THE CREATION OF THE UNIFIED HEALTH SYSTEM (SUS) as a universal policy for all constitutes one of the most important achievements of the brazilian society in the XX century. Consecrated in the Federal Constitution of 1988, in its articles 196 to 198¹1 Brasil. Constituição da República Federativa do Brasil [internet]. Brasília, DF: Senado Federal; Coordenação de Edições Técnicas; 2016 [acesso em 2018 abr 20]. Disponível em: https://www2.senado.leg.br/bdsf/bitstream/handle/id/518231/CF88_Livro_EC91_2016.pdf.
https://www2.senado.leg.br/bdsf/bitstrea... , the SUS must be valued and defended as a milestone for citizenship and civilizational advancement. The universalistic, egalitarian and integral character of the constitutional health project, since its inception, faced resistance from economic and political forces that have barred and hampered its implementation. The main mechanism used is to prevent adequate and permanent financing of the System.

The recurrent arguments are that health spending is too low and resources are poorly applied, when it is known that Brazil invests a few public health resources - less than 4% of the Gross Domestic Product (GDP) -, while countries with similar systems invest about 8%. In addition, it is important to emphasize that the enormous social inequality in the Country produces vulnerabilities that, along with the aging of the population, increase the consumption of health services. Therefore, the health financing debate must start from the premise that the healthier a people has, the more care and assistance it will need. The projections are that health care would require an additional resource input of about 37% over the next 20 years²2 Noronha JC, Noronha GS, Costa AM. A revolta contra os pobres: saúde é para poucos. Saúde debate [internet]. 2017 Mar [acesso em 2018 abr 23]; 41(112):13-19. Disponível em: https://www.scielosp.org/article/ssm/content/raw/?resource_ssm_path=/media/assets/sdeb/v41n112/0103-1104-sdeb-41-112-0013.pdf.
https://www.scielosp.org/article/ssm/con... .

Contrary to health needs, present and future, of the population, the government that took power after the coup in 2016, at the service of national elites, was able to approve in the national Congress amendment to the Constitution that freezes the primary expenditures of the federal government for 20 years3. While expenditures on public debt will remain unlimited, health, education, social security and social assistance expenditures, infrastructure, defense, culture and all other public management expenditures will be corrected only by inflation measured by the Broad National Consumer Price Index (IPCA).

Health, as a right provided for by the Constitution, established a system essentially public and unique, reserving the private sector a complementary role, in other words, to act where the public system was not present, through explicit needs under the decision and regulation of the SUS. This would prevent imbalances or even the replacement of the public sector. But it has not been so. What was seen in the three decades of existence of SUS was an exponential growth of the private sector and the financialisation of the sector, as health became a profit and interest of financial capital.

Among the 200 million brazilians, a quarter is covered by private health plans in a heterogeneous way, since the higher income sectors have plans with greater coverage of procedures and different hotel services. Among those earning 20 minimum monthly salaries or more, coverage is about 80%. Most of the plans are contracted by employers, and the employer's contribution, evidently, is passed on to the final price of the product or service and, therefore, paid by the final consumer. By the condition of benefit, it is not taxed as income of the worker. The part paid for this, as well as for plans contracted directly by individuals, is deducted from gross income for tax purposes. There is, therefore, simultaneously, a waiver of collection and a 'tax' on hidden consumption. Permissiveness for the performance of the private sector in the Country is evidenced by the total revenue of health plan operators, which in 2015 was R$ 143 billion⁴4 Mendes A, Weiller JAB. Renúncia fiscal (gasto tributário) em saúde: repercussões sobre o financiamento do SUS. Saúde debate [internet]. 2015 Jun [acesso em 2018 abr 23]; 39(105). Disponível em: http://www.scielo.br/pdf/sdeb/v39n105/0103-1104-sdeb-39-105-00491.pdf.
http://www.scielo.br/pdf/sdeb/v39n105/01... , 1.4 times higher than the budget executed in the same year by the Ministry of Health. Despite all the obstacles imposed to the SUS, chronic underfunding and economic policies that privilege servitude to the payment of interest and debt services, its implementation managed to change the logic and expand access, previously linked to merit: who paid social security had the right to medical care; the rest remained excluded from the system. With this, we changed from a contributory model to a universalism inspired by the Beveridgian model.

