This article is the result of a narrative literature review. The objective is to show the development of an overview on the ideological debate on the design of state health policies. We argue that the role of the state in the development of health policy, even under the pressure of the global market, may create alternatives to promote and drive economic and social development, meaning they are not subject to economic constraints imposed by the liberal ideal of market. Here is a part of a theoretical discussion about the construction and presence of the State in Latin America, particularly in Brazil. We take the approaches of the Marxist tradition and liberal to the issue as reference. This discussion allows us to understand the historical role of the state in the maintenance of social policies, specifically health, is an alternative to public control eases the intense capital mobility promoted by economic globalization. In this sense, the theme makes the Brazilian health an important issue of social sciences, why is the historicity of the construction of the Brazilian health system, as a public policy that can mirror the actual reconstruction of the institutional framework of the Brazilian state with the establishment instances of negotiation between the various spheres of power that strengthen the state in this process of democratization of Brazilian society.
State; Public Health Policy; Policy Innovation; Public Management
This article results from a narrative bibliographic revision aiming to develop an overview of the ideological debate on the concept of the State in health policies. Referencing Rother (2007)ROTHER, E. T. Revisão sistemática x revisão narrativa. Acta Paulista de Enfermagem, São Paulo, v. 20, n. 2, p. 5-6, 2007. Disponível em: <http://www.scielo.br/pdf/ape/v20n2/a01v20n2.pdf>. Acesso em: 15 maio 2014.
http://www.scielo.br/pdf/ape/v20n2/a01v2... , this review is a description of the state of the topic in question, considering authors relevant to grasping the contexts based on which the public policy problems were elaborated in the Social Sciences field in general and in Brazilian Public Health in particular. Thus, the aim of this work is not to establish a methodological path, nor to select studies using statistical proceedings. On the contrary, this article is a critical analysis of the role of the Brazilian state in developing health policies. We argue that, even with the pressure of the globalization of the market, alternatives to promote and guide economic and social development can be created, which does not mean submitting to the economic restrictions imposed by the liberal market ideal. The discussion, therefore, places health as the central issue in Social Sciences debate. We agree with Kerstenetzky (2012KERSTENETZKY, C. L. Sobre a crise do estado de bem-estar: retração, transformação fáustica ou o quê? Dados, Rio de Janeiro, v. 55, n. 2, p. 447-485, 2012. Disponível em: <http://www.proac.uff.br/cede/sites/default/files/td67.pdf>. Acesso em: 26 abr. 2013.
http://www.proac.uff.br/cede/sites/defau... , p. 250) when he states that publicly financing health care "[…] is effective insurance against the medical risks that are not covered by private insurance, whereas publicly financing education ensures the risky and uncertain investment in education in early life". These actions provide an effective instrument against poverty and social exclusion.
In times of crisis, the Brazilian State has managed, to a certain extent, to respond to social demands through a set of public interventions aimed at promoting wellbeing, based on an extensive, universal and free health care system, involving the participation of the population in the various spheres of decision making.
For the purposes of this article, we will define the importance of the study of the State and its interpretations on a Latin American basis. Although knowledge of the importance of this institution in producing society has accumulated, we review how this topic is approached in the Social Sciences as, especially in Europe, it is in crisis and the value placed on it has oscillated considerably in public debate over the last few decades.
Whereas some interpretations were questioned in Europe and the United States in the 1970s and 1980s, in 1990s Brazil the debate followed another course, especially concerning discourse on the end of the Welfare State. This debate arose from the internal contradictions of capitalism itself, through inconsistent and unequal growth, triggering large scale chronic problems, and through the need to incorporate pressing social demands.
Although it appears almost natural to study the State as an institution present in individuals' everyday lives, it is not. The modern State was created as the product of the end of feudalism and the rise of capitalism from its primordial form; mercantile. Centralizing power which was previously dispersed throughout society and divided between secular and religious institutions lead to the creation of a totally new sphere of European life. For the first time, one single institution came to be responsible for distributing justice, collecting tax and defending the territory associated with it. This process is well understood in an extensive study of the historical construction of the concept of sovereignty developed by Kritsch (2002)KRITSCH, R. Soberania: a construção de um conceito. São Paulo: Humanitas, 2002..
This new fact has been observed, studied and analyzed extensively and has produced various essays in the Social Science field in general, including Political Geography (Gregory; Martin; Smith, 1996GREGORY, D.; MATIN, R.; SMITH, G. (Org.). Geografia humana: sociedade, espaço e ciência social. Rio de Janeiro: Zahar, 1996.). From the 16th century onwards, a plethora of intellectuals, philosophers, lawyers and sociologists have tried to explain this new institution, its origin and its purposes. Texts by theorists such as Machiavelli, Hobbes, Locke, Montesquieu, Rousseau, Marx and Weber today form an integral part of the discipline of applied sociology and are used in other courses outside of the Social and Human science fields. Friedrich Ratzel (who came up with the idea of lebensraum, living space) and Halford Mackinder (responsible for establishing Geography as a discipline in British universities) may be remembered for the influence their ideas had on the advance of political theory in the field of Geography.
