The Brazilian Unified National Health System 25 years later
On October 5, 1988, against the neoliberal tsunami, Brazil's Federal Constitution created the Brazilian Unified National Health System (SUS), a common good consolidated in the midst of successive internal crises. Twenty-five years later, the still-young National Health System is experiencing doubts about its own survival.
According to the article by Jairnilson Silva Paim in this issue, concerns raised by the undermining of basic principles in Brazil's Health Reform should not overcloud the urgent defense of a health system capable of reestablishing the Constitutional social pact.
Guest authors debating the paper by Paim expound on the country's paradoxical challenge: how to vigorously support the concept of citizenship underlying the public health system in the face of cumulative privatization policies, how to fit a universal national health system into a social structure that has changed with the country's democratic transition, but which remains stratified and unequal, and how to insist on the idea of building a redistributive social state when policies are subsumed by the interests of capital.
The failure of the neoliberal recipe sheds light on the SUS, especially for those who view Brazil's current income distribution policies and social policy investment as the fulcrum for a new national development strategy. The struggle here will be to distinguish between true change-inducing processes and mere rhetoric, or change for the sake of change. The defeat of SUS is not evitable, like some flash flood that drags everything with it (even the riverbed itself ); still, it will not be simple to preserve from the past the principles of comprehensive, universal access to health with equality and people's participation.
The country is witnessing an economic impasse: to achieve primary surpluses, invest in infrastructure, and reduce the public debt imposes social policy spending cuts. The insufficiency and lack of definition of funding sources add to the impasse, while the private sector closes the siege beyond funding and provision of healthcare services and now also captures the public administration itself.
The wager is on the private health plan market, with an eye on the rising mass of workers, scrambling for public subsidies which fail to deliver on what they sell but have their presence guaranteed in the way regulation is implemented.
Thus, there is still no clear definition of the model and system that will mobilize a nation with more than 200 million inhabitants and that has been called on to improve its health indicators, decrease illness and death, and tackle the determinants associated with high-priority and avoidable health problems.
How can Brazil achieve a fair health system with case-resolution capacity and quality? How can it reorganize the roles of administrators, health workers, providers, and users in ensuring the rights of citizenship? How can it train, value, and retain health workers (including but not limited to physicians) in order for them to truly produce health? Adequate answers to such questions increasingly require the mobilization of theoretical inputs and methodological approaches.
The health system thus urgently needs an expanded agenda: a democratic political reform that extends the possibilities for participation, a socially just tax reform, and the re-articulation of SUS with the social security and social welfare systems, as provided by the 1988 Constitutional model, including the sharing of current and future social security revenues.
At this time of intense public unrest, we can only hope that the chimeras haunting us will give way to glimpsing a health system capable of generating development, that gives us pride, and that occupies a leading position in the country's life.
Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil.