THE UNIFIED HEALTH SYSTEM (SUS) IS GOING THROUGH ONE OF ITS MOST SERIOUS CRISES. Since the 2016 coup, several health policies and programs have been insidiously and deliberately disrupted¹1 Costa H, Chioro A, Soter APM, et al. O golpe contra a democracia, a austeridade e o ataque ao SUS: 2016, o ano que não acabou. Perseu: História, Memória e Política. 2020 [acesso em 2023 fev 22]; 14(19):136-164. Disponível em: https://revistaperseu.fpabramo.org.br/index.php/revista-perseu/article/view/363.
https://revistaperseu.fpabramo.org.br/in... . Both the Brazilian Center for Health Studies (Cebes), through positions and outstanding political action as one of the coordinating entities of the Front for Life (FpV), and the journal ‘Saúde em Debate’, in several editorials²2 Costa AM, Rizzotto MLF, Lobato LVC. Na pandemia da Covid-19, o Brasil enxerga o SUS. Saúde debate. 2020 [acesso em 2023 fev 22]; 44(125):289-292. Disponível em: https://www.scielo.br/j/sdeb/a/PbzsnQF5MdD8fgbhmbVJf9r/?lang=pt.
https://www.scielo.br/j/sdeb/a/PbzsnQF5M... and articles published in that period, significantly contributed to the critical analysis and denunciation of the enormous damage to Brazil caused by the Temer and Bolsonaro administrations.

In the last government, in particular, the disorganization of the Ministry of Health (MS) reached such a point that it drastically affected the coordination capacity of the SUS and the articulation of inter-federal responses, necessary to face the health crisis caused by the COVID-19 pandemic. The only reason why the situation was not even more critical is because of the resilience demonstrated by the SUS, to which the responses produced by state and municipal managers and the selflessness and capacity for reinvention of its workers contributed greatly – in addition, of course, to its vigorous resistance, led and conducted by the National Health Council (CNS) and by entities and social movements in defense of the SUS and of democracy.

In facing Bolsonaro and his far right project, a broad alliance of political forces was formed who positioned themselves in favor of the rule of law. The result of the polls in 2022 expressed the sovereign will of the Brazilian people, who yearn for a return to democratic and institutional normality. The health issue, one of the most relevant in the electoral debate, emerged as a public commitment assumed by Lula, the president-elect. The opportunity to value and vigorously resume the implementation of the SUS presents itself as a concrete possibility and fills militants and defenders of health as a universal right with expectations.

The Transitional Government was formally instituted in November 2022, based on current legislation³3 Brasil. Lei nº 10.609, de 20 de dezembro de 2002. Dispõe sobre a instituição de equipe de transição pelo candidato eleito para o cargo de Presidente da República, cria cargos em comissão, e dá outras providências. Diário Oficial da União. 23 Dez 2002. [acesso em 2022 dez 27]. Disponível em https://www.planalto.gov.br/ccivil_03/leis/2002/l10609.htm.
https://www.planalto.gov.br/ccivil_03/le... ,⁴4 Brasil. Decreto nº 7.221, de 29 de junho de 2010. Dispõe sobre a atuação dos órgãos e entidades da administração pública federal durante o processo de transição governamental. Diário Oficial da União. 29 Jun 2010. [acesso em 2022 dez 27]. Disponível em https://www.planalto.gov.br/ccivil_03/_ato2007-2010/2010/decreto/d7221.htm.
https://www.planalto.gov.br/ccivil_03/_a... , under the coordination of the elected vice-president Geraldo Alckmin.

Compared to the previous ones, what we saw was a very unique government transition process. 34 Technical Groups (GTs) were set up, including GT-Health. As a matter of principle, but also due to pressure from society, efforts were made to guarantee regional diversity and the presence of women, blacks, and young people in the composition of the GTs, as well as the plurality of political, economic, and social representations of the victorious alliance at the polls.