Since the foundation of the State, the nomothetic Social Sciences (Politics, Economy, Sociology), as well as scientific disciplines and History, have studied it as a central locus of the organization of modern life, at least until 1945. This only occurred when the study was of Western nations, as anthropology, for example, and even the nomothetic sciences, did not use the State as a reference or centrality of organized social life when studying non-Western societies. However, with the introduction of research on the topic of development after the Second World War, the Social sciences also began to study countries in their state units as a singular space for development (Calouste Gulbenkian Foundation, 1996). This was due to the introduction of the Breton Woods system, which created international monetary control and financial aid institutions, in particular the International Monetary Fund and the World Bank.
Although not all Social sciences consider the State as the natural limit of social action, state-centric analyses remained prominent until the mid-1960s and early 1970s. After this period, severe criticism of the State as the agent guaranteeing future progress, much as boasted by scientific positivism in the late 19th century, erupted onto the world stage.
One if the main Western currents of thought that came to amalgamate the new intellectual posture of relativizing the importance of the State was, without a doubt, culturalism, which thrived in Anglo-Saxon Social Sciences from the late 1960s onwards. In Geography, in particular, there was significant output of studies on communities and criticism of cultural changes in post-war Great Britain between the mid-1950s and the early 1970s (McDowell, 1996MCDOWELL, L. A transformação da geografia cultural. In: GREGORY, D.; MARTIN, R.; SMITH, G. (Org.). Geografia humana: sociedade, espaço e ciência social. Rio de Janeiro: Zahar, 1996. p. 159-188.). Also of great importance was "New History" in its most recent aspect, the history of mentalities and small say-to-day facts (in contrast to the life of those at court and of the wielders of power).
The State's loss of centrality in human sciences studies taking place at the same time as the weakening of the "ultimate determinants" which occurred at the level of explanations and of the so-called crisis of the grand narratives. It should be emphasized, however, that this "state-centric" focus is from continental Europe, as in the English intellectual tradition, the State was never one of the most relevant objects of study. Anglo-Saxon theorists made much more use of the concept of the political system; nevertheless, in the late 1970s and early 1980s the State was also reborn as an important conceptual element in understanding the organizing process of those societies in their domestic environment. The domestic counterpoint is necessary as this concept, understood as the national unit against other national units, always in play in the international panorama, has never been difficult to understand (Easton, 1982EASTON, D. O sistema político sitiado pelo Estado. In: LAMOUNIER, B. (Ed.). A ciência política nos anos 80. Brasília, DF: UnB, 1982. p. 129-150.).
Referring to this discussion of establishing the State as an analytic concept and its antinomy, the political system, Schwartzman (1982a)SCHWARTZMAN, S. Comentário: quem tem medo do Estado? In: LAMOUNIER, B. (Ed.). A ciência política nos anos 80. Brasília, DF: UnB, 1982a. p. 151-156. reminds us that the preference for the concept of the political system manifests itself according to a historical-cultural specificity, that is, the almost lack of State in the USA and in England compared to continental Europe. Actually, this comment is almost a quote the author used from J. P. Nettl who talked of the "[…] relative loss of interest […]" (Schwartzman, 1982aSCHWARTZMAN, S. Comentário: quem tem medo do Estado? In: LAMOUNIER, B. (Ed.). A ciência política nos anos 80. Brasília, DF: UnB, 1982a. p. 151-156., p. 153; Schwartzman, 1982bSCHWARTZMAN, S. Bases do autoritarismo brasileiro. Brasília, DF: UnB, 1982b., p. 42) in the topic of the State in Marx's writing after he moved to England. Researchers in these countries much more commonly use the terms government or authority in the studies, closer to the "simple and light functional entities than to the historically weighty notion of the State" (Schwartzman, 1982aSCHWARTZMAN, S. Comentário: quem tem medo do Estado? In: LAMOUNIER, B. (Ed.). A ciência política nos anos 80. Brasília, DF: UnB, 1982a. p. 151-156.).
Obviously, this historical-cultural outline neither exhausts nor circumscribes the problem as the political-philosophical tradition of the researcher affiliated with a range of concepts and notions is internal to the cultural backgrounds. This affiliation enables us to recognize a discursive matrix in it which locates it at some point between the left and right wing of the political spectrum, both in practice and in political reflection.
Let us digress briefly discussing how some of those possible positions view the problem of the State and its presence in the everyday life of individuals and societies. We will consider three positions: the Marxist left, the social democrats (post Second International) and the liberals. These were, after all, the positions that informed the debate on the State and its role in Brazilian Social Sciences.
The State according to some thinking
For the Marxist left, the character of the State has always been a means, the existence of which was determined as part of the long term project, that of societal self-determination, although the revolutionary trajectory of diluting State power, paradoxically, strengthens its power in the dictatorship of the proletariat.
Self-determination is expressed in the councils' topics. The extinction of the State would be the logical derivation of organizing the proletariat as the dominant class, as it would not become the dominant class in order to perpetuate its power, but rather to abolish class dominion, the practical justification for the existence of the modern State. The State is understood as organized violence on the part of one class towards another - in the capitalist system the bourgeois towards the proletariat, according to Valentino Gerratana (1979)GERRATANA, V. A temática dos conselhos e a extinção do Estado. In: CARDOSO, F. H; MARTINS, C. E. (Org.). Política esociedade 2. São Paulo: Nacional, 1979. p. 60-72. (Biblioteca Universitária. Série 2. v. 54), Italian Communist Party Militant and organizer of the celebrated edition of Antonio Gramsci's Prison Notebooks by the Editora Einaudi, in 1975.