However, it should be recognized that we are far from having guaranteed access and quality care in health services. There are still thousands of people who wait months to be served in services of medium complexity, access to elective procedures is time-consuming, hospital beds are lacking, there are restrictions on access to medicines and procedures. But it is necessary to account for and celebrate the advances of a system that included thousands of people, expanded the service network, implemented basic care and configured itself as an important productive sector that generates jobs and activates the industrial park through the acquisition of inputs and health technologies.

The enormous problems and challenges whose main causes are external to the health sector do not mean the failure or the infeasibility of the SUS. Neither, do they disqualify it as a public policy nor do they indicate that it is necessary to create another health system. The awareness of the population of the right to health, in general, is shaped by the logic of consumption and guided by a media that does not favor social rights. Society must recognize the difference between the right to health and the purchasing power of health services; recognize the meaning of SUS as a social achievement that universalized actions of basic care, health surveillance, emergency and that has 75% of the population as an exclusive user. A difficult task for individualistic times, but necessary if Brazil chooses, at this complex crossroads, the future path of a solidary and democratic society.

Democracy involves a State model where social policies protect citizens and reduce inequalities. Participatory democracy in the field of health is a guideline that values social participation, strengthens citizenship and contributes to ensuring the exercise of social rights, political pluralism and well-being as values of a fraternal, pluralist and unprejudiced society, as provides for the Constitution1.

This year, when the XVI National Health Conference (CNS) (8ª+8 = 16ª) will be carried out, the social democracy and social justice ideology of the Health Reform Movement (MRS), embodied in the motto 'Health is democracy', is taken up in a more radical way to feed the national debate on the health project that we want for all brazilians and that we have sought to build over these 30 years. The banner of the MRS of then was the construction of a new health system, the SUS. Our banner, today, is the intransigent defense of health as an expression of the struggle against social inequalities, as a universal right that materializes in its aspects of vigilance and attention in the SUS. Defense of a democratic State whose center for its development are people and populations, not market interests.

The debate that the Brazilian Center for Health Studies (Cebes) proposes is based on the finding that a coup d'état was generated not only to withdraw a party from the government, but to return Brazil to a subordinate condition in the international game. The cooperation of the political elites in power and sectors of the judiciary and the Public Ministry with authorities from the United States, without the intermediary of the executive power, configuring an illegality, has as a direct consequence the dismantling of the oil and gas chain in the country and the weakening of the brazilian nuclear program. The inflection in post-coup international relations of Brazil, with the emptying of the BRICS, the Southern Common Market (Mercosur), the Union of South American Nations (Unasur) and automatic realignment with the United States, makes it clear that, in Brazil, an unconventional war occurred, where the people lost what little they had conquered.

The changes promoted by so-called popular governments, though timid in many aspects, have brought to the majority of the people an experience that misery is not a natural condition and that poverty is not inexorable. Hence, the bet in the way of the politicization of the population, especially of the most exploited classes. There is no more room to negotiate or postpone necessary and structuring reforms. The rapidity and greed of the dismantling of the Country already present its results with the deterioration of the living and working conditions of sectors that in the last decade had left the condition of poverty, with improvement of the condition of the workers. The reversal of this national tragedy will not come from the ruling classes, but from the classes and fractions of classes that are suffering and will suffer the consequences of the dismantling of the brazilian State and the loss of rights. Cebes will be together in this fight.

Maria Lucia Frizon Rizzotto
Scientific editor of 'Saúde em Debate'
Ana Maria Costa
Executive director of Cebes
Lenaura de Vasconcelos Costa Lobato
Director of editorial policy of Cebes

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