized way. The basic task of (re)building new leaderships and movements in defense of SUS, as well as of participating in the theoretical and political debate, is an important step to fight narratives such as that of the World Bank, in order to avoid the end of SUS as it is now.

References

Datas de Publicação

Histórico