Obviously, the discussion is neither so simple nor so free of contradictions within the left wing all over the world, especially in the debate between members of the First and Second International. This debate is expressed in Lenin's The State and the Revolution, among others, criticizing the gradualist reading of "opportunists" abolishing the State. Gradualism would be derived from an opportunist reading of the clash between Engels and the anarchists, when he affirmed, responding to them, that the State would not abolish itself, but would extinguish itself when the necessary conditions for its existence extinguished themselves. According to Lenin, this reading would have justified the way the Second International "opportunists" appropriated State machinery to perpetuate their power while waiting for what was to come (Gerratana, 1979GERRATANA, V. A temática dos conselhos e a extinção do Estado. In: CARDOSO, F. H; MARTINS, C. E. (Org.). Política esociedade 2. São Paulo: Nacional, 1979. p. 60-72. (Biblioteca Universitária. Série 2. v. 54)).
More recently, Poulantzas (Political power and social classes; State, power and socialism and; The problem of the capitalist state) sought to develop - in contrast to what is usually known as the lack of Marxist theory of the State - a deeper reflection on this entity in its historical significance. However, despite this attempt, it seems that clarity and precision in the concept of the State remains in progress. In this respect, David Easton's (1982)EASTON, D. O sistema político sitiado pelo Estado. In: LAMOUNIER, B. (Ed.). A ciência política nos anos 80. Brasília, DF: UnB, 1982. p. 129-150. critical theory appears most pertinent. This author states that the concept in extending Poulantzas' work gained various synonyms, even metonyms, such as a part (taken) for the whole. At some points, Easton states that the "[…] State is the ever evasive flower of Estado Poulantzas' theory" (p. 133), and later concludes:
So…what IS the State? It is not only political power, that is, class practices. It is not class power relationships. It is not an "intrinsic entity". It is not a Thing. It is not a subj ect. It is not a set of functions. It is not governmental or ideological apparatus, although it manifests itself through them.(Easton, 1982EASTON, D. O sistema político sitiado pelo Estado. In: LAMOUNIER, B. (Ed.). A ciência política nos anos 80. Brasília, DF: UnB, 1982. p. 129-150., p. 141)
Even Poulantzas, however, the theorist with the most weight who tried to advance a Marxist State theory, also professed the practical-theoretical desire to effect the Marxist teleology of the end of the State political power) through abolishing the structure of class domination.
The path of the concept of state as reaped by the international left does not seem to be easily transposed. In The State in Capitalist Society, Ralph Miliband also sought to demonstrate Marx's concept of the State, principally in the particular form of economic formation, showing how at that time of his life the German philosopher was reading this concept in a variety of way; however, his premise was always that the defense of property was its central fulcrum, irrespective of its form (Miliband, 1979MILIBAND, R. O Estado na sociedade capitalista. In: CARDOSO, F. H.; MARTINS, C. E. (Org.). Política esociedade 1. São Paulo: Nacional, 1979. p. 62-70. (Biblioteca Universitária. Série 2. v. 53).). Of the critiques of the State as absolute, in Hegel, from the bourgeois executive committee in the Communist Manifesto to the brilliant analysis of The 18th Brumaire of Louis Bonaparte, Marx has the State as an instance of the reality with relative autonomy, the latter reading being the most mature of his work.
For classic liberals, it is enough that the State defends property and maintains the monopoly on the use of legitimate violence, the so-called rule of liberal law, separated into three autonomous powers, as opposed to absolutism in the constant pursuit of the "eternal pursuit of possible balance." The premise of separation between society and the State is the keystone of this theory, as "[…] society continues to be based on the private availability of the means of production; thus, economic life regulates itself, in principle, on the classical institutions of private law" (Habermas, 1979HABERMAS, J. Participação política. In: CARDOSO, F. H; MARTINS, C. E. (Org.). Política e sociedade 1. São Paulo: Nacional, 1979. p. 375-388. (Biblioteca Universitária. Série 2. v. 53)., p. 381).
Those classical law institutions, the maximum expression of which is the liberal constitution, assume that "[…] political rights should be realized on the economic scale", as long as society is "[…] a society of autonomous citizens enjoying uniformly distributed private property" (Habermas, 1979HABERMAS, J. Participação política. In: CARDOSO, F. H; MARTINS, C. E. (Org.). Política e sociedade 1. São Paulo: Nacional, 1979. p. 375-388. (Biblioteca Universitária. Série 2. v. 53)., p. 378). This premise leads the author to conclude that no such society has existed at any time. This was the period in which the modern State was established in the early days of the development of capitalist society, when the idea of generalized liberties and the end of the still clinging darkness of the feudal system was the project of the newly ascendant class.
However, with the development of the capitalist system of production, both State and liberal activites changed:
The entrepreneurial and state regulatory activities correspond to the logic of reproducing the system at its current stage. The expansion of state planning activities and directly productive investment by the State meets the requirements of a new market structure and of the dominance of large oligopolistic units within.(Abranches, 1979ABRANCHES, S. H. Estado e desenvolvimento capitalista: uma perspectiva de análise política estrutural. Dados, Rio de Janeiro, n. 20, p. 47-69, 1979., p. 53)
The invisible hand of the market should be able to devote some of its primacy to regulatory state action. Until the 1990s, state intervention in the economy was seen as a necessary measure to compensate for the market's "imperfections". From the 1930s onwards, both liberals and social democrats have understood the need to maintain good investment conditions for private enterprise. In the 1980s, however, an offensive was mounted by the liberals, in the guise of neoliberals, to withdraw the State from activities into which the 1930s' crisis had pushed it. The new "minimalist State" was underway.
