Cebes and the emergence of the Brazilian Sanitary Reform Movement

The struggle for the right to health in Brazil resulted in the conquest, in the Federal Constitution of 1988, of health as a universal right and duty of the state to be assured through integrated economic and social policies, aimed at the production of well-being and quality of life of the Brazilian population, and in a universal public healthcare system: the Unified Healthcare System (Sistema Único de Saúde, SUS).

The struggle for a universal public healthcare system began in the 1970s and persisted over the following decades, aiming at the implementation and consolidation of SUS. That has been a permanent task of action and mobilization by the Health Reform Movement (MRS), of which the Brazilian Center for Health Studies (Cebes) was the main protagonists.

According to Paim¹1 Paim J. Depoimento: a danação dos direitos sociais e a saúde: atualidade da questão democrática da saúde. In: Camargo ATSP, Costa AM, Lobato LVC, et al., organizadoras. Cebes 40 anos: memorias do futuro. Rio de Janeiro: Cebes; 2016.p. 383-390., people refer to the 1988 Constitution as a starting point for the creation of SUS. However, in reality, the Brazilian Sanitary Reform (RSB) movement, which formulates a broad concept for health and the SUS project itself, was born with Cebes in 1976, based on the initiative of David Capistrano Filho, a public health doctor and political activist. He managed to bring together a group of academics, students, professionals, and social movements in an effervescent debate on public health in a problematic Brazilian historical moment which was the period of the military dictatorship (1964-1984).

Concurrent to the advent of Cebes and as a communication strategy of the entity, the Revista ‘Saúde em Debate’ (RSD) journal was created in 1976, to disseminate knowledge and reflections about health and the new political project that Cebes announced. In the first number of RSD, the banner for the defence of the right to health was raised. In the second issue, the foundations of the Sanitary Reform proposal were explained.

The launch of the journal mobilized, at that time, important sectors of society, especially academics and students from public universities, health professionals, and social movements, helping in the construction of a broad national movement that received the name of Sanitary Reform Movement (MRS)²2 Escorel S. Reviravolta na Saúde: origem e articulação do movimento sanitário. Rio de Janeiro: Fiocruz; 1998.^,33 Amarante P, Rizzotto MLF, Costa AM. Memória de um movimento: a revista Saúde em Debate e a reforma sanitária brasileira. Ciênc. Saúde Colet. [internet]. 2015 [acesso em 2019 set 14]; 20(7):2023-2029. Disponível em: http://dx.doi.org/10.1590/1413-81232015207.05752015.
http://dx.doi.org/10.1590/1413-812320152... .

In 1979, during the First Conference on National Health Policy of the Chamber of Deputies, Cebes released the document entitled ‘The democratic issue in the health area’. The ideas brought up by this document were among politicians, in particular, among the members of the then Brazilian Democratic Movement (MDB), an opposition party to the military government that housed several clandestine political groups and parties. Thus, the outline of an alliance began to promote changes in the health sector, whose scenario was chaotic, both in terms of epidemiology and organization of the healthcare system.

‘The democratic issue in the health area’ is a landmark document of the RSB, notably because it inaugurated a positioning strategy that characterized the purposeful political influence of Cebes by clearly establishing a direction in which to walk and where it was necessary to go. The document puts forward the motto ‘Democracy is health’, which has never been abandoned, as well as the content of the political proposal to reorganize the national healthcare system. It is precisely in this document that the creation of a decentralized and democratic ‘Unified Healthcare System’ is mentioned for the first time. The document analyzed the health situation based on its social and economic determination, understood, therefore, as a result of the population’s living and working conditions. When considering health as a result of living conditions, it is necessary to understand its structural connection to economic development, equity, environmental sustainability, and the political mobilization of society.