The GT-Health was made up of 21 members and 16 technical supporters, in addition to collaborators, all of whom worked on a voluntary and unpaid basis. Its composition was plural and marked by heterogeneity. It was attended by, among others, four former Ministers of Health (one of them responsible for coordinating the GT and another one for reporting), managers, professors and researchers, leaders of national health entities, parliamentarians, renowned doctors, the former and the current president of the CNS, parliamentarians, among others.

For each thematic GT, two products were ordered. A first summary document, of a preliminary nature, should contain the alerts specially identified by control bodies, the preliminary assessment of the direct and indirect administration structures, and the main budgetary emergencies. The GT’s second mission was the production of a Final Report, containing: executive summary; evaluation of programs and actions that were implemented in recent years and those implemented in the Lula and Dilma administrations that were discontinued; evaluation of contracts, terms of collaboration, and partnership to expire that would imply stoppage of services or considered ‘sensitive’; elaboration of proposal for organizational restructuring of the area; and list of eventual normative acts that should be immediately revoked by the new president. In addition, suggestion of actions and priority measures for the first hundred days of government.

In addition to the results of the GT-Health work, the process of listening to the most diverse actors that make up the vast field of health in Brazil must be highlighted. 38 hearings were held with different segments of society and government bodies and 223 documents were received. The work produced by GT-Health was, therefore, also the result of suggestions, recommendations, and warning points received from the health sector, a democratic process. In these hearings, the common highlight was the resumption of the dialogue banned in the previous government.

The diagnosis of the situation presented in the Final Report of GT-Health⁵5 Brasil. Comissão de Transição Governamental. Relatório do Grupo Técnico de Saúde – Produto 2: Relatório Final. Brasília, dezembro de 2022. [acesso em 2023 fev 14]. Disponível em: http://conselho.saude.gov.br/images/noticias/2023/GT-Saude_Relatario_Final_1.pdf.
http://conselho.saude.gov.br/images/noti... confirms and exposes the depths of what was already known: the health chaos in the Bolsonaro government. The document, presented to the CNS in December 2022, indicates that the dismantling of the MS and the government’s negligent and denial-based action, rejecting evidence and reasoned scientific practices, were not restricted to the way in which they dealt with COVID-19.

Since the 2016 coup, several health indicators have progressively deteriorated. The reduction in coverage of all vaccines, which worsened during the Bolsonaro administration to critical levels, was already underway. During that period, an increase in maternal mortality and a stagnation of infant mortality can be observed, which had been reducing, until then, at the annual rate of 0.4%⁶6 Chioro A, Padilha A, Costa H, et al. Atuação do Partido dos Trabalhadores na gestão do Ministério da Saúde: agendas estratégicas visando a garantia do direito a saúde e a defesa do SUS. Perseu: História, Memória e Política. 2020 [acesso em 2023 fev 22]; 14(19):35-67. Disponível em: https://revistaperseu.fpabramo.org.br/index.php/revista-perseu/article/view/360.
https://revistaperseu.fpabramo.org.br/in... . Unacceptably, there was an increase in hospitalizations of babies with severe malnutrition, which expresses the return of hunger and the general neglect of early childhood.

This scenario lays bare the deterioration of the MS, which was militarized and promoted the dismantling of SUS policies and programs. It expresses institutional, budgetary, and regulatory setbacks and indicates, above all, the authoritarian and centralizing posture adopted by the Bolsonaro government, which replaced cooperative and solidary inter-federative management with a confrontational federalism.