The post-1917-revolution social democrats, forged in the fires of constructing the European Welfare State, attempted to maintain their historical conquests of protecting employment and working families, won after much struggle within and outside of the State: regulated working day, workers' rights that were respected by employers, the prohibition of child labor, work safety conditions within the capital-labor relationships; establishing social security, public housing policies for workers, universal health and education, protecting women, children and the elderly within the public ambit of the State.
The idea of democratizing the large spheres of power, be they administered by the State, be they large private companies, entered the debate in the latter decades of the 20th century. This was the role of the social democrats, whose greatest exponent was Norberto Bobbio. The study of the State was the greatest concern during this period, especially based on Antonio Gramsci's particular reading of the concept of civil society in works such as The concept of civil society - O conceito de sociedade civil and The future of the State - O futuro do Estado, published in Brazil in 1982 and 1986 respectively. The State was not understood as an epiphenomenon of the economic determinants, but rather as an essential element in the organization and conformation of social reality in its entirety. In other words, an actor fully acting and interacting with the other forces competing to define the course of the future of the society in which they found themselves.
The State in Latin America and Brazil
It was a disagreement between liberals and Marxists on the State's role, its ontology and its bases, referred to by the North American David Easton earlier in this reflection. The author is uncomfortable with the return of the State to the discussion of political science in the United States and defends the use of the concept of the system and more appropriate for explaining the phenomena of party competition for political power. However, for Latin American countries, especially Brazil, this discussion has no connection with reality, given the process of the State's construction here. State presence is so marked and preponderant that the idea that the national state was born even before the nation is coherent with accepted thinking in academic political science; otherwise, see these remarks by sociologist Fernando Henrique Cardoso:
[…] For us, who graduated historically within a tradition occupied by the notion of the State, it is difficult to think of a society without a State, although the Americans talk about "stateless society". For us, it is almost impossible to think of it, because we were born in the Portuguese Empire, subjugated by an all-powerful state. Sometimes we forget, therefore, that this is not in fact necessarily a permanent situation (…)
The independent national state in Brazil was born after the transfer of the imperial state Portuguese to this country. It was the only situation in Latin America in which the Metropolitan State and all its bureaucracy, moved with D. João VI to a colony (…) And in the process of Independence, the national state inherits this state apparatus of the Portuguese Empire(Cardoso, 1977CARDOSO, F. H. O Estado na América Latina. In: PINHEIRO, P. S. (Coord.). O Estado na América Latina. Rio de Janeiro: Paz e Terra, 1977. p. 77-99., p. 84)
The inspiration of the above interpretation by Cardoso is clearly rooted in the Weberian tradition, with Raymundo Faoro the first theorist to outline it in all its sophistication in The owners of power - Os donos do poder. In fact, this is an interpretation that deeply marked Brazilian social thinking in the first half of the 20th century. The idea of the formation of the State, before even the birth of the nation, had profound consequences in the way the intellectual elite and national cultures view and act towards the role of civil society in Brazil. The latter, and its popular classes, came to be seen as an amorphous mass needing to be shaped, cared for and guided towards superior illuminist thinking that gave meaning to their future and to "civilized order". This way of viewing civil society was not the privilege solely of the conservative thinker. When drawing up theories, academia also centralized its analysis on the State's role and functions as the inducing agent of society movement as a whole. The discovery of civil society was one of the tasks to which the new generation of intellectuals dedicated themselves, academically maturing in the forges of resistance through the urban social movements of the 1970s. An emblematic expression of this is Éder Sader, with the work When new actors enter the scene - Quando novos personagens entram em cena, the research and writing of which were developed in the early 1980s.
Symptomatically, it was in this period that French intellectuals such as Michel Foucault and Félix Guatari were systematically presented to Brazilian academia, the texts and reflections of which placed much greater emphasis on the day-to-day relationships of power, the so-called micro-powers.
However, the State did not lose its effectiveness, neither in life nor in future academic reflections. We must not throw out the baby with the bathwater. Given the theft to which work in Brazil is still subject, the State is the institution to which the entire trade union movement refers in its clashes with capital. Despite the catastrophic panorama presented by Robert Kurz in The collapse of Modernization - O colapso da Modernização, placing us on the international scale among "[…] deindustrialization indebted" countries (Kurz, 1992KURZ, R. A crise do sistema mundial produtor de mercadorias. In: ______. O colapso da modernização: da derrocada do socialismo de caserna à crise da economia mundial. São Paulo: Paz e Terra, 1992. p. 198-222., p. 214) - where neither the State nor any other agent has the least chance of bringing us into the circuit of successful accumulation - the State continues to be the institution to which the eyes of all those who dispute projects of power turn.
Brazil recovers its public sense of democracy in the decade in which the world saw the collapse of the social alternatives (real socialism) to the exploitation of labor as the modus operandi of the material production system. In the same period, the modern Western version of the State is questioned in the center of the goods producing world, the one in which that same State was born as necessary for organizing large scale production and social control of public life inherent to the capitalist system of production. In this sense, the reflections by the Brazilian historical and intellectual tradition are closer to Boaventura de Sousa Santos, in Reinvent democracy - Reinventar a democracia (Santos, 2002SANTOS, B. S. Reinventar a democracia. Lisboa: Gradiva, 2002.) than to those of the English intellectuals, concerning the daily life of workers as a way of distancing themselves from State preeminence, as the analytical focus of the human phenomena of the struggle for power.
