Abstract

The World Bank has been influencing the direction of the Brazilian National Health System over the last 30 years. This study analyzed the projects funded by the World Bank for the health sector in Brazil between 2003 and 2014. A documentary analysis was conducted on projects financed by the World Bank for the Brazilian health sector in the three government spheres, categorized according to content analysis. Of the 174 projects financed in the country, 31 contemplated the health sector in their composition, with 64.53% of these being signed with the state governments. Most of the health projects were signed in the second Lula government and the main structuring themes were: Human Development and Gender, Public Sector Management and Private Sector Development. The strategic displacement of the World Bank, which approached the state and municipal governments, was evident since the second administration of the Lula government. This movement denoted the World Bank’s ability to identify global changes in progress, especially regarding the geopolitical and economic scenario. The results show that the World Bank increased its interest in the Brazilian health sector and that the proposals contributed to boost the principles of state reform in the country.

Keywords:
International Bank for Reconstruction and Development; Health Policy; Brazilian National Health System

Introduction

The World Bank influences the Brazilian National Health System (SUS) for nearly 30 years, since the establishment of the Brazilian healthcare service. The World Bank, created during the Bretton Woods Conference held in 1944, had as its first mission act as multilateral institutional framework to ensure social, economic and financial stability post-World War II. Its main goal was to ensure the possibility of international trade activity, without restraints, obstacles or borders (Lichtensztejn; Baer, 1987LICHTENSZTEJN, S.; BAER, M. Fundo Monetário Internacional e Banco Mundial: estratégias e políticas do poder financeiro. São Paulo: Brasiliense, 1987.). Since then, several researchers (Mattos, 2001MATTOS, R. A. As agências internacionais e as políticas de saúde nos anos 90: um panorama geral da oferta de ideias. Ciência e Saúde Coletiva, Rio de Janeiro, v. 6, n. 2, p. 377-389, 2001.; Pereira; Pronko, 2014PEREIRA, J. M. M.; PRONKO, M. (Org.). A demolição de direitos: um exame das políticas do Banco Mundial para a educação e a saúde: 1980-2013. Rio de Janeiro: Escola Politécnica de Saúde Joaquim Venâncio , 2014.; Rizzotto, 2000RIZZOTTO, M. L. F. O Banco Mundial e as políticas de saúde nos anos 90: um projeto de desmonte do SUS. 2000. Tese (Doutorado em Saúde Coletiva) - Universidade Estadual de Campinas, Campinas, 2000.) have been working in an attempt of comprehending the effects of such relation to the healthcare policies in Brazil since the early 1990s, when the creation of SUS materialized the right to health.

Seeking to adjust its modus operandi to the geopolitical rearrangement imposed by the Cold War (Fiori, 2004FIORI, J. L. O poder americano. Petrópolis: Vozes , 2004.; Lichtensztejn; Baer, 1987LICHTENSZTEJN, S.; BAER, M. Fundo Monetário Internacional e Banco Mundial: estratégias e políticas do poder financeiro. São Paulo: Brasiliense, 1987.), in addition to overcoming the capitalist crisis, the World Bank started a new cycle in its history from the 1980s on, moving to intervene on the macroeconomic balance of in-debt countries, along with opening credits lines towards social areas. The body offered, to the in-debt countries, loans for structural adjustment provided they agreed with the creditors’ demands, with the premise of reinserting them in the international market (Almeida, 2014ALMEIDA, C. O Banco Mundial e as reformas contemporâneas do setor saúde. In: PEREIRA, J. M. M.; PRONKO, M. (Org.). A demolição de direitos: um exame das políticas do Banco Mundial para a educação e a saúde: 1980- 2013. Rio de Janeiro: Escola Politécnica de Saúde Joaquim Venâncio, 2014. p. 183-232.).