The weakening of the national coordination capacity of the SUS, of articulation of health policies and programs, and the weakening of the national health authority resulted in a weak response to the pandemic, but also in the disruption of successful policies and programs, such as the National Immunization Program (PNI), Primary Care, More Doctors, STD-Aids, Mental Health, Women’s Health, Popular Pharmacy, Industrial Health Complex, among others. The disruption of the National Primary Care Policy and the Health Care Networks (RAS), associated with mistakes in managing the pandemic, also reflected in the serious decrease in patient access to the health care network, with an increase in queues for appointments, surgeries, and diagnostic and therapeutic procedures performed by the SUS. It delayed the start of treatment and resulted in the worsening of chronic diseases, such as cardiovascular disease and neoplasms⁷7 Bigoni A, Malik AM, Tasca R, et al. Brazil’s health system functionality amidst of the COVID-19 pandemic: An analysis of resilience. Lancet Reg Health Am. 2022 [acesso em 2023 fev 22]; 10:100222. Disponível em: https://pubmed.ncbi.nlm.nih.gov/35284904/.
https://pubmed.ncbi.nlm.nih.gov/35284904... . In the meantime, several initiatives have made room for ‘market solutions’, such as low-cost popular clinics and poor resolution, among others.

The deconstruction of the National Mental Health Policy and its inhuman conduct under the aegis of asylums contributed to significant setbacks, in the context of an explosion in cases of mental disorders and the abusive use of alcohol and other drugs with the pandemic.

Not even the annual schedule for acquiring vaccines and medicines, a basic task in the MS routine, had been carried out by December 2022. The Butantan and Bio-Manguinhos institutes, which supply most immunizers, had not received a request for vaccines.

In the COVID-19 Parliamentary Commission of Inquiry (CPI), there were already enough elements to characterize the genocide committed against the original peoples⁸8 Brasil. Senado Federal. CPI da Pandemia: Relatório Final. Brasília, DF; 2021. [acesso em 2023 fev 12]. Disponível em: https://download.uol.com.br/fi-les/2021/10/3063533630_relatorio_final_cpi_covid.pdf.
https://download.uol.com.br/fi-les/2021/... . However, Bolsonaro continued to fail to implement actions to protect indigenous populations until the end of his presence in government, resulting in hunger, malnutrition, disease and violence of all kinds, due to the unpunished action of miners, loggers, and traffickers. As the GT-Health Final Report indicates, the Bolsonaro government suspended measures to protect and care for indigenous peoples – including actions to mitigate food and nutritional insecurity – and dismantled the Special Secretariat for Indigenous Health (SESAI). More than half of the contracts for the Special Indigenous Sanitary Districts (DSEI) were close to expiring or had already expired, with allegations of corruption and management deficiencies. The SESAI had its budget for 2023 cut by 59%. Prioritization instruments and provision of physicians for indigenous health were disjointed. The food and nutrition surveillance and information systems for indigenous health care were disrupted. The Yanomami tragedy is an expression of this debacle. It should be noted that indigenous health is the sole responsibility of the Federal Government, through the SESAI, and there is no way to outsource responsibilities.

The MS budget situation was profoundly serious. The ministry had already lost, between 2018 and 2022, due to the Ceiling Amendment, almost R$60 billion⁹9 Chioro A, Moretti B, Harada J, et al. Financiamento do SUS e garantia de direitos [livro eletrônico]: orientação técnica e produção de dados na garantia de direitos no contexto da pandemia Covid-19. São Paulo: Unifesp – Lascol; 2021. 140 p. [acesso em 2023 fev 22]. Disponível em: https://redeaps.org.br/wp-content/uploads/2021/06/ebook.pdf.
https://redeaps.org.br/wp-content/upload... ,¹⁰10 Ocké-Reis CO. Sustentabilidade do SUS e renúncia de arrecadação fiscal em saúde. Ciênc. saúde coletiva. 2018 [acesso em 2023 fev 22]; 23(6):2035-42. Disponível em: https://www.scielo.br/j/csc/a/fpzPVyhXgvk9SpDLSRxmYqh/?lang=pt.
https://www.scielo.br/j/csc/a/fpzPVyhXgv... . In the 2023 budget, R$12.4 billion were cut from fundamental actions, such as Popular Pharmacy, purchase of vaccines, drugs for HIV/AIDS, hepatitis and cancer, scholarships for resident physicians, indigenous health. Although the alleged objective was to comply with fiscal austerity rules, these cuts were intended to make room for the ‘secret budget’. It was in this context that the discussion on the importance of the approval of the Emergency PEC by the GT-Health took place, which obtained an extra R$22.8 billion in the health budget to recover the cuts and strengthen the SUS in 2023.