The Brazilian State, from the narrowest perspective, concurrently with the creation of society itself, presents itself to the citizens as a Siamese twin to its existence. The social movements that occurred in Brazil in the 1970s were directed at the State viewing it not as an enemy but rather as legitimizing their needs and demands, as Silva and Ribeiro (1985)SILVA, L. A. M.; RIBEIRO, A. C. T. Paradigma e movimento social: por onde andam nossas idéias? In: ANPOCS. Ciências Sociais Hoje, 1985. São Paulo: Cortez: ANPOCS, 1985. p. 318-336. show. The contradictory vision which pits civil society against the State does not seem to resonate in the lives of the majority of the population not served by the collective consumption goods ordinary to modern urban life. A simple example of this perspective is the 1996 election for mayor of São Paulo. The administration system of the Health Care Plan (Plano de Assistência à Saúde - PAS), proposed by then Mayor Paulo Maluf, included an instrument to register the client population with determined health care teams according to their place of residence, so a particular person would only be treated in a particular health center if they live in the area covered. This was the so-called PAS Card (like today's proposed SUS Card). To some intellectuals this sounded like limiting in choice; to the population that uses municipal health care services, however, it was presented as a document of their "existence" for the State. Recognizing citizenship.
Nor is it strange for the trade union movement to seek State justice when it clashes with capital over defending workers' rights, or for urban social movements who appeal to the same actor to satisfy collective consumption needs. In other words, in Brazil, neither the popular classes nor the trade-union-organized working classes view the State as a mere bourgeois "executive committee" or a a mere entity that regulates contracts.
With the exception of the anarchist movements of the 1910s and 1920s, organized by new Italian leaders who began to work directly in the middle of urban industry and for whom the State was society's policeman, the struggle of the Brazilian trade union movement was limited to the factory environment, outside of the public regulation space in the early days of organization. Being a tributary of an enslaved society, Vargas' state was a counterpoint to the savagery of the working conditions imposed by the old agrarian exporter order and by the devaluation of work as an established activity of civilized life, according to the standards of the capitalist mode of production.
In truth, Brazil, as with the majority of Latin American countries, only saw political democracy re-established on more consolidated bases, due to the processes of urbanization and the increasing complexity of societies, in the late 1980s and early 1990s. Coincidentally, it was in this period that the "Washington Consensus" (Batista, 1995BATISTA, P. N. O consenso de Washington: a visão neoliberal dos problemas latino-americanos. São Paulo: PEDEX, 1995.; Portela Filho, 1994PORTELLA FILHO, P. O ajustamento na América Latina: crítica ao modelo de Washington. Lua Nova, São Paulo, n. 32, p. 101-132, abr. 1994.) came into force changing the State in the region, weakening its capacity to arbitrate at the very moment when the chance for power to alternate between various groups and factions of social classes became more real. However, despite the countless privatizations of economic activities and the State's withdrawal from a variety of fields in which it used to have the monopoly (social security, safety, oil extraction), a great part of its creative force remained. In Brazil, In Brazil, the cases of several citizens' councils working in state administration and the experiences of participatory budgeting (even considering their limitations) are emblematic of the possibilities.
From the perspective pointed out by Santos (2002)SANTOS, B. S. Reinventar a democracia. Lisboa: Gradiva, 2002., therefore, first of democratically rediscovering work, looking at the State as a brand new social movement then becomes more socially attractive and more concrete for Brazilian society. It is not unusual for us, in our day-to-day practices, political struggle and demands, to turn to the State and understand it as the legitimate agent to settle disputes and meet collective demands for goods, especially in these times of possibilities to dispute a variety of electoral projects, something that has only occasionally occurred in our history. In other words, the democratic discovery of the State and the chance to experience alternative governance projects.
Rethinking the role of the State in Brazil based on public and social policies
Brazilian Social policies should be understood with reference to the State. The discussion of the nature of public policies is tributary to Social Science reflections on state development and planning in its dynamic. According to Augusto (1989AUGUSTO, M. H. O. Políticas públicas, políticas sociais e políticas de saúde: algumas questões para reflexão e debate. Tempo Social, São Paulo, v. 1, n. 2, p. 105-119, 1989., p. 84), the notions of public planning and policies are, given the characteristics, very "[…] close, similar and, therefore, interchangeable […]", although not free of distinctions. Whereas planning, especially in the 1950s and 1960s, can be seen as state action par excellence with a more ambitious horizon for structural change in society, public policies do not have this objective, with lower capacity for transformation.
Public policy refers to state action in the "[…] different dimensions of social life […]" and the function of which is to impose "[…] a specific rationality on the various orders of State action, rearranging things, sectors and situations" (Augusto, 1989AUGUSTO, M. H. O. Políticas públicas, políticas sociais e políticas de saúde: algumas questões para reflexão e debate. Tempo Social, São Paulo, v. 1, n. 2, p. 105-119, 1989., p. 84).11That seems to be one of the key administrative features that the creation of the federal program "Bolsa Família" represents when it groups different forms of assistance into one single rubric. All of this internal movement in the State reflects its contradictory nature and its space of domination and conflicts, which take on a corresponding design at each moment in history and set of specific forces. The same reasoning is applied to political sciences.