A growing subservience of several emergent countries ensued the expansion of the bank scope, by the implementation of reforms in the public sector in accordance to the neoliberal prerogatives (Pereira, 2017PEREIRA, J. M. M. Metamorfoses da política de ajuste estrutural do Banco Mundial (1980-2014). Sociologias, Porto Alegre, v. 19, n. 44, p. 390-422, 2017.). The World Bank expanded its role as a political, intellectual and financial actor (Pereira, 2016PEREIRA, J. M. M. Assaltando a pobreza: política e doutrina econômica na história do Banco Mundial (1944-2014). Revista de História, São Paulo, n. 174, p. 235-265, 2016.), by focusing on social policies aiming to “fight poverty” (Rizzotto, 2000RIZZOTTO, M. L. F. O Banco Mundial e as políticas de saúde nos anos 90: um projeto de desmonte do SUS. 2000. Tese (Doutorado em Saúde Coletiva) - Universidade Estadual de Campinas, Campinas, 2000.; Ugá, 2008UGÁ, V. D. A questão social como “pobreza”: crítica a conceituação neoliberal. 2008. Tese (Doutorado em Ciências Humanas) - Instituto Universitário de Pesquisas do Rio de Janeiro, Rio de Janeiro, 2008.).

During the 1990s, the adoption of neoliberalism by the federal governments led to the State Reform agenda. Strongly influenced by the Washing Consensus principles -which resulted in ten measures of macroeconomic adjustment for peripheral countries (Rizzotto, 2000RIZZOTTO, M. L. F. O Banco Mundial e as políticas de saúde nos anos 90: um projeto de desmonte do SUS. 2000. Tese (Doutorado em Saúde Coletiva) - Universidade Estadual de Campinas, Campinas, 2000.) -, Brazil started the reform in 1989, by adopting platforms such as privatization, outsourcing, deregulation, and reduction of the state interference in the economy (Bresser-Pereira, 2000BRESSER-PEREIRA, L. C. A reforma gerencial do Estado de 1995. Revista de Administração Pública, São Paulo, v. 34, n. 4, p. 7-26, 2000.). Such reconfiguration of the state role had a direct impact on social policies, also especially causing the healthcare policies to conflict with the sanitary reform movement.

While the SUS is recognized as the greatest social Brazilian reform, grounded on the principles of universality, equality and integrality (Alves, 2005ALVES, V. S. Um modelo de educação em saúde para o Programa Saúde da Família: pela integralidade da atenção e reorientação do modelo Assistencial. Interface: Comunicação, Saúde, Educação, Botucatu, v. 9, n. 16, p. 39-52, 2005.), its trajectory was marked by tensions and conflicts that strayed it from the radical democracy of its original conception (Bahia, 2018BAHIA, L. Trinta anos de Sistema Único de Saúde (SUS): uma transição necessária, mas insuficiente. Cadernos de Saúde Pública, Rio de Janeiro, v. 34, n. 7, e00067218, 2018.; Kruger, 2014KRUGER, T. R. SUS: da perda da radicalidade democrática ao novo desenvolvimentismo. Revista Katálysis, Florianópolis, v. 17, n. 2, p. 218-226, 2014.). The restraints imposed by the interests of the power structures prevented the system from consolidating, given that the universal right to health is not part of liberalism and health is a consumer good, offered by the market (Rizzotto; Campos, 2016RIZZOTTO, M. L. F.; CAMPOS, G. W. S. O Banco Mundial e o Sistema Único de Saúde brasileiro no início do século XXI. Saúde e Sociedade , São Paulo, v. 25, n. 2, p. 263-276, 2016.).

From the 2000s on, the reconfiguration of the global political powers caused a theoretical effort seeking to understand the limits between the capitalist interests and the democracy in modern days. In our case, we need to comprehend the existing relations between the economic development and the maintenance of social rights in Brazil (Bahia, 2018BAHIA, L. Trinta anos de Sistema Único de Saúde (SUS): uma transição necessária, mas insuficiente. Cadernos de Saúde Pública, Rio de Janeiro, v. 34, n. 7, e00067218, 2018.).

The arrival of the Workers’ Party (Partido dos Trabalhadores - PT) to the federal government, by the election of President Lula in 2002, brought a new perspective to the building of a state project, now based on the radicalization of social rights and overcoming inequalities. As for the healthcare policies, the constitutional SUS had an expectation of finally becoming a reality. However, despite great advances (especially in social areas), what followed was the maintenance of liberal cutbacks, regulated by the adoption of three macroeconomic pillars, primary surplus, inflation targeting, and a floating exchange rate, what, in Lula’s second term and Dilma’s first, mismatched the expectation of the progressive sectors in society.

In face of a context full of contradictions, as it was the case with the Brazilian health system during the 12 years the PT’s terms lasted, this article sought to analyze the projects funded by World Bank in the health sector between 2003 and 2014.

