THE WORLD HEALTH ORGANIZATION (WHO), by issuing the Universal Health Coverage slogan in its 201011 Organização Mundial da Saúde. Relatório mundial da saúde 2010: financiamento dos sistemas de saúde - o caminho para a Cobertura Universal [internet]. Genebra: Organização Mundial da Saúde; 2010. [acesso em 2019 dez 6]. Disponível em: https://brasil.campusvirtualsp.org/node/198176.
https://brasil.campusvirtualsp.org/node/... report, stating that it was the “most powerful concept that public health could offer”, caused great controversy. Firstly, because both the Universal Declaration of Human Rights and the WHO Statutes enshrined as powerful and essential the right of all to health. Secondly, because the 30th World Health Assembly of 197722 World Health Organization. Resolution WHA30.43. In: World Health Assembly, 30. Geneva: Thirtieth World Health Assembly, 2-19 May 1977 [inter net]. (part I: resolutions and decisions: annexes. World Health Organization). [acesso em 2019 maio 5]. Disponível em: https://apps.who.int/iris/handle/10665/86036.
https://apps.who.int/iris/handle/10665/8... had renewed the commitment by launching the Health for All slogan in 2000, preceding the famous Alma-Ata Primary Health Care Conference held in 1978. Thirdly, because it produced a semiotic dystopia when resignifying the concept of ‘coverage’ of services traditionally employed in health, depriving it of the essential attributes of access and use33 Noronha JC. Cobertura Universal de Saúde: como misturar conceitos, confundir objetivos, abandonar princípios. Cad. Saúde Pública. Rio de Janeiro, 2013; 29(5):847-849.. Fourth, because it also dissociated from the concept of ‘universality’, relevant ancillary attributes of equity and justice. Fifth, because it posed as its starting point the issue of the mode of financing of benefits, in particular the issue (relevant but improperly appropriated) of catastrophic personal spending resulting from expenditure on health services. Sixth, because the WHO set aside the important report on the Social Determinants of Health44 Organização Mundial da Saúde. Redução das desi gualdades no período de uma geração. Igualdade na saúde através da ação sobre os seus determi nantes sociais. Relatório final da Comissão para os Determinantes Sociais da Saúde. Genebra: OMS; 2010., finished two years earlier, limiting health to service provision.
A serious researcher from the World Bank, in an article published on his blog at the time, when wondering if the case was that of ‘old wine in a new bottle’, sought to identify what the proposal brought as novelty55 Wagstaff A. Universal health coverage: Old wine in a new bottle? If so, is that so bad? [internet]. World Bank Blogs; 2013. [acesso em 2019 dez 4]. Disponível em: https://blogs.worldbank.org/developmenttalk/universal-health-coverage-old-wine-in-a-new-bottle-if-so-is-that-so-bad.
https://blogs.worldbank.org/developmentt... . He warned that, in order to be useful, it was necessary to add the dimensions of equity, associating the obtaining of care to its need, not to the ability to pay for it. He added that it was necessary to ensure coverage ‘de facto’ (i.e. access and use), and not simply ‘de jure’ (‘on paper’) and the quality of the services provided.
It was not long before one discovered where the heart of dystopia lied. It was essentially about securing the ‘de jure’ coverage and a curious package (pooling) of funds to ‘protect’ people from ‘catastrophic spending’ on health services. However, such expenses only occurred and still occur due to the private provision of health services, including medicines and other supplies which, in the absence of public services, are charged from patients and their families. Wrong diagnosis, wrong therapy. If services are charged by individuals, rather than organizing free public services, they propose pooling resources to compensate providers. However, this pooling must be obtained through specific charges, either by private intermediaries (health insurances) or by additional specific taxation other than the taxes, contributions, and fees that governments employ for their provisions.
This eliminates the need to build universal health systems that guarantee ‘de facto’ equity and coverage and that ensure access to and use of quality health services according to the needs of each individual. In fact, the creation and expansion of specific private or public paying third-parties is promoted which, by means of amounts different from the premiums or fees charged for the ‘de jure’ coverage, stratify even more the supply, organizing ‘castes’ of users with access to differentiated quality services and with barriers defined by authorized procedures, as well as other semi-hidden barriers, such as waiting lists or location of services.
