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The struggle for health as a universal right in Brazil

Since enactment of the 1988 Federal Constitution that established health as a right for all in Brazil, substantial advances have occurred in the health sector. During the period 1990–2015, observers witnessed sizeable reductions in rates of mortality and morbidity. The population’s life expectancy increased from 68.4 to 75.2 years. Overall, age-standardized mortality rates fell by 34%. By expanding prevention activities, especially vaccination, Brazil reduced communicable disease morbidity and mortality [1]. By expanding its public network of facilities, mainly for primary care, Brazil increased medical visits and curbed hospitalizations. Admissions due to causes that could be prevented by greater reliance on primary care fell from 120 to 66 per 10,000 inhabitants between 2001 and 2016 [2].

It is undeniable that advances in the Unified Health System (SUS) combined with social and economic policies to improve the health of Brazilians. However, it is also true that these advances involved the public, non-profit, and private sectors heterogeneously, resulting in segmentation of services among clients with different capacities to pay. Thus, Brazil does not have a unified health system, just a fragmented set of services that compete for the same resources. Current service provision reflects and reproduces social inequalities and compromises the effectiveness of the health system because it prioritizes diagnosis and treatment of diseases and illnesses to the detriment of prevention and health promotion.

A shortage of health professionals and regional disparities in the quality of care persist, mainly reflecting the influence of socioeconomic factors [3]. A comparison of the average income of the wealthiest segment of the population with that of the poorest segment illustrates the disparity: the wealthiest 20% have an income 17 times higher than the income of the poorest 20% [4].

Economic recession starting in 2015 and a political response since then of fiscal austerity have been undermining efforts to address these problems. In 2016, the National Congress approved restrictive economic measures, including a Constitutional Amendment (CA-95) limiting federal expenditure for the next 20 years.

In 2019, the new federal government deepened budget cuts in almost all areas, including Social Security and environmental protection. In the health sector, government reduced budgets of the More Doctors Program and the National Vaccination Program.

The positive trend in health status of the population from 1990 seems to have ended. Infant mortality rates increased between 2015 and 2016 [5]. Microsimulations have shown that the reduced coverage of the Bolsa Família Program and the Family Health Strategy will increase the number of deaths of children up to 5 years of age [6] and premature deaths of people under 70 years of age [7]. In 2016 PAHO awarded Brazil the Country Without Measles certificate, but in 2018 and 2019, outbreaks in several states brought the disease back. For environmental risks, neglect of protective measures by the Bolsonaro government will expand devastation, including in the Amazon forest.

Brazil’s recent political history helps to explain the status of the health system—as a result of disputes between two different elements of society: those who backed the popular-democratic Health Reform Movement and others who favor the liberal-conservative ideology and prefer to link health to the private sector.

Since the end of the military regime in 1985, the Health Reform Movement achieved essential victories with strategies of three types: parliamentary, technical-institutional, and socio-communitarian. However, the political forces that succeeded in developing these strategies failed to maintain unity and lost influence later in the process [8]. The gains achieved were not sufficient to ensure the universal right to health.

The private sector opposed the expanded SUS and competed successfully for the financial, material, and symbolic resources that Brazilian society assigns to health services. The private sector that opposed the creation of the SUS in 1988 is not made up of the same players that, three decades later, compete for public resources. Currently, the private health sector is led by multi-sector financial corporations. They hold capital from many sources, some in the health sector (health plan operators, hospitals, drug companies, and laboratories), and some from companies in other economic sectors [9].

In sum, the current health ‘system’ reflects more than conscious acts of political agents and can be understood as a consequence of a capitalist society immersed in class struggles [10]. The SUS remains essential for this renewed private sector, as demonstrated by proposals for public–private integration [11]. In practice these translate into broader access to public resources and more private influence in formulating official policies.

How do people who believe that health should be a universal right promote it under these circumstances?

The 16th National Conference of Health (NCH), held in August 2019 discussed the current challenges to promote the universal right to health in Brazil. This NCH had been inspired by the 8th one (1986). The latter strongly influenced the formulation of the Constitution and stressed the intrinsic relation between health and democracy.

The final report of the 16th Conference [12] states that the most important things to do are to respect the popular will by defending Brazilian democracy, promoting social welfare, and strengthening the Unified Health System as part of a comprehensive set of social policies.

Brazilians need to develop the nation in a way consistent with health as a human right. That is, development must be socially inclusive and sustainable. This approach is antagonistic to the ultra-liberal economic policy of the current federal government that instead promotes privatization, divestment in science and technology, social exclusion, and environmental devastation. A democratic-popular approach requires a strategy of overcoming the finance-led economy and valuing productive activities [13].

It is essential to preserve democracy. The government inaugurated in 2019 is attacking all social, political, and civil rights. The president supports Social Security reform that penalizes workers, censors freedom of expression, and promotes violence against indigenous, poor, women, black, and LGBT people. Thus, it is impossible to promote the right to health without defending all rights.

Preservation of democracy requires articulation of coordination among all rights-advocacy movements, including those who struggle for the democratization of the mass media. Protection of democracy includes the demand for release from incarceration of ex-president Lula and a fight against politicizing the police and judiciary.

The struggle for the right to health requires the adoption of specific strategies to improve the SUS:
  • The biggest challenge is to reorient the health care model to overcome the biomedical and mercantilist approach, and to strengthen health promotion practices. Brazil needs intersectoral action directed at the social determinants of health, while extending coverage and improving the quality of prevention, diagnosis, and treatment of diseases and injuries.

  • It is necessary to improve efficiency of the SUS through professionalizing management, health regionalization, strengthening personnel policy to encourage multidisciplinary teams, and ensuring decent work conditions for health care workers.

  • SUS also needs strengthening of financing. Overcoming structural underfunding will require consolidation with the Social Security budget. Immediately, it is vital to defeat the proposal to terminate the constitutional guarantee that, at least, 15% of federal government net current revenues be allocated in the health sector. It would lead to an even bigger reduction of SUS funds than that caused by the Constitutional Amendment 95/2016.

Clearly, implementation of this agenda will not be easy. It requires coordination among all democratic forces working to strengthen citizens’ rights, nationally and globally. In Brazil and worldwide, youngsters and students are occupying the streets to defend public education, indigenous people are struggling for their rights, human rights activism is present, and the global climate strike is under way. Even conservative political agents argue that capitalism has failed to meet the most urgent needs of the population and call for reinvention of free enterprise capitalism [14]. The future cannot be predicted, but prolonging the status quo is virtually impossible.

Luis Eugenio de Souza

Professor at the Collective Health Institute - Federal University of Bahia

Counselor of Abrasco - Brazilian Association of Collective Health

Notes

References

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