Method

In the analysis of healthcare public policies, qualitative methodologies are structuring a great deal of the knowledge production, given that such approach “applies to the study of history, relations, representations, beliefs, perceptions and opinions” (Minayo, 2014MINAYO, M. C. O desafio do conhecimento: pesquisa qualitativa em saúde. 13. ed. São Paulo: Hucitec, 2014., p. 57). In this work, politics are a fundamental trigger for changes in social relations and, in this perspective, we understand that when one takes interest in analyzing politics, then one is, in a way, making or engaging in politics - meaning one is already an analyst of the political environment (Baptista; Mattos, 2011BAPTISTA, T. W. F.; MATTOS, R. A. Sobre política (ou o que achamos pertinente refletir para analisar políticas). In: MATTOS, R. A.; BAPTISTA, T. W. F. (Org.). Caminhos para análise das políticas de saúde. Rio de Janeiro: Cepuerj, 2011. p. 52-91.).

Setting the analyzed universe is fundamental and must consider the context, the use and role of documents, given that these are means to understanding and deciphering a specific case in a life history or process (Flick, 2009FLICK, U. Introdução à pesquisa qualitativa. 3. ed. Porto Alegre: Artmed, 2009.). This study comprehends the World Bank and the three government levels in Brazil, which requested funding for projects contemplating the health sector - a terminology adopted by the bank in its documents to refer to health services in the country.

The period in this work comprehends the timeframe between 2003 and 2014, in which the Workers’ Party ran the country in three consecutive terms. The “Coligação Lula Presidente: PT/PCdoB/PL/PMN/PCB” political alliance ran the first term (2003-2006); the “A Força do Povo PT/PRB/PCdoB/PL” political alliance ran the second (2007-2010), and the “Para o Brasil Seguir Mudando PT/PMDB/PDT/PSB/PR/PRB/PTN/ PSC/PTC/PCdoB” political alliance ran the third term (2011-2014).

We used documentary research to collect data. It enables “identifying factual information in the documents based on questions or hypothesis of interest” (Lüdke; André, 1986LÜDKE, M.; ANDRÉ, M. E. D. A. Pesquisa em educação: abordagens qualitativas. São Paulo: EPU, 1986., p. 38). In addition, this methodology allows reaching conclusions about specific questions regarding certain research problems.

The selection of analyzed documents is not random, depending on the problems for needing an answer. The research relies on the objects and hypothesis over the theoretical framework: to identify the projects financed in Brazil, we conducted a detailed research in the World Banks’s website. First, we accessed the “Projects & Operations” section. There, we could find the links leading to all countries with ties to the body. In the Brazil section, we could find all projects contracted by the country. According to this study’s objective, we filtered by “Health Sector,” identifying all projects of interest falling under the timeframe. Lastly, once we identified the projects, we were able to obtain the documents signed by the parties.

To identify the subjects, relations and contradictions related to the conformation of public policies, this work conducted a qualitative analysis of data. We used the Content Analysis (Bardin, 2011BARDIN, L. Análise de conteúdo. 6. ed. São Paulo: Edições 70, 2011.) as the methodological strategy.

The method allows us to find in-depth meanings present in the communications field, subjacent to the surface of the message issued (Oliveira, 2008OLIVEIRA, D. C. Análise de conteúdo temático-categorial: uma proposta de sistematização. Revista Enfermagem UERJ, Rio de Janeiro, v. 16, n. 4, p. 569-576, 2008.); or, also, “produce conclusions from a text to its social context in an intended manner” (Bauer, 2002BAUER, M. W. Análise de conteúdo clássica: uma revisão. In: BAUER, M. W.; GASKELL, G. (Org.). Pesquisa qualitativa com texto: imagem e som. Petrópolis: Vozes, 2002. p. 189-217., p. 191).

Then, we conducted a pre-analysis, in which we read the documents and explored the material through selected and categorized excerpts according to the descriptions and/or remarks they had concerning the objective of the study. This is why Kripka, Scheller and Bonotto (2015KRIPKA, R. M. L.; SCHELLER, M.; BONOTTO, D. L. Pesquisa documental na pesquisa qualitativa: conceitos e caracterização. Revista de Investigaciones Unad, Bogotá, DC, v. 14, n. 2, p. 55-73, 2015.) argue that, during the analysis process, it is fundamental to comprehend who produced the document, for who it was made, and the intent in its elaboration. The authors found this analytical movement to be fundamental, given that the documents should not be understood and analyzed as a single pack of information, but rather as a way of contextualizing data. Thus, the documents are communicative devices, methodologically developed in the production of facts versions.

