This new issue of 'Saúde em Debate' (Health in Debate) begins with a reflection on the book 'Everyday Bioethics', by Giovanni Berlinguer. The author, who died in April last year, was one of the great mentors of the Health Reform in Brazil and even published, in 1988, the book 'Reforma Sanitária - Itália e Brasil' , in partnership with Sonia Fleury and Gastão Wagner. The journal continues with a series of articles in which predominate the themes of organization, management, and evaluation of health services. The set of articles, preceded by the article about Giovanni Berlinguer, calls us to reflect on the course of Health Reform and health policies in Brazil.
Over time, public policies tend to have a course marked by relative stability or, better said, by a certain directionality, however, at times, that course is interrupted by great and rapid changes. The course of stability that is favored by the very institutionalization of a policy suggests that policies change only gradually incrementally. However, in times when the problems pile up or when new problems emerge, there may be significant changes that suggest that the course of public policies is episodic. The process of these changes is set by a number of factors, including the general political and social context, the mobilization of political actors both new and old, the conflicts that oppose or combine the actors. The effectiveness of changes will also significantly depend on the institutional structures of formulation and definition of policies and how such structures delimit access to the process, but not only. Speeches and ideas that support changes are also important.
The creation and implementation of the Unified Health System (SUS) show that overall dynamics of public policies. With the process of transition from the military government to a democratic one, a window of opportunity was opened. At that time, several factors concurred to enable a radical change in health through the creation of the SUS: the entry of political actors who had been previously repressed or marginalized in the area (sanitarians, trade union movements of health professionals, trade union movements), the emergence of new institutional structures of health policymaking (VIII National Health Conference, the National Constituent Assembly), the production of new discourses and ideas on health (health is democracy, unified health system, the principles of universality, equity, completeness, hierarchy, and decentralization) that enabled the section 'Da Saúde' (Of Health) as an integrant part of the chapter 'Seguridade Social' (Social Security) of the 1988 Federal Constitution (BRAZIL, 1988BRASIL. Constituição (1988). Constituição da República Federativa do Brasil. Brasília, DF, 1988. Disponível em: <http://www.planalto.gov.br/ccivil_03/constituicao/ConstituicaoCompilado.htm>. Acesso em: 15 jan. 2015.
After the long period of political transition, the SUS gradually found a political context full of ambiguities: the institutional structure of policymaking was extended with new devices (conferences and councils) aiming at popular participation, but at the same time the traditional old policy persisted, and the secular resistance of the middle classes and elites to social policies that promote social inclusion was stripped; the return to a democratic regime and further conquest of municipal, state, and federal governments by the Partido dos Trabalhadores - PT (Workers Party) culminated in a decline of social movements, although that is not true for all, and so, in the health area, organizations such as the Associação Brasileira de Saúde Coletiva - Abrasco (Brazilian Association of Collective Health) and the Centro Brasileiro de Estudos em Saúde - Cebes (Brazilian Center for Health Studies) have persistently continued to struggle for the effective implementation of the SUS against the commodification of health, even if that fight has been battled more in the academic field; the production of speeches and ideas has shifted to the areas of epidemiology and health management, producing important knowledge for the implementation process of the SUS , but often leaving the production of political discourses in a vacuum.
In this context, the old directionality of health policies set by the ambiguous relationship between the 'public' and the 'private', marked either by tension or opposition, or by a symbiotic relationship, which was thought to be overcome with the creation of the SUS, continued to be reproduced in new ways: on the one hand, the SUS, a public system based on the principles of universality, equity, and integrity and operating according to the logics of social rights, and on the other hand, the private companies which produce health actions and services according to a commercial logic; the SUS providing health care to the majority of the population and developing actions of health promotion and prevention for all, and the private companies providing care for employees of large companies or for the Brazilian elites and shares of the population with high income who behave like they have more right to health; the first marked by a chronic underfunding, and the latter benefited from direct and indirect government financial incentives.
The current political, economic, social, and ethical crisis deepens the tension and opposition as, on the one hand, the Executive power constrains the budget of the SUS through 'structural adjustment' policies and, on the other hand, the Legislative power favors private health companies through proposals of constitutional amendments that strengthen the penetration of foreign capital in health, the coverage expansion to private plans, and the privatization of the management of public services. However, as the 'polycrisis' threatens the SUS project, at the same time it creates new possibilities, raising the mobilization not only of health workers, but of all social forces that resist to the reduction of social rights.
The challenges that health policies guided by the principles of universality, equity, and integrality face all the time in an extremely unequal society, in which the elites oppose to the extension of social rights, permanently raise questions that require a critical positioning, the preparation of proposals for the action and mobilization of groups, movements, and academic leaderships interested in the improvement of health policies and practices in the SUS and in the production of knowledges that can support those actions. In that perspective, the role that the journal 'Saúde em Debate' took on in 1976 remains highly relevant and also finds expression in the current issue.
Cornelis Johannes van Stralen
- BRASIL. Constituição (1988). Constituição da República Federativa do Brasil. Brasília, DF, 1988. Disponível em: <http://www.planalto.gov.br/ccivil_03/constituicao/ConstituicaoCompilado.htm>. Acesso em: 15 jan. 2015.
- Publication in this collection