Nísia Trindade, former president of Fiocruz, was chosen for the position of Minister of Health in a historic milestone, due to her competence and attributes, but also because she is the first woman to take on the position since 1953, when the ministry was created. The Minister’s choice mobilizes respect and many expectations from the health field. Her presence at the head of the MS signals the constitutional course that the government intends to give to health. The scenario in the sector is complex, and market interests are continually competing against the implementation of the project defined by the Federal Constitution.

The universal right to health, the main objective of the struggle of the Health Reform Movement (MRS), cannot be reduced to the enormous challenge of consolidating the SUS. Its objectives aim to guarantee the set of rights and social policies that produce quality of life and enable the accumulation of more citizenship¹¹11 Brasil. Constituição, 1988. Constituição da República Federativa do Brasil. Brasília, DF: Senado Federal; 1988. [acesso em 2023 fev 22]. Disponível em: https://www2.senado.leg.br/bdsf/bitstream/hand-le/id/518231/CF88_Livro_EC91_2016.pdf.
https://www2.senado.leg.br/bdsf/bitstrea... . It is essential, in the present context, to reiterate that health can only be achieved with democracy and articulated public policies, which express a model of a built State and in consonance with popular interests.

Years without democracy and marked by obscurantism and authoritarianism caused much damage to the country. The performance of the National Congress in these times did not favor democracy, nor did it favor the interests and needs of the people. With the rapporteur’s amendments, known as the ‘secret budget’, parliamentarians gained even more power to do business, define policies and advance the functions of the Executive, especially compromising two sectors: health and education.

The legal devices identified in the transition period and revoked at the beginning of the Lula government express part of the deviant setbacks of the constitutional SUS. In addition to the irrecoverable losses of human lives, with the pandemic, there was a significant increase in deaths due to lack of assistance; and the lack of care during this period will congest queues for assistance for a long time. The accumulated health problems are gigantic, and the people expect quick answers to the extent of the health emergencies they experience on a daily basis.

The MS will be responsible for formulating and implementing responses and, at the same time, advancing initiatives to consolidate the right to health and the SUS. Ending the queues, responding to the damming of demands, expanding vaccination coverage, among other priorities, constitute emergencies. Simultaneously, it will need to dedicate to the search for stability and adequacy of financing, to the improvement of the system’s management model, in addition to supporting regionalization, the creation of consortia, and the implementation of the RAS. Another imperative task will be to act in the implementation of paralyzed policies, such as those promoting equity for blacks, indigenous peoples, women, and other vulnerable groups and in conditions of intolerable inequality.

In the context of pending agendas that accumulate over the decades of implementation of the SUS, emphasis should be given to the challenging theme of the workforce, training of Human Resources (HR), permanent education, careers, strengthening and qualification of the actors and the processes of participatory management and social control. The resumption of the SUS National Negotiating Table is just a first step.

The climate emergency will require a special investment by the health sector in environmental surveillance, at the same time that it will be necessary to respond to warnings about the seriousness to health resulting from the registration, commercialization, and use of pesticides and agricultural inputs.

In recent decades, the inadequate and insufficient funding of the SUS and the predatory presence of the private sector constituted obstacles in the way of the constitutional project to guarantee the universal right to health. Since the approval of Constitutional Amendment No. 95, the situation has deteriorated profoundly. From underfunded, the picture evolved to one of explicit unfunding.

There is clear evidence that investment in health is not an expense. On the contrary, it must be understood as an essential basis for the country’s development project, yielding multiple benefits and impacts that range from improving the health situation of the population to consolidating health as a strategic productive sector for the economy and national sovereignty. There is a delay in the conquest of technological sovereignty, whose effects were especially marked in the pandemic and which need to be faced.