Characteristics of the health sector projects funded by the World Bank in Brazil

From 2003 to 2014, the World Bank offered lines of credit to 174 Brazilian projects. Of these, 31 contemplated the health sector.

For the World Bank, the health sector is a strategic area for its credit operations. In addition to favoring the expansion of the medical-industrial complex, and the draining of public funds, its recommendations, in this regard, go towards the reduction of public health policies aiming to fight poverty. The basis for the bank definition of health is the same as the World Health Organization’s (WHO), understanding it as a state of complete physical, mental and social welfare - and not merely the absence of disease or infirmity (World Bank, 2016aWORLD BANK. Sector taxonomy and definitions. Washington, DC, 2016a.).

Three axes structure the sector with the purpose of financing by the World Bank: (1) health; (2) health facilities and construction and, (3) public administration - health (World Bank, 2016aWORLD BANK. Sector taxonomy and definitions. Washington, DC, 2016a.). These three axes have a coded range of activities that expose the goals and priorities of the World Bank with the intent of enhancing the quality and availability of data for monitoring, reports, and decision-making process concerning the sector (World Bank, 2016bWORLD BANK. Theme taxonomy and definitions. Washington, DC, 2016b.).

Table 1 shows that eight projects only had the federal government as borrower in the period (25.8%). Of the remaining contracts, state governments correspond to 64.52%, with 20 projects; municipal governments correspond to 6.45%, with two projects, and the Federal District corresponds to 3.23%, with one project.

These data point to a change in the allocation of World Bank resources in the financing of projects in Brazil. While during the 1990s the lines of credit mostly targeted the federal level, boosting the state reform and tensioning the principles and directives of the newly created SUS (Rizzotto, 2000RIZZOTTO, M. L. F. O Banco Mundial e as políticas de saúde nos anos 90: um projeto de desmonte do SUS. 2000. Tese (Doutorado em Saúde Coletiva) - Universidade Estadual de Campinas, Campinas, 2000.), during the first decade of the 20^th century it assumed a different outline, given that the credit shifted towards projects conducted by states and municipalities. According to Rizzotto and Campos (2016RIZZOTTO, M. L. F.; CAMPOS, G. W. S. O Banco Mundial e o Sistema Único de Saúde brasileiro no início do século XXI. Saúde e Sociedade , São Paulo, v. 25, n. 2, p. 263-276, 2016.), the reason for the shift is a greater autonomy of the public agents in this power level.

The capillarization of financial resources from the World Bank strongly contributed for the dissemination of the Bank’s ideals, such as the reduced and focused comprehension of the right to health, the governance, efficacy and efficiency concepts, and the semantic change of the universality principle through the proposal of universal coverage (Banco Mundial, 2008BANCO MUNDIAL. Estratégia de parceria com o Brasil 2008-2011. Washington, DC: Banco Mundial, 2008.; Gragnolati; Lindelow; Couttolenc; 2013GRAGNOLATI, M.; LINDELOW, M.; COUTTOLENC, B. 20 anos de construção do sistema de saúde no Brasil: uma análise do Sistema Único de Saúde. Washington, DC: The World Bank, 2013.). Through the contracts, the bank is able to impose to the borrowers its liberal principle, which understands health as a good, rather than as a citizenship right (Gonçalves, 2009GONÇALVES, R. O Banco Mundial no Brasil: da guerra de movimento à guerra de posição: análise do documento Estratégia de Parceria com o Brasil, 2008-2011. Brasília, DF: Rede Brasil, 2009.; Rizzotto; Campos, 2016RIZZOTTO, M. L. F.; CAMPOS, G. W. S. O Banco Mundial e o Sistema Único de Saúde brasileiro no início do século XXI. Saúde e Sociedade , São Paulo, v. 25, n. 2, p. 263-276, 2016.).

The entire technical advisory work at the World Bank is coordinated by the Projects & Operations area. When a borrower applies for a loan, a series of requirements and demands are in place for the projects and programs to comply with the body’s rules. Thus, the composition of proposals may engage a single sector or, also, several areas, being those called multi-sector projects. It is noteworthy that the participation of each sector represents a certain percentage in the project’s final composition, according to the concerned interests and goals.