Numerous departments of preventive and social medicine at public universities were present at the inception of the MRS. They played a fundamental role in the development of critical thinking regarding the overall health situation, healthcare policies, and the organization of existing healthcare services. Many of Cebes’ original members trace their origins to those university departments⁴4 Escorel S, Nascimento DR, Edler FC. As origens da reforma sanitária e do SUS. In: Lima NT, Gerschman S, Edler FC, et al., organizadores. Saúde e democracia: história e perspectivas do SUS. Rio de janeiro: Fiocruz; 2005. p. 59-81.. Since the late 1970s, the debate on the universal right to health has been strengthened, spreading articulations between the various social movements, unions, and workers’ entities for political action in defence of the democratization of Brazilian society, articulating a wide range of bodies in the health field.

Cebes’ activities have become the “cornerstone, although not the only one, of the health movement as an organized social movement”²2 Escorel S. Reviravolta na Saúde: origem e articulação do movimento sanitário. Rio de Janeiro: Fiocruz; 1998.⁽⁷⁶⁾. Credit should be given, as well, to the work of banned leftist political parties that contributed to the consolidation of the MRS during the military dictatorship in the 1970s²2 Escorel S. Reviravolta na Saúde: origem e articulação do movimento sanitário. Rio de Janeiro: Fiocruz; 1998.. Cebes’ prompt elaboration of a healthcare proposal was crucial and had repercussions on the Constituent Assembly (1986-1988).

Conservative sectors had no project to change an exclusionary, fragmented and ineffective healthcare system. On the other hand, they also did not want to hold the state responsible and, therefore, did not uphold a public healthcare system, despite being unable to articulate an alternative proposal. Fleury⁵5 Fleury S. Anos de Viagem. In: Camargo ATSP, Costa AM, Lobato LVC, et al., organizadoras. Cebes 40 anos: memorias do futuro. Rio de Janeiro: Cebes; 2016. p. 150-161. analyzes that, under this situation, the MRS had a power resource that the conservatives did not: a consistent proposal, supported by several sectors. The extended collective process of building that project resulted in a sizeable reforming coalition.

In the early 1980s, when the first signs of a return to the democratic rule of law were outlined, several Cebes members occupied institutional spaces in the public healthcare sector. They influenced reforms to expand access to healthcare and change the basis of the health care model.

According to Paim⁶6 Paim JS. Reforma sanitária brasileira: contribuição para a compreensão e crítica. Salvador; Rio de janeiro: EDUFBA; Fiocruz; 2008.⁽³⁶⁾, the RSB is a sociohistorical phenomenon that contemplates different moments as “idea - proposal - project - movement - process”. The health reform shapes the health movement as it engages in the struggle for democratization and vice-versa. The MRS identified itself as nonpartisan, although there was a clear relationship between movement entities and political parties. Regarding Cebes, despite initially influenced by members from the former Brazilian Communist Party (PCB), the entity stood out for cross-partisanship and sought to protect itself, avoiding corporatism⁷7 Rodriguez Neto E. Saúde: promessas e limites da Constituição. Rio de Janeiro: Fiocruz; 2003..

In 1986, the VIII National Health Conference was held, following the end of the military rule and the subsequent redemocratization process. The participation of Cebes and MRS members who held strategic positions in the government, together with the popular mobilization the conference were of great importance for the expansion of social support for the proposal to create SUS. Paim¹1 Paim J. Depoimento: a danação dos direitos sociais e a saúde: atualidade da questão democrática da saúde. In: Camargo ATSP, Costa AM, Lobato LVC, et al., organizadoras. Cebes 40 anos: memorias do futuro. Rio de Janeiro: Cebes; 2016.p. 383-390. recalls that, during this conference, the first one with popular participation, a sign held at a demonstration would read: ‘Health is Democracy and Democracy is Health’, complexifying and widening the articulation between health and democracy.