Since the 1970s, when the notion of planning gave way to discussions on public and social policy, the driving force of the evaluation of these forms of state intervention was economic efficiency as a unit of measure. This debate continued into the 1980s, profoundly marking social policies as either redistributive or merely compensatory. The poor cousin of the redistribution versus compensation equation, equity, as a rule, was impaired in the name of efficiency. It does not, however, invalidate the elevation of the political social idea as an action that is not subservient to economic policies but rather with relative autonomy of objectives. This process took place in the 1970s (Augusto, 1989AUGUSTO, M. H. O. Políticas públicas, políticas sociais e políticas de saúde: algumas questões para reflexão e debate. Tempo Social, São Paulo, v. 1, n. 2, p. 105-119, 1989.).
Two topics, the foci of State action, were included in the concerns of the military government as essential to achieving the planned development of the time: health and education. Two topics that strongly mobilized discussion of the State's role in maintaining the workforce through indirect salary, thus easing the payment costs for capital
In the health care sector, associated with this discussion on maintaining the workforce using public funds, the issue of the "health industry" also emerged, the whole population benefitting from the expansion of individual medical care, not just INSS (Social Security) contributants and their dependents. This was an extensive discussion in the 1970s and 1980s and there is a vast amount of literature on the topic, as public health has always been the object of political dispute between social actors (Giblin, 1999GIBLIN, B. Pourquoi la santé publique est devenue une question géopolitique? Hérodote, n. 92, p. 3-11, 1999.). Public health is, therefore, a fertile field for investigating power relationships and the way in which the State is constituted, through the policies established and practiced. With the establishment of the Brazilian Unified Health Care System, after the 1988 Constitution, which proposed to universalize services, from public health activities to high complexity care in hospitals, the discussion took on new shape.
The State and the national health policy in Brazil: some notes
Brazilian public health has thrown light on the difficulty of articulating the different spheres of power - municipal, state and federal - the fruit of a lack of effective federal agreement in the Brazilian republic, since its genesis. At certain periods of the history of public health in this county, a process can be observed of concentration into the central sphere, state institutions present and controlling the territory from the center. At other times, the authority of State governments and initiatives at a local level to meet the population's health needs can be seen more clearly. In both situations, studying public health threw light on social relationships of competition and cooperation, outlining the geographic scales around which power is exercised and contested (Guimarães, 2006GUIMARÃES, R. B. Saúde pública na América Latina: questões de geografia política. In: LEMOS, A. I. G.; SILVEIRA, M. L.; ARROYO, M. (Org.). Questões territoriais na América Latina. Buenos Aires: CLACSO, 2006. p. 1-21.).
To exemplify, the health policies in the First Republic (1889-1930) played an important role in creating and increasing the Brazilian State's capacity to intervene in national territory. Since 1914, with the establishment of health legislation, the Brazilian public authorities began to provide legal and institutional apparatus and human resources to control the health conditions of urban housing and the production and sale of foodstuffs. The following were the responsibility of the central (federal) government: health services at the ports, supervision of medical, pharmaceutical and laboratory activities (including the control of vaccines and serum), organizing demographic and health statistics and imposing compulsory notification for various diseases (typhoid, cholera, yellow fever, plague, smallpox, diphtheria, typhoid, tuberculosis and leprosy).
Little by little, national health policy constituted itself into a network of public institutions that shared a general concept of health and disease, transforming communicable diseases into a political problem. The Spanish flu epidemic that engulfed the country in 1918, which also affected the elite, lead to a minimal consensus concerning the urgent need for change in public health. Under the impact of this epidemic, the federal public authority has made progress in its ability to act coercively towards society during the 1920s (Hochman, 1998HOCHMAN, G. A era do saneamento. São Paulo: Hucitec, 1998.).
In the early 20th century, no one knew better than sanitation doctors how to exploit this situation politically. Through speeches, leaflets, journal articles and representation in the National Congress, they convinced Brazilian public opinion that health was one of the most significant problems in the country and called for discussion of the alternatives for overcoming what was deemed Brazil's main sanitation issue: the "sertão - wilderness".
With the success of public health in controlling the principal epidemics by the early 20th century there was a progressive decline in the model of the organization of services such as the power of the police, which lacked meaning. The field of public health experienced a period in which its course was redefined and priorities were changed according to the agent defined by the health movement, with emphasis on health education and combating rural endemic disease. The 1917 sanitation service reforms were an initial framework for these changes (Gonçalves, 1994GONÇALVES, R. B. M. Tecnologia e organização social das práticas de saúde. São Paulo: Hucitec, 1994.).
Resulting from this new organizational model were the health centers, which held educational lectures, created posters and leaflets and organized exhibitions with projections of slides and films. Thus, they diffused education with the goal of creating a health awareness, introducing a new character to public health services: the health educator. Priorities were caring for sexually transmitted diseases, leprosy and tuberculosis (Ribeiro, 1993RIBEIRO, M. A. R. História sem fim: inventário da saúde pública. São Paulo: UNESP, 1993.).
Getúlio Vargas' rise to power in 1930 signaled a new period of strong centralization of health policies. The area of public sanitation immediately became one of the sectors Vargas targeted most, especially in São Paulo, where sanitary reform conferred autonomy on health districts. A series of centralizing measures from the "revolutionaries" affected sanitation services in 1930 and 1931: health center activities were reduced and they were transformed into dispensaries subordinate to the Hygiene, and Infant Care Inspectorate, annulling their preventative actions in favor of curative medicine. In the same year, the Ministry of Health and Education was also created, the National Department of Health and Medical-Social Care of which coordinated special services to prevent and treat tuberculosis and leprosy, hospitals, laboratories and health centers in the bigger cities and health centers in the rural areas.