Contributing to the analysis about the change in the profile of the World Bank’s loans, Gonçalves (2009GONÇALVES, R. O Banco Mundial no Brasil: da guerra de movimento à guerra de posição: análise do documento Estratégia de Parceria com o Brasil, 2008-2011. Brasília, DF: Rede Brasil, 2009.) analyzed the Country Partnership Framework (FY2008 - FY2011) (Banco Mundial, 2008BANCO MUNDIAL. Estratégia de parceria com o Brasil 2008-2011. Washington, DC: Banco Mundial, 2008.). The author argues that, concomitantly to redirecting of federal government resources to the state and municipalities governments, happens the redirecting of the preferential space for political disputes, with the expectation of a greater direct pressure from the Bank over governors and mayors for the implementation of the liberal, deregulation and privatization agendas.

With this, the bank enlarges its array of opportunities, aiming to pressure the state to stay in the track of structural reforms; its tactics seek to produce consensus among the federative entities as to consolidate the peripheral liberal model in the country (Gonçalves, 2009GONÇALVES, R. O Banco Mundial no Brasil: da guerra de movimento à guerra de posição: análise do documento Estratégia de Parceria com o Brasil, 2008-2011. Brasília, DF: Rede Brasil, 2009.).

Regarding the number of projects financed by the World Bank in the health sector, the Chart 1 shows a significant increase during the 12 years the Workers’ Party was in the office, especially during Lula’s second term and Dilma’s first. Matching this tendency, we also see an increase in the volume of resources employed from 2008 on, totaling a little over 8 billion dollars.

Although the financial volume is small in relation to the Brazilian needs for financing, the increase in the projects approved from the second Lula’s term on reinforces the World Bank strategy of getting closer to the subnational instances of government. By getting closer to the administrators who work in these power levels, the World Bank finds fertile ground for spreading its principles (Gonçalves, 2009GONÇALVES, R. O Banco Mundial no Brasil: da guerra de movimento à guerra de posição: análise do documento Estratégia de Parceria com o Brasil, 2008-2011. Brasília, DF: Rede Brasil, 2009.).

In the case of health (which structures itself in a decentralized system), the World Bank relies on the autonomy of local actors to maintain its role as spokesperson of the neoliberal ideal, misleading not only the SUS original concept, but also the very notion of the right to health that grounds the system. Thus, in general, the projects and programs aimed the poorest populations, such as the focusing of actions, access to public services and microcredit offer (Kruger, 2014KRUGER, T. R. SUS: da perda da radicalidade democrática ao novo desenvolvimentismo. Revista Katálysis, Florianópolis, v. 17, n. 2, p. 218-226, 2014.; Ugá, 2008UGÁ, V. D. A questão social como “pobreza”: crítica a conceituação neoliberal. 2008. Tese (Doutorado em Ciências Humanas) - Instituto Universitário de Pesquisas do Rio de Janeiro, Rio de Janeiro, 2008.).

The World Bank agenda for the health sector

From the early 1980’s on, the World Bank launched a new financing product. The loan targeted the materialization of public policies, provided the borrower countries met a series of imposed conditions that sought, basically, changes in the domestic economy - with the purpose of adjusting them to the international context, continuing the payment of foreign debt. The agreement also imposed the reduction of the fiscal deficit, the focusing of public policies in the extreme poverty and the cost control of programs of income distribution (Pereira, 2013PEREIRA, J. M. M. O Banco Mundial e a construção política dos programas de ajustamento estrutural nos anos 1980. Revista Brasileira de História, São Paulo, v. 33, n. 65, p. 359-381, 2013.). All these measures, according to Vilas (2014VILAS, C. M. O Banco Mundial e a reforma do Estado na América Latina: fundamentos teóricos e prescrições políticas. In: PEREIRA, J. M. M.; PRONKO, M. (Org.). A demolição de direitos: um exame das políticas do Banco Mundial para a educação e a saúde: 1980-2013 . Rio de Janeiro: Escola Politécnica de Saúde Joaquim Venâncio , 2014. p. 65-85.), marked the structural adjustment required by the bank, expressed by the encouragement of: the liberalization of international trade; free movement of capital; elimination or reduction of protectionist barriers and of devices of state regulation of economic and financial activity; devaluation of national currency; promotion of exports; major reduction of the public sector deficit. In addition to the reorientation of the social policy towards the primary healthcare and primary education, focusing on sector of extreme poverty.