Health has a tradition of institutionalized social participation in councils and conferences, which have been important in this complex political scenario. In 2023, the 17th National Health Conference will be held. It is also the moment when the MS and the CNS will discuss and approve the new National Health Plan. It is, therefore, a strategic moment. However, this fight needs more participation and broad mobilization and engagement of society as a whole. Perhaps now, more than ever, mobilization and participation in institutional spaces – but, above all, the presence of the people on the streets – will be able to make a difference in expectations for progress. In this sense, Lula has given signs that encourage democratic radicalization, mobilizations, and popular participation as a method to advance and ensure that popular interests prevail, even if this has not occurred satisfactorily in previous popular governments.

The hard learning from Dilma’s impeachment, Lula’s unjust and long imprisonment, and the overwhelming presence of the far right in the last government and still present in society are facts and circumstances that cannot be erased from the country’s political memory. The Brazil that presents itself today no longer hides its original peoples, its blacks, its marginalized people, and wants to rebuild itself starting from them. In order for it to be able to decolonize itself, it will be necessary to continue betting on the radicalization of democracy.

The creation of a Council articulated to the interministerial Social Participation System involving institutions and government agencies constitutes an important initiative of dialogue between government and social groups, of democratization of management, but it cannot end the mobilization of society that must and needs to be free, autonomous, and instituting as subject of Politics.

Decree No. 11.407/2023¹²12 Brasil. Decreto nº 11.407, de 31 de janeiro de 2023. Institui o Sistema de Participação Social. Diário Oficial da União. 31 Jan 2023. [acesso em 2023 fev 22]. Disponível em: https://www.planalto.gov.br/ccivil_03/_ato2023-2026/2023/decreto/d11407.htm#:~:text=DECRETO%20N%C2%BA%2011.407%2C%20DE%2031,que%20lhe%20confere%20o%20art.
https://www.planalto.gov.br/ccivil_03/_a... that creates such System explains its mission to “structure, coordinate, and articulate the government’s relations with the different segments of society” in a transversal way to public policies, and will certainly be a powerful tool for reducing inequalities in the Country, guiding initiatives in the various sectors of government.

For health, the scenario in the National Congress will not be simple, since there is no strong bench in the consistent defense of the SUS and the universal right to health. Successive legislatures show the growth of conservatism in which growing numbers of extreme right-wing parliamentarians are housed. This 57th legislature of the Chamber of Deputies repeats the profile trend of deputies. Only 126 representatives are linked to center, center-left and left-wing parties. Once again, the so-called ‘big center’ houses the largest number of parliamentarians elected by parties or party aggregations without an ideological political project and adjustable to conditions of greater proximity to power that allow them to carry out their business and maneuvers. In the Federal Senate, the political profile of senators is no different.

The reality is that it was not this time that the people elected a significant group to guarantee the fulfillment of popular needs. The forces and interests present in the National Congress will not give a truce, and this will require social mobilization and a virtuous articulation of government members and the governmental base to guarantee the necessary changes.

The participation of evangelicals in the National Parliament, since 1999, has been growing, reaching 132 deputies in the current legislature, that is, 25% of the total. In the Senate, this contingent also increased to 14 senators. Some issues will be particularly targeted by these groups and will require the government not to accept the place of hostage. This is the case of sexual and reproductive rights and psychiatric reform, among other issues so important to the SUS.

This scenario outlines an enormous responsibility for health activism. It is essential to expand and strengthen its mobilization and ensure consistent and permanent political action in the National Congress. It is always worth remembering and valuing the powerful political strategy of dialogue and pressure by the MS under the National Constituent Congress, which was intense, permanent, and fundamental in the approval of the Health Chapter of the Federal Constitution.

These are times of hope, but they are also marked by challenges and the need to fight against inequalities, for social rights, for the SUS, and for democracy.

References

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