But the reverse movement, towards decentralization and strengthening of the local level in formulating and implementing health policy, is also a trademark of Brazilian public health. Perhaps at no other time in history has this process been as intense as that which occurred from the 1980s onwards, with the political opening and democratization of the country.
The yearning for community participation and the State's ability to meet the needs of its citizens was winning over the streets. Countless professional associations, public and private institutions and neighborhood associations joined forces so that their criticisms and claims became political guidelines for the VIII National Health Conference in 1986, and the 1988 Federal Constitution.
In the 1990s, the formulation and implementation of the Organic Health (federal) Law and the municipalization of public health services expressed in legal terms, the guarantee of a unified health system under community control. The SUS was guaranteed by law, under single administrative control at every level of government - municipal, state, and federal. Moreover, there was a significant change in management, creating community participation mechanisms in the decision-making process. The creation of municipal health councils, with equal representation of users, service providers and government agents, was one of the main mechanisms.
A survey of the profile of Brazilian municipalities, conducted by the IBGE in 1999, shows the extent of these changes: 99% had regulated and established health councils that year, of which 82% were deliberative (IBGE, 2001IBGE - INSTITUTO BRASILEIRO DE GEOGRAFIA E ESTATÍSTICA. Perfil dos municípios brasileiros: pesquisa de informações básicas municipais. Rio de Janeiro, 2001.). In another study (Pessoto; Nascimento; Heimann, 2001PESSOTO, U. C. As políticas de saúde para América Latina e Caribe da Organização Pan-americana da Saúde e do Banco Mundial: uma análise dos documentos e seus discursos. 2001. Dissertação (Mestrado em Integração da América Latina) - Programa de Integração da América Latina da Universidade de São Paulo, São Paulo, 2001.), the formation of local health councils is considered a milestone in enhancing community participation in the public policy decision-making process. The dissemination of experience throughout the country raises important political debate, such as the nature of participation in councils (who the counselor represents and how this representation is given) and the legitimacy or otherwise of their deliberations.
Along with the expansion of health care came democratizing of participatory mechanisms included in the general scope of the SUS, the demand for public control over the management of health resources was in fact a counter-hegemonic movement in the global trend for funding and organization of public services. The World Bank proposal, strongly presented and praised in the 1990s, for financing essential clinical services, even undertaken by the World Health Organization (WHO), was the discourse and the hegemonic policy in force in most of the reforms occurring in developing countries in the last decade of the twentieth century (Pessoto, 2001PESSOTO, U. C. As políticas de saúde para América Latina e Caribe da Organização Pan-americana da Saúde e do Banco Mundial: uma análise dos documentos e seus discursos. 2001. Dissertação (Mestrado em Integração da América Latina) - Programa de Integração da América Latina da Universidade de São Paulo, São Paulo, 2001.).
As with health policy, the other social policies in force in Brazil since the 1990s are also more complex than the discussion of the 1980s indicated, mainly because they are synchronous with the democratization process of the Brazilian State, which saw positive externalities such as, for example, the demand for participation in various councils (education, health and social care). The mobilization engendered at the local level may be a more sensitive indicator than mere economic efficiency for the purposes of evaluating these policies.
A political-administrative innovation made possible by the development of the National Health System was to establish trading and deliberation forums among managers of the three spheres of government of the Brazilian executive authorities.
As a way of removing barriers to problem solving among federal entities the Bipartite Inter Commissions (CIB) and the Tripartite Commission (CIT) were created. The former commissions meet in the states, the federal units, and are composed of representatives of the municipal and state Health secretariats. The CIT meets at the federal level and is composed of representatives of local and state departments of Health and representatives from the Ministry of Health (Nascimento, 2002NASCIMENTO, P. R. SUS: instâncias de negociação entre os gestores: as comissões intergestores e a questão federativa. 2002. Dissertação (Mestrado em Saúde Pública). Faculdade de Saúde Pública da Universidade de São Paulo, São Paulo, 2002.).
In these committees conflicts are resolved and solutions put forward to problems demanded by service managers and the Brazilian health system. It is also in these commissions that requests for extension and creation of new services in the States or municipalities are approved. Problems that remain unresolved by these executive bodies are sent to the National Health Council, the highest political body of the SUS.
The modernization of the Brazilian state - the result of democratization period occurring in the 1980s - can be illustrated by these artifacts of institutional engineering, created in the wake of the decentralization of financing, provision and management of health services. The strategy for decentralization was the municipalization of services and their management, thus creating a system integrated into the three levels of the federation. This process began in the late 1980s, continued throughout the 1990s and until the early 21st century. In this period there were also four national health conferences (9th CNS in 1992, 10th CNS in 1996, 11th CNS in 2000 and the 12th CNS in 2003). Meetings between civil society and the State, in a deliberative forum where the health system guidelines for the following years are defined (Yunes, 1999YUNES, J. O SUS na lógica da descentralização. Estudos Avançados, São Paulo, v. 13, n. 35, p. 65-70, 1999. Disponível em: <http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0103-40141999000100006&lng=pt&nrm=iso>. Acesso em: 17 jul. 2013.