To categorize the projects based on its “offered ideas” (Mattos, 2001MATTOS, R. A. As agências internacionais e as políticas de saúde nos anos 90: um panorama geral da oferta de ideias. Ciência e Saúde Coletiva, Rio de Janeiro, v. 6, n. 2, p. 377-389, 2001.), the World Bank structured a set of eight themes for the proposals and actions, which should guide the entire framework of the projects. These were: (1) Economic Policy; (2) Environment and Natural Resources Management; (3) Public Sector Management; (4) Finance; (5) Urban and Rural Development; (6) Social Development and Protection; (7) Human Development and Gender, (8) Private Sector Development (World Bank, 2016bWORLD BANK. Theme taxonomy and definitions. Washington, DC, 2016b.).

The themes represented the goals and objectives of activities of interest for the body. In addition, they were tools to seek support for the activities that aim the sustainable development (World Bank, 2016bWORLD BANK. Theme taxonomy and definitions. Washington, DC, 2016b.). As Chart 2 shows, the following are the three main themes present in the health sector projects financed between 2003 and 2014: Human Development and Gender (93.5%), Public Sector Management (61.3%), and Private Sector Development (54.8%).

By analyzing the main themes, we notice their use as devices for the implementation of reforms in the public management, covering, among others, the administrative decentralization, public finances management, tax policy, and legal system reform (Pereira, 2017PEREIRA, J. M. M. Metamorfoses da política de ajuste estrutural do Banco Mundial (1980-2014). Sociologias, Porto Alegre, v. 19, n. 44, p. 390-422, 2017.). The increase of projects during the PT’s terms, the distribution of projects in the subnational levels, and the ideological subtract grounding these themes point, clearly, to the increase in the World Bank political action. In addition to financing the projects, all the three main themes concern the “institutional development,” that is: they have the goal of promoting the restructuration of the public administration in all levels, accelerating the state reform from the three government levels (Pereira, 2017PEREIRA, J. M. M. Metamorfoses da política de ajuste estrutural do Banco Mundial (1980-2014). Sociologias, Porto Alegre, v. 19, n. 44, p. 390-422, 2017.).

“Human Development and Gender” is a theme present in nearly all projects - it is one of the main pillars of thought at the World Bank, grounded in the “personal freedom” logic argued by the Indian economist Amartya Sen (2000SEN, A. A perspectiva da liberdade. In: SEN, A. (Org.). Desenvolvimento como liberdade. São Paulo: Companhia das Letras, 2000. p. 27-50.), one of the main influencers of the directives assumed by the World Bank. Personal merit anchors the perspective of human development. In other words, human development distances itself from the perspective of provision of social rights, having its principle connecting, therefore, the “welfare” image to those of the equal opportunities, without caring for sharing the results. In this context, the central idea in the human capital theory, according to Ugá (2008UGÁ, V. D. A questão social como “pobreza”: crítica a conceituação neoliberal. 2008. Tese (Doutorado em Ciências Humanas) - Instituto Universitário de Pesquisas do Rio de Janeiro, Rio de Janeiro, 2008.), understands the labor of individuals as a form of capital, and their education as the result of a deliberate decision of investment for developing such human capital.

According to the ideas presented by Sen (2000SEN, A. A perspectiva da liberdade. In: SEN, A. (Org.). Desenvolvimento como liberdade. São Paulo: Companhia das Letras, 2000. p. 27-50.), the economic and social development does not relate only to the growth in Gross Domestic Product. It is also related to the development of people capabilities, thus understood as a required device for reaching individuals self-goals and objectives. Such conception has in its core, according to the author, the premise of freedom - a fundamental element that would give people the opportunity of writing their histories in the personal context, as well as in the market or public level, always starting with an individual initiative.

The World Bank refreshed the “human capital” narrative for the health and education areas in the 1990s, according to the directives defended by the Washington Consensus. The documents issued by the World Bank in this period highlighted the separation between social and economic policies. They reproduced the logics that overcoming poverty would depend on personal efforts, once that a large range of possibilities was available for the individuals to develop their capabilities and, consequently, reach their goals strictly through their own merit (Pereira, 2016PEREIRA, J. M. M. Assaltando a pobreza: política e doutrina econômica na história do Banco Mundial (1944-2014). Revista de História, São Paulo, n. 174, p. 235-265, 2016.).