The democratic dimension of healthcare becomes even more meaningful once it is established that the right to health requires rendering it an endogenous, rather than marginal, part of the formulation of a social and economic model of development in Brazil, to ensure that a healthcare agenda surpasses the sectoral debate and, instead of being insulated, becomes a part of the country’s development pattern as a state policy⁸8 Costa AM. Saúde é Desenvolvimento. In: Sader E, organizador. 10 anos de Governos Pós-Neoliberais no Brasil: Lula e Dilma. São Paulo: Boitempo; Rio de Janeiro: Flacso; 2013. p. 239-253..

In this perspective, the democratic issue is at the origin of the health movement, and whenever democracy is threatened, this movement is rearticulated to act in defence of social and democratic rights. For Cebes and MRS, health should not be restricted to a sectoral issue but should have a broad dimension, which seeks dialogues with various sectors that organize society. The SUS as a cause is weakened if it is not articulated and associated with the set of changes in the state model that guarantees not only healthcare but also the quality of life and well-being.

The Healthcare Reform project has a necessary radicality, which is related to a set of principles stemming from social solidarity. Those principles are also fundamentally guided by the equality attained through universality and equity as a means to achieve the emancipation of human beings, which are essential democratic principles. The Brazilian health reform encompasses democratization of the State, the democratization of society, the democratization of culture and of health itself.

The democratization of health goes far beyond the processes of participatory democracy and civil society control. When dealing with the right to care, democratization is not limited to the offer and equal access to health services but implies an equal and universal right to a healthy life. In this sense, Paim¹1 Paim J. Depoimento: a danação dos direitos sociais e a saúde: atualidade da questão democrática da saúde. In: Camargo ATSP, Costa AM, Lobato LVC, et al., organizadoras. Cebes 40 anos: memorias do futuro. Rio de Janeiro: Cebes; 2016.p. 383-390. states that the Brazilian health reform has a radical project that requires broader changes in society, including cultural transformation, in the ethical sense, in the sense of Gramsci ‘intellectual and moral reform’.

It can be said that the RSB is a counter-hegemonic political project with flows and inflows, with advances and setbacks that depend on each conjuncture. Its scope became a reference to the healthcare reform as ‘a civilizing project’, affirming its values as important to the Brazilian nation as a whole. From this perspective, the healthcare reform did not limit its actions to the time of the democratic transition process after the ‘years of lead’. Nor is it paralyzed at the present moment, when the State withdraws from its responsibilities with social and health policies. The health movement is struggling to defend democracy and human rights and continues to strive for its ideal.

It is worth mentioning that the state-building and healthcare system project advocated by the Healthcare Reform born in Brazil took much of its inspiration from authors and activists from other parts of the world, especially those in Italy who carried out the Italian Health Reform. However, the historical and political credit of the Brazilian Healthcare Reform must be given to popular movements and popular mobilizations. For Paim¹1 Paim J. Depoimento: a danação dos direitos sociais e a saúde: atualidade da questão democrática da saúde. In: Camargo ATSP, Costa AM, Lobato LVC, et al., organizadoras. Cebes 40 anos: memorias do futuro. Rio de Janeiro: Cebes; 2016.p. 383-390., the RSB was not born from the State, international organizations, governments, or political parties, conferring a profound national and popular democratic component to the movement, which remains undaunted under the continuous threats to acquired rights of late.

Cebes: political action for the construction of SUS and democracy

Cebes upholds democracy and health by working towards implementing the 1988 Federal Constitution, whose Article 196 affirms the right to health

While encompassing the diverse set of issues related to the social and economical determination of health, Cebes channels its efforts to the process of implementing SUS under the doctrinal principles of universality, integrality, and equity. Such principles, in turn, should work under the organizational guidelines of decentralization, regionalization, hierarchy, and social participation.

Cebes’ actions are articulated with a set of social movements and entities that include the Landless Movement (Movimento Sem Terra, MST), the popular demonstrations Grito dos Excluídos, as well as the feminist, workers’, black, and LGBTI movements, among others. Cebes also has ties to entities such as the Brazilian Association of Public Health (Abrasco), the Brazilian Association of Health Economics (Abres), Rede Unida Brazilian Association (Rede Unida) and others that make up a Forum for Health Reform exerting influence on the Executive, Judiciary and Legislative Powers.

