ON THE 26TH ANNIVERSARY OF THE UNIFIED HEALTH SYSTEM (SUS), Brazil faces a crucial election also for our democracy as for the assurance of the universal right to health. In these 26 years, SUS has been facing an uneven competition with the private health system, which benefits from tax subsidies, purchase of services by the State, and broad social support. The private sector competition in relation to SUS has taken on a new character in recent years, with a growing space being occupied by the misleading proposal of 'universal health coverage'. Behind this expression apparently favorable to the right of all and to public health services is hidden the most insidious form of private interest defense that sees health as mere business. This period prior to elections demands a deep debate on the urgency of the 'universal health coverage' rejection and a clear commitment also to the deepening of the universal right to health as to the improvement of public health services.

Universal right to health is a flag to the Brazilian social movement since the 1970s. Cebes, itself, was born from these struggles in July 1976. The 8^th National Conference on Health held in 1986 was a landmark in the recognition of the right of all persons to health. Driven by the pressure coming from the streets, the 1988 Federal Constitution established the formula: "Health is a right of all persons and a duty of the State" (art. 196). The political transition, however, was characterized by the strong influence of conservative sectors, such as 'Centrão' (political parties with no color, between the left and the right), which managed to keep national institutions behind the progress pace, including health, which continued 'freed to private initiative' (art. 199) as a business and not only as a right. The permanence of a health private sector considered one of the largest ones in the world became the biggest obstacle to the universality completion.

Despite the unfavorable political context and the vetoes of President Collor, Health Organic Law (LOS), passed in 1990, enshrining the universal right to health as SUS first principle. However, as did the Constitution, LOS unfortunately preserved the freedom to operate health as a business: 'health is freed to private initiative' (art. 21). Therefore, since SUS creation, the implementing of the universal right to health has ever had to live together and compete with private market interests, which sees health as a business to be explored also in the provision of services as through the sale of private insurance and health services. All forms adopted by the private sector to negotiate health in Brazil historically benefited from public policies and resources, condition that remains until today. The so-called complementary sector, composed of companies selling health plans, private insurance and health services, had ensured the maintenance of a 100% tax waiver for its customers, a tax incentive ensured by the 1966 Tax Code and bestowed by the Military Dictatorship.

The dispute between the universal right to health and its exploration as a business achieved few years ago a new dimension with the emergence of the 'universal health coverage' proposal led by the Rockefeller Foundation and the World Health Organization (WHO). The proposal, in spite of using the idea of universality, aims to tackle the concept of universal right to health so to strengthen the role of the private sector in the provision of health insurances and services. Such proposal has been strengthened since 2005, when WHO Assembly approved resolution 58.33 - "sustainable health financing: universal coverage and social health insurance". The resolution assumes that there are different sources of financing health systems, followed by their inherent financial risks, what would justify their need for protection through larger participation of private capital. These financing ideas of risk and protection contained in WHO document constitute the core of the private insurance sector, specific financial market segment that moves a fortune by selling coverage or protection to a number of risks to the market.

The 'universal health coverage' formula appears through its crudest form in the document published by the Rockefeller Foundation "Future Health Markets: a meeting statement from Bellagio". This document resulted from a meeting carried out by the Foundation in 2012 and openly advocates that an increasing portion of the population of various countries is willing to pay for health services, and that powerful market actors are available to invest in so that middle and low income countries adopt health systems based on the insurance logic. In the same year of the Bellagio meeting, the United Nations Assembly approved in their 67^th session a resolution pro 'universal health coverage', and Brazil voted for it. Currently, Cebes, the National Health Council and Abrasco are committed with the reversal of this Brazilian vote in the United Nations due to the risk that this position represents to the right of all persons to health. A victory of the idea of 'universal health coverage' or of health as a business means the shortening of the right to health.

In 2013, more than 49 million Brazilians paid for health private insurance, making private expenditure on health equivalent to 53% of all the Country' expenditure with health. This sector earned R$5,417 billion in 2012, according to the National Regulatory Agency for Private Health Insurance and Plans (ANS) site, equivalent to 12.7% more than in year 2011 (R$ 84,657 billion (ANS). Only for comparison terms, the Ministry of Health total expenditure in 2011 was R$62,621 billion, i.e., less R$22,036 billion. It is a sector with strong economic and financial power, which spends billions of dollars a year in advertising that certainly contributed to the result of a recent research revealing that 90% of Brazilians wished private health plans, prioritizing this 'benefit' in the wish list of the population.

Such attraction power exercised by the private health insurance market contributed to that major part of trade unions representativeness in Brazil be attracted by private health insurances and clear from public health. At least since the mid-1970, labor unions have been fighting for a broaden access to the private sector in its collective bargaining with employers' unions. Although fighting for access to private health plans, the vast majority of workers do not have access to them after retiring simply because they can't afford the sharp increase in prices for aged people. Workers have access to private health plans in adulthood, when they need less, and face difficulties of access exactly when they are elderly and need it most. This situation corresponds to a real swindle operated by the private market towards employees, the reason why it needs to be strongly denounced.

For the last ten years, there has been a substantial growth in private management of public health services by Civil Society Organizations of Public Interest (OSCIP) or by Social Organizations (OS). Such organizations have been increasingly responsible for the management of hospitals, health centers, Urgency Units (UPA) and family health units. Possibly the major one is São Paulo Association for the Development of Medicine (Associação Paulista pelo Desenvolvimento da Medicina; PMDS-Saúde), which operates in six States and employs about 40 thousand workers, all of them entitled to private health plan. It is entirely funded by resources arising from contracts with the public sector. Entities such as this one, in addition to depending on public funds and contributing to strengthen the private health insurance market when providing health plans to their employees, have also contributed for the insertion into the public health units they manage of a set of techniques and typical values applied by the private market and of dubious benefit to public service.

Since its creation, SUS has always faced insufficient funding, a situation that is aggravated by the loss of resources suffered by the system for the benefit of the private sector. Tax waiver related to tax exemption on plans and private health services expenditures was maintained in recent legislation, and continues to benefit the private sector and to undermine public health. An IPEA study shows that in 2011 waiver amounted to R$15,807 billion, equivalent to 22.5% of the federal expenditure on health. Another form of SUS loss of resources in favor of the private sector is the State provision of health insurance plans for public employees and their relatives. Also in 2011, federal government expenditures with private health plans for public employees accounted for 5% of the Ministry of Health budget. Such practice, also implemented in many State and local governments, not only reduces expenditure on public health as transmits to public employees the clear message of distrust towards SUS services, and another message to the population in general, discriminated and relegated to worse quality services.

For the 2014 elections, Cebes urges the whole Brazilian population and the candidates for political office to repudiate: (1) the misleading and malicious proposal of 'universal health coverage'; (2) Brazil's vote in favor of such proposal at the 67^th session of the United Nations General Assembly in 2012; (3) the maintenance of the tax waiver on the expenditure of persons and companies on private health plans; (4) the practice of federal, states and municipal governments of providing private health plans to public employees and their relatives; (5) as well as the hiring of private entities for the management of public health services due to their responsibility for the insertion of a private logic to the detriment of public interests in these services. Cebes urges the entire population and the candidates for political office in the 2014 elections to fight for: (1) the Brazilian government increasing in health expenditures to a minimum of 10% of the federal budget; (2) the strengthening of SUS public network and of the State capacity of managing public health services.

Cebes National Board

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