The “Public Sector Management” theme appeared in 19 of the 31 analyzed projects. As per two documents addressed to the SUS in the period (Banco Mundial, 2008BANCO MUNDIAL. Estratégia de parceria com o Brasil 2008-2011. Washington, DC: Banco Mundial, 2008.; Gragnolati; Lindelow; Couttolenc, 2013GRAGNOLATI, M.; LINDELOW, M.; COUTTOLENC, B. 20 anos de construção do sistema de saúde no Brasil: uma análise do Sistema Único de Saúde. Washington, DC: The World Bank, 2013.), the World Bank assumes that the SUS, despite achieving relevant progresses for the Brazilian health, is a system that suffers from the lack of efficiency and efficacy in its management. Thus, the bank argues that failing to optimizing the available resources is inherent to the public level, which directly causes a failure in reaching expected results.

This perspective lies in the “minimal state” idea, defended by the neoliberals, gaining a strategic standing in achieving the hegemonic interests of capitalism (Duménil; Lévy, 2005DUMÉNIL, G.; LÉVY, D. O neoliberalismo sob a hegemonia norte-americana. In: CHESNAIS, F. (Org.). A finança mundializada. São Paulo: Boitempo, 2005. p. 85-108.). Thus, a window of opportunity emerges generalizing the privatization of public services; although its creators do not admit such strategy. They start to associate the provision of rights to the private sector, devised under the efficiency of services prerogative and welfare pluralism (Pereira, 2004PEREIRA, P. A. Pluralismo de bem-estar ou configuração plural da política social sob o neoliberalismo. In: BOSCHETTI, I. et al. (Org.). Política social: alternativas ao neoliberalismo. Brasília, DF: UnB, 2004. p. 135-159.). Thus, according to Pereira (2004)PEREIRA, P. A. Pluralismo de bem-estar ou configuração plural da política social sob o neoliberalismo. In: BOSCHETTI, I. et al. (Org.). Política social: alternativas ao neoliberalismo. Brasília, DF: UnB, 2004. p. 135-159., the central question is not about the reduction of the state presence in the building of social policies, but, rather, of its private role in ordering the maintenance of established social rights.

In this sense, we emphasize that the reconfiguration of the social policy, subjected to the demands of fiscal adjustment, plans it to be an expenditure, assuming a patronizing nature, and redefined as transitory (Pereira, 2016PEREIRA, J. M. M. Assaltando a pobreza: política e doutrina econômica na história do Banco Mundial (1944-2014). Revista de História, São Paulo, n. 174, p. 235-265, 2016.) - despite many progresses at the federal level and the fact that state reform followed its path finding in the management of strategic services a way of reaching its objectives. The developmentalism model gradually incorporated throughout the three Workers’ Party terms could not rupture from the 1990s neoliberal policy. It granted concessions to the elites and to conservative power structures instead, subjecting social policies to the liberal perspective, whose objective does not aim the extension of rights, but rather the reduction in their offer, and the focusing of its products, set to minimize the vicious effects of capitalism.

As for the “Private Sector Development” theme, we found that more than half of projects presented it as one of their core pillars, corroborating the liberal agenda of minimizing the state proposed by the World Bank. The bank sees, in the cutback policies towards social areas (such as health), a very profitable market, which drains the public funds towards the medical-industrial health complex (Bahia, 2018BAHIA, L. Trinta anos de Sistema Único de Saúde (SUS): uma transição necessária, mas insuficiente. Cadernos de Saúde Pública, Rio de Janeiro, v. 34, n. 7, e00067218, 2018.; Mendes, 2014MENDES, A. O fundo público e os impasses do financiamento da saúde universal brasileira. Saúde e Sociedade, São Paulo, v. 23, n. 4, p. 1183-1197, 2014.). In this context, along with the settling of the debate concerning the economic development of the country, are the reforms and interests of the capital - among them, the narrative of privatization of public services (Kruger, 2014KRUGER, T. R. SUS: da perda da radicalidade democrática ao novo desenvolvimentismo. Revista Katálysis, Florianópolis, v. 17, n. 2, p. 218-226, 2014.).