At the international level, Cebes is part of the Latin American Social Medicine Association (Alames) and is affiliated with the Peoples’ Health Movement as a network, and an active participant in the World Social Forum. It is, therefore, an integral part of the global movement for the universal right to health.

Cebes is organized under a structure that includes a national executive board, an expanded board with an advisory role, and branches present in several Brazilian cities. There are currently eighteen autonomous branches in different operating situations under the entity’s constitutive principles: the defence of democracy, health as a social right, and cross-partisanship. The branches were reorganized with the Cebes Refoundation movement, started in 2006, after a period of low mobilization by the entity. The proposal was to expand Cebes to the bases, expanding its role as a social movement and creating new leaderships. This process was quite fruitful, but there remains a certain inconsistency in the activities of the entity, part to any social movement. Cebes’ core groups play an essential role in monitoring the healthcare sector in the states and cities where they belong, and their members are usually prominent actors, being members of health councils, professional associations and integrating other social movements.

The political directives of Cebes are defined in biannual symposiums when the national board is elected for a two-year term. All Cebes members, from the boards to the core groups, exercise their functions in the entity voluntarily, without remuneration.

As an entity based on policy formulation, scientific dissemination, and social mobilization, Cebes is represented through voting at the National Health Council, in several municipal health councils, and health national and subnational conferences. Health councils are an achievement of MRS to guarantee popular participation, participatory democracy, and social control throughout the construction of SUS, democratizing the system’s management while taking into account the needs and demands of the population.

For the dissemination of political conjuncture and healthcare issues, Cebes has a website (http://cebes.org.br/) and is present on social networks such as Twitter, Facebook, and Instagram. The internet is a powerful means to the dissemination of analysis and reflections influencing actors in the health field and for supporting other non-specialized partner media. Another channel is Cebes journal, RSD, currently at its 123rd issue. The editorials constitute the entity’s positions on topics related to health, with national and international politics that have repercussions on health and the very existence of SUS as a universal social policy. The journal is a reference in the health area, mainly for health policies and services, since it is highly sought after by professionals and managers who are on the SUS front line and systematize their practical experience in academic studies. In addition to RSD, Cebes publishes the journal ‘Divulgação em Saúde para Debate’, addressed for research or institutional projects. The entity also publishes books and has traditional lines of publications for training in public health, always from the perspective of Health Reform. All Cebes publications are freely accessible and available on the website.

Cebes as part of the resistance against authoritarianism and the dismantling of the right to health.

Democracy is health. Health is democracy

Health reform can be understood as the process of changes in the power structure, in the institutional apparatus, in access to health and health practices. In its constitution and consolidation, the RSB had a counter-hegemonic character and, as such, was related to a political context with the construction of alliances, which can be identified by 1) recovery of democracy after the dictatorial regime 2) opposition to traditional and archaic structures of health organization and management; 3) meeting social demands resulting from the exclusion of significant sectors of the population from the benefits of economic growth, expressed in health, due to the lack of access to health care¹⁰10 Lobato LVC. Prefácio. In: Lobato LVC, Fleury S, organizadoras. Participação, Democracia e saúde. Rio de Janeiro: Cebes; 2009..

The construction of an alternative project was based on the aggregation of forces around proposals in that context, which had three essential points: 1) the democratization of political power and the State; 2) the universalization of access to health as a right and as a State responsibility; 3) the construction of a democratic institutional and organizational apparatus, decentralized and with a single authority, responsible for the consolidation of the previous precepts. The implementation of the health reform was constrained by the conservative and anti-democratic tradition of the Brazilian State and the health sector¹⁰10 Lobato LVC. Prefácio. In: Lobato LVC, Fleury S, organizadoras. Participação, Democracia e saúde. Rio de Janeiro: Cebes; 2009..

