Equity in Health
Regina Maria Giffoni Marsiglia
FCMSCP e APSP
Equity is the central theme of discussion in issue 15/2 of Saúde & Sociedade, especially related to modern state and sanitary reform in Brazil. The authors bring important contributions to the reflection of the theme, mainly in the context of the implementation and evaluation of the Unified Health System in the country.
The first article, written by Carme Borrell from Public Health Agency of Barcelona, analyses the causes of social inequalities in health, highlighting the role of sanitary services, of financing, and of services organization, recognizing that those do not represent the main determinants of inequalities. As example, presents inequalities in the use of sanitary services in Catalunha where there is a National Health System.
The worry of Gastão Wagner S. Campos is the analysis of the different concepts of equity and their practical implications. Considers that there is an absolute opposition between the analysis of the concept in the systems of laws and social values and the analysis of the everyday functioning of the system. In the case of Brazil, the author calls attention for the progress of equity in health with the implementation of the Unified Health System SUS, in the last decade, side by side with the permanence of inequalities in the access, financing and use of services.
On the other hand, reminds that it is necessary to recognize that some policies as agrarian reform, job generation, protection of the work income value and income transfer for those in most vulnerable economic situation have more immediate effects in the decrease of inequalities than public health, security, housing and education policies.
The central question posed by Jairnilson Silva Paim from UFBA is if the Unified Health System - SUS can be considered a public policy to promote equity. But to which SUS project the question is directed? To formal SUS, to democratic SUS, or to the real SUS? Considering the cycles of any public policy, it is necessary, as highlights the author, to analyze the phases of its formulation, implementation and evaluation. The sanitary reform and the Unified Health System of Brazil did not have the World Bank or the Inter American Development Bank as patrons in the 80's. At that time, the proposals of these institutions met "certain resistance or open opposition" in Brazil, because organized social movements adopted the ideas of democratization of health, of human rights and of citizenship. In spite of the constraints imposed by structural adjustments, it was possible to maintain, in the 90's, the legal instruments that guaranteed the universal right to health.
The Ministry of Health has given incentives to Committees for Equity Promotion, understood as the provision of services for specific needs of groups or persons, that are able to express their needs and to demand answers from government.
Ana Maria Costa and Tatiana Lionço, respectively Director and Technician, of the Secretary of Participative Management of Ministry of Health, reveal their worries with the production of knowledge about equity and with the implementation of public polities that can change unequal social conditions. As conclusion they point that academic production and the reinforcement of social movements, together, have contributed for mobilizing society for equity.
Two other articles do not refer directly to the issues of equity, but touch them in analyzing SUS in Brazil. The paper by Maria Raquel Pires and Pedro Demo of University of Brasilia, discusses the possibilities of the Unified Health System in the context of the crisis of the welfare state. Facing the ambiguities of a health system that aims equity and the market oriented health services that prosper they point ideas to face the situation that would reinforce the democratic control of public polities by society and the construction of autonomy of subjects.
In other article, Telma Menicucci investigator of Fundação João Pinheiro, observing the Unified Health System of Brazil in the 90's, reminds us that the implementation of a policy is a continuous process: the political and economical contexts of adjustments, as well as the effects of the previous health polities acted as "constraints" to the implementation of the sanitary reform as planned. In the process, the approval of regulation of the private health assistance contested the principles of universalism of SUS and the financing of the system, ending by the consolidation of a dual health system: public and private, according to the author.