Among the chances experienced by the social policies, one of the most remarkable ones was the increasingly strong presence of the third sector in its actions along with the public level. The most common hypothesis in the dominant economic circles at the time was that these civil society arrangements, manifested in diverse ways, optimized the duties of the “public,” by working in partnership with the third and the private sector. The growth of the third sector was overwhelming during the 1990s, receiving billions of dollars during that period. Thus, what happened in the 1980s first half was the combination of two agendas: one that valued the articulation among the public power, the private and third sectors in the fight against poverty; and a second, that valued the power concentration and pro-privatization, while despising the exercise of democracy (Pereira, 2013PEREIRA, J. M. M. O Banco Mundial e a construção política dos programas de ajustamento estrutural nos anos 1980. Revista Brasileira de História, São Paulo, v. 33, n. 65, p. 359-381, 2013.). In this context, Pereira (2017PEREIRA, J. M. M. Metamorfoses da política de ajuste estrutural do Banco Mundial (1980-2014). Sociologias, Porto Alegre, v. 19, n. 44, p. 390-422, 2017.) argues that the relation of the World Bank to the national and subnational governments must not be understood unilaterally, as a mere external imposition, but rather as a complex and growing network involving national and international, public, private, non-governmental, philanthropic and businesses agents. The author argues that the discourse and the practices by the World Bank seek to minimize conflicts between domestic competitors and consolidate power stands and its own ideological beliefs, as to establish mutual worldviews and interests.

Final remarks

This work identified and characterized the projects financed by the World Bank for the Brazilian health sector during the 12 years the Workers’ Party ran Brazil. We found that the body kept its influence, acting not only as a creditor, by financing projects in the health sector, but also performing the role of a political actor, by approaching federative entities and spreading the neoliberal ideals, providing advising for the projects under contract.

From the identified projects, we could see the strategic shift of the World Bank, approaching the subnational instances - especially from the second term of President Lula on. Despite the low volume of loans, the World Bank benefits from a respectful technical image to boost the spreading of its ideas and directives (now closer to the states and municipalities), in addition to pressuring the federal government towards adopting a liberal cutback agenda.

This move showed the ability of the World Bank in identifying the ongoing global changes, especially those caused by the realigning of power in the world’s economic and geopolitical settings. This enabled the body to shape its acting in the world for over 70 years now, in the pursue of its economic liberalization, privatization agendas, focusing on social programs and reducing the state - mostly in the countries at the margins of capitalism, as is the case with Brazil.

Mainly in Brazilian states, the health sector appeared significantly less in state-proposed projects. The hypothesis for these findings is that the bet on multi-sector projects would align with the interest for the management of public services, more than really for the development of these areas.

Thus, a connection between the political and ideological agenda of the World Bank and its sectorial investment in programs increasingly capillarized exists. When observing the most prevalent themes, we see the emphasis of the narrative directed to the “development” term, only reached through the investment in the human capital, in privatization, and in the increasingly strict control of management. That is because, in numerous analysis of the Brazilian public services, the World Bank always emphasize the inefficiency and inefficacy in expenditures.

While we recognize the progress in social policies between 2003 and 2014, the Lula and Dilma terms did not stray from the liberal agenda - both in the economy, maintaining their choice for the three macroeconomic pillars, and in the social rights. Concerning health, they did not solve the chronic financing issue, imposing severe restraints to the system, which remains distant from its original conception. In addition, they provided room for the exponential growth of the economic-industrial health complex, which largely benefited from tax exemption, tax incentives, precarization of the SUS, privatization of the healthcare services management, among other measures.

We must emphasize that the work of the World Bank in Brazil does not happen unilaterally, but rather is a result of a power network that involves several actors, from international bodies that dictate the market rules to small non-governmental organizations that engage in bids to manage the several instances of public service. For this power group, the conception of the right to health as established in the Brazilian constitution is unacceptable. They rather see health as a great business, capable of opening different markets and mobilizing great deals of businesses. From this perspective, a public health system would be responsible for providing poor service, restricted to marginalized populations or complementary to private services, inverting the constitutional logic in those health sector domains less attractive to the market.

Thus, we conclude that the World Bank increased its interest for the Brazilian health sector in the analyzed period and that the offers made by the bank contributed to boost the principles of state reform in Brazil. By following this path, the SUS will remain presenting a series of circumstances and risks that may be crucial for its survival. A system aiming the poor, with a minimal cost-oriented services offer, straying from the universality ideal may prevail.

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