These tensions resulted in the prevalence of guaranteeing universality through the construction of SUS, the most visible and concrete outcome of the reform. However, the fact that a universal, public and high-quality system was not achieved weakened its sustenance.

Today, society and political actors recognize the importance of SUS. However, which type of SUS should prevail is a matter of significant divergence. Cebes’ proposal for a public, universal and integral SUS is not a majority. Within the social imaginary, the prevalent conception is that SUS is a system for those who ‘cannot pay’, although the system is broad, covering the whole society and not only guaranteeing healthcare for the less fortunate, and paying for the highest cost procedures, both for the poor as for non-poor. The vulnerabilities of the system have always been intensely recorded, contrasting with the sparse support for the countless successful initiatives. The middle classes support the right to health, but consider the cost of social organization to their benefit high and choose to pay health plans, even if their quality is dubious. The high stratification of Brazilian society, with deep social inequalities, hinders broad social solidarity projects and encourages individualization of access to health as a synonym for social status.

This lack of solidarity has been amplified with the arrival in power, in 2019, of a far-right government, averse to solidarity initiatives and against State responsibility to social protection. And, above all, anti-democratic and socially reactionary. President Bolsonaro’s administration represents an unprecedented association between far-right principles in politics with economic liberalism, upholding a conservative agenda in the social sphere supported by ultraliberal proposals in the economic field. The project is in line with the advancement of financialization over national resources at a global level, expanding the concentration of income, for which it uses the asphyxiation of democratic politics as a legitimate field of intermediation of conflicts arising from the structural conditions of capitalism¹¹11 Lobato LVC, Costa AM, Rizzotto MLF. Reforma da previdência: o golpe fatal na seguridade social brasileira. Saúde debate [internet]. 2019 [acesso em 2019 set 22]; 43(120):5-14. Disponível em: http://dx.doi.org/10.1590/0103-1104201912000.
http://dx.doi.org/10.1590/0103-110420191... .

In this context, the health reform project is more threatened than ever, precisely because it defends democratic radicalism and the universal right to health. The social movements in defence of the Health Reform maintain their agenda and, at the moment, adopt a strategy of resistance, being vocal about the link between democracy and health, and denouncing government’s privatism and individualistic initiatives. Cebes has a prominent place in this scenario, defending: 1) universalization and state responsibility for health; 2) public health system as an instrument of social development and construction of equal citizenship, in addition to individual rights; 3) health as an element of deepening democracy, by expanding the public character of the State and expanding the direct participation of citizens in public affairs; 4) health as the construction of collective well-being and, therefore, integrated with a set of social security policies and the guarantee of basic needs¹⁰10 Lobato LVC. Prefácio. In: Lobato LVC, Fleury S, organizadoras. Participação, Democracia e saúde. Rio de Janeiro: Cebes; 2009..

While Cebes joins movements that resist the dismantling of social policies and the right to health, it does not neglect its main characteristic of following the initiatives of social and institutional actors, government measures, the movement of the conjuncture, political actors; and to debate the propositions at stake critically. The in-depth knowledge of health and related topics through the gathering of countless specialists in different areas makes Cebes a cross between a social movement and a specialist group, and it is in this field that we contribute the most. We are a social movement insofar as we associate and support the various movements with intensive knowledge production. We associate the plural and nonpartisan stance to a critical praxis, which allows us to establish a dialogue with movements from different areas and agendas. The biggest challenge today is to resist by opening dialogues, innovating in political action, expanding and consolidating social movements in Brazil and Latin America, without renouncing to the critical analysis of our position, the role we play and the challenges that lie ahead.

Cebes has remained, since its creation in 1976, committed to the struggle for the universal right to health, elucidating the economic, social and environmental processes of social determinants of health and aligning itself with all political and social movements in defence of democracy and the construction of a fair and supportive society.

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