However, would the Brazilian health system be consistent with this critical view of the WHO concept? The 1988 Constitution undoubtedly is. Its article 196 establishes health as a right of all (therefore universal) and a duty of the State to be guaranteed by social and economic policies (consistent with the founding mandate of the WHO) and by universal and equal access to health actions and services. Such statement, although considered as imposing some jurists, has in practice been programmatic. Given that, were it imposing, we would have been living in constitutional infringement since its promulgation. Nevertheless, is this not the case despite all the advances we have made since then in expanding access and expanding coverage, especially through the provision of primary care by the Family Health Program?
Over the past three decades, the Brazilian health system has moved away from universal coverage ‘de facto’ in the access and equitable use of quality services as defined in the Constitution. Radical decentralization, associated with fragmentation of care, has accentuated micro and macroregional differences. The absence of an integrated and aggressive investment policy did not allow the improvement of the quality of services provided by the Unified Health System (SUS) and the decrease in the unequal distribution of human and physical resources to meet the growing needs of services determined by the aging population and for the correction of the unequal distribution of supply. Regulatory centers collect long queues, especially in the poorest regions. Support resources for primary care find only atrophy.
Direct and indirect incentives to health plans and insurance associated with the underfunding of the SUS came to constitute ‘castes’ of users with differentiated coverage. There is already a long distance between supply, quality, access, and use of services between the quarter of the population covered by plans and insurance and the rest of the population. Furthermore, even among policyholders, castes are established at the premium paid to operators. Cruel modalities of pre-selection of risk by the so-called ‘membership plans’ or ‘tailor-made’ business plans for stratified population groups, and by another semiotic distortion, called ‘population health’ that ‘skim the milk’ from high-risk people and patients from private intermediaries, casting them into the ‘universality of the SUS’.
The trends at this end of the second decade of the new century do not seem auspicious. The obstruction of the country’s development by ‘austerity’ economic policies, freezing or shrinking spending on social policies, including health, persistent high unemployment, increased labor informality, increased violence, degradation of public services, such as transportation, education, safety, and leisure, do not forecast better days for the health of Brazilians.
It is time to resume the foundations of the Citizen Constitution of 1988. It is time to resume political arrangements that will allow us to place the country once again on the route of Hope and Development. It is time to regain the unitary brilliance and fighting power of social movements to rebuild a Fair and Sovereign Brazil.
- 1Organização Mundial da Saúde. Relatório mundial da saúde 2010: financiamento dos sistemas de saúde - o caminho para a Cobertura Universal [internet]. Genebra: Organização Mundial da Saúde; 2010. [acesso em 2019 dez 6]. Disponível em: https://brasil.campusvirtualsp.org/node/198176
- 2World Health Organization. Resolution WHA30.43. In: World Health Assembly, 30. Geneva: Thirtieth World Health Assembly, 2-19 May 1977 [inter net]. (part I: resolutions and decisions: annexes. World Health Organization). [acesso em 2019 maio 5]. Disponível em: https://apps.who.int/iris/handle/10665/86036
- 3Noronha JC. Cobertura Universal de Saúde: como misturar conceitos, confundir objetivos, abandonar princípios. Cad. Saúde Pública. Rio de Janeiro, 2013; 29(5):847-849.
- 4Organização Mundial da Saúde. Redução das desi gualdades no período de uma geração. Igualdade na saúde através da ação sobre os seus determi nantes sociais. Relatório final da Comissão para os Determinantes Sociais da Saúde. Genebra: OMS; 2010.
- 5Wagstaff A. Universal health coverage: Old wine in a new bottle? If so, is that so bad? [internet]. World Bank Blogs; 2013. [acesso em 2019 dez 4]. Disponível em: https://blogs.worldbank.org/developmenttalk/universal-health-coverage-old-wine-in-a-new-bottle-if-so-is-that-so-bad
- Publication in this collection
19 June 2020
- Date of issue