Emerging: let us fight
José da Rocha Carvalheiro
Consultant of Saúde e Sociedade, together with Augusta Thereza de Alvarenga, from 1992 to 1998. Editor of Revista Brasileira de Epidemiologia.
In this volume 14 (issues 1 and 2), of 2005, Saúde e Sociedade goes deeply in the knowledge about the nature of the crisis of financing the Brazilian Health System. In the first issue, re-visited the theme of Social Security and SUS. Author of an article published in the first issue of Saúde e Sociedade, Sólon Magalhães Vianna analyses the parting of Social security resources, after 13 years of his original contribution. This re-visit is enriched by a comment by Eduardo Jorge, a federal legislator, the main responsible for the approval of the Constitutional Amendment 29 that allocates a fixed contribution for SUS from the three levels of government. Eduardo Jorge's article's title, "Seventy cents", gives idea of how much is spent per person, per day, for all SUS activities.
We have called our Special Editorial of that first issue "A dive in a recent past". We aimed to call attention for the risks of writing history of the present. We thought in analyzing how our time carries the bias of activity in the field of formulation and implementation of public policies. In this Special Editorial, calling for fight, we assume our bias, that was already in the former editorial transcribed bellow:
"Solon presents a picture in which SUS is in a double and opposite way. Brazil denies accepting the liberal model for health services as recommended by World Bank: to focus in positive externalities as vaccination and sanitation programs, but leaving individual care for private business; on the other hand, through SUS, the country tries to revert this process. By adopting the universality principle, effective in some developed countries, Brazil goes in another contrary way. Differently than the other countries that adopt this principle, in our country the private expenses with individual care are already larger than the public expenses".
"The original text by Sólon, its re-visit after 13 years, Eduardo Jorge's comments and the reply must be a re-joy for readers of Saúde e Sociedade. Far from de-motivating, they must serve as stimulus for fighting is the last phrase of the debate".
Keep fighting is what we do in this new issue 14/2 of Saúde e Sociedade. Three articles of re-known specialists conduct us to the interpretation of "the hybrid character" which is taking form in an each time greater speed by the Health System constructed in Brazil.
Lígia Bahia presents "Patterns and Changes in the financing and regulation of the Brazilian Health System: impacts on the public/private relations". In this paper she considers that the universal right to the Health System is a rupture with previous public policies of the country. And more, that the acceptance of some government bureaucracy sectors to the new-liberal agenda contributed to the challenge of universalizing the access. Considers the initial division between ANS and the Ministry of Health the adoption of regulation model similar to the one for economic sector, and that the SUS Agenda and the debate about it reinforce the dichotomy between the public and the private. Analyses the demand characteristics and the offer of medical assistance of Social providence in the previous and in the actual SUS model. She also compares the financing in the two models. Considers that social movements and Judiciary Power appear as new social actors in this dispute. She concludes that: "The demarcation of frontiers between the public and the private sector... can contribute to put closer the real country to the formal country".
Rosa Maria Marques and Áquilas Mendes contribute with "SUS and Social Security: in search of the lost link". They analyze the main conflicts in the annual definition of SUS financing: expenses reduction and changes in the definition of "health actions and services". They consider the obstacles to the implementation of the Constitutional Amendment 29, of 2000, and to the financing of Social Security and of SUS due to opposite views from the economic sector of FHC and Lula governments. They analyze the present day tendency to de-attach health and educational resources, violating constitutional rights that establish percentages for contributions of Federal, State and Municipal governments.
José Carvalho de Noronha presents "The directions of the Brazilian State and SUS: Social security as society and state public policy". The author makes a historical revision of the issue of social security since the first mandate of Getúlio Vargas, highlighting the 1988 Brazilian Constitution and the years 1990. Affirms that the speech against social security becomes stronger after the new-liberal winds of Collor mandate, in the beginning of the 1990, recognizing there a "counter sanitary reform". Concludes with an interesting proposal: "I ask myself if this isn't the time to work for the institutional reform of Federal government with the creation of the Social Security Ministry, grouping the Ministers of Health, Providence and Social Development, in order to have a strong ministry with enough resources for a more convincing dialogue of the social sector with the economic sector of government.
Papers presented emphasize a constant conflict between the formulation and the implementation of public policies, not only in the health sector. There are conflicts of interests, defended by collective lines of though with interests in controlling power using knowledge as weapons. They are the so-called "epistemic communities" by some authors. In the case of health there are two of them: the economists and the sanitarians. The first are under leadership of the World Bank and have expression in the economic sector. The others, under leadership of WHO, have voice in the social sector. The articles published highlight the existence of accidents in the process of implementation of public policies in federal level. The reality of health services, de-centralized and not only de-concentrated, permits re-interpretation of the determinants in the central level, executing street level policy. For something must have served the fight of the Brazilian Sanitary Movement, for thousand of municipalities to find a way in the middle of the cipoal.