In the 2000s regional agreements between municipalities and regional representatives of state health secretariats were created. They are the Regional Management Collegiates (CGR), established to carry out forms of joint management between municipal health secretariats in the same health district (Brasil, 2006BRASIL. Ministério da Saúde. Secretaria Executiva. Departamento de Apoio à Descentralização. Coordenação-Geral de Apoio à Gestão Descentralizada. Diretrizes operacionais dos pactos pela vida, em defesa do SUS e de gestão. Brasília, DF, 2006.). They are horizontal cooperation mechanisms that simultaneously represent the radicalization of the process of decentralization and vertical cooperative relations in CIB and CIT.
In this sense, society's participation in health councils is here considered an innovative institutional arrangement in response to the social demand experienced in the 1970s and 1980. In view of this, Ribeiro and Guimarães (2007)RIBEIRO, E. A. W.; GUIMARÃES, R. B. O lugar da participação popular na gestão de saúde: matrizes conceituais e os rumos da política brasileira. RAE GA: o espaço geográfico em análise, Curitiba, n. 13, p. 29-41, 2007. Disponível em: <http://ojs.c3sl.ufpr.br/ojs2/index.php/raega/article/view/7144/9078>. Acesso em: 29 maio 2013.
http://ojs.c3sl.ufpr.br/ojs2/index.php/r... and Guimarães and Ribeiro (2009)GUIMARÃES, R. B.; RIBEIRO, E. A. W. Plano Nacional de Saúde e o lugar social em disputa. Saúde e Sociedade, São Paulo, v. 18, n. 4, p. 609-619, 2009. Disponível em: <http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-12902009000400005&lng=en&nrm=iso>. Acesso em: 26 abr. 2013.
http://www.scielo.br/scielo.php?script=s... argue that the degree of the councils' innovation is in including government representatives, professionals and health care providers on an equal footing with user representatives, chosen by civil society associations.
These were the steps taken by civil society and by the Brazilian State in the late 20th century and early 21st century, to think about the complexity of a management system that could give voice to national diversity and the wide range of regional blocks or subsystems and political representation sites.
It is very important to discuss the role and functions of the State today in order to understand the conflicts in which they sometimes became enmeshed when constructing the Unified Health System in the first decades of the 21st century. Based on a narrative bibliographical review, we seek to give a brief overview of discussion on the State itself, according to the intellectual traditions that informed the construction of Brazilian social thought about the genesis of our State.
The choice of authors and reference works was marked by the breadth and temporal extension of the analysis. Internationally, in the case of the C. Gulbenkian Foundation, Boaventura S. Santos, Raquel Kritsch and David Easton, discussing the State as an object of study of the various social sciences disciplines and its historical construction. At the Brazilian level we tried to select authors whose analysis is considered dedicated to the very subject of this essay, as is the case of Hochman, Gonçalves, Abranches, Schwartzman, and Silva Cardoso and Ribeiro as, especially on the national level, the discussion of State and health policy becomes more clearly defined.
Forms of public health facility management that require contracts with private organizations, such as social organizations, public interest social organizations and others, raise the issue of privatization or capture of public goods by private interests. This debate is of great importance in the current SUS arena and the various controversies generated by it22Caso da recente polêmica levantada pelo editorial do jornal paulista O Estado de S. Paulo, de 19 de maio de 2014, intitulado "Estatismo na Saúde" e a resposta da Associação Paulista de Saúde Pública (APSP) ao editorial. Disponível em: <http://cebes.com.br/2014/05/o-setor-privado-e-a-exploracao-da-saude-como-negocio/>. should, in our view, be understood in the context of discussion developed in this article.
The State's weight and prominence in Brazilian society should not be neglected when analyzing the formatting of demands for rights, expressed in the form of services. The reflection by Silva and Ribeiro (1985)SILVA, L. A. M.; RIBEIRO, A. C. T. Paradigma e movimento social: por onde andam nossas idéias? In: ANPOCS. Ciências Sociais Hoje, 1985. São Paulo: Cortez: ANPOCS, 1985. p. 318-336. on intellectual output concerning social movements in the 1970s showed that this prominence, at the same time as demand for housing, education, work and safety refer to this same privileged actor in Brazilian history.
We understand that, contrary to the Washington Consensus tonic, Brazil's return to democracy represented the resumption of dialogue between the two great actors of contemporary life: Civil Society and the State, demonstrating that in Hispanic-Portuguese tradition America the centers of gravity for intellectuals and social movements concerns alternate, but do not go under.
Political investment in a State that enables public social policies to be maintained, together with the encouragement of popular participation as a practice of public control for these same policies, is a way of diminishing the intense capital mobility encouraged by economic globalization. The new articulations that capitalism establishes hinder the State's own functionality, because they impose barriers to ownership and distribution of wealth. In historical perspective reviewing innovations in public health management system was effective in the Brazilian case. Whether these instruments still meet the demands that the current situation requires and if this discussion can be applied to other historical and geographical contexts, is a future agenda.
- 1That seems to be one of the key administrative features that the creation of the federal program "Bolsa Família" represents when it groups different forms of assistance into one single rubric.
- 2Caso da recente polêmica levantada pelo editorial do jornal paulista O Estado de S. Paulo, de 19 de maio de 2014, intitulado "Estatismo na Saúde" e a resposta da Associação Paulista de Saúde Pública (APSP) ao editorial. Disponível em: <http://cebes.com.br/2014/05/o-setor-privado-e-a-exploracao-da-saude-como-negocio/>.
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