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Health care that ensures the lives of the exploited and oppressed

Programmatic Editorial

Health care is one of the issues of most concern to the Brazilian population. According to opinion polls, 67% of the population in April 2020 was more worried about health care than their financial situation. This index echoes results collected in 2018, in which health care ranked the highest among all the important issues that Brazilians cared about in similar surveys.

Health care is a basic humanitarian principle, being an essential foundation for social advancement within a country. In Brazil, the right to health care is guaranteed in the 1988 Constitution, and it is the duty of the State to establish and ensure this right for the entire population. The struggle of the working class and the social movements in the 1980s, and in particular the struggles around health reform, were fundamental to the creation of the Sistema Único de Saúde (SUS – Unified Health System) as a public health model that was both universal (one which everyone has access to) and comprehensive (covering all levels of health care). But 30 years after the creation of the SUS, its principles, its guidelines, and its model of care have not been fully implemented. The fight for health care as a right, and not just based on a business model, remains as urgent as ever.

The situation around the world after the crisis of 2008

The building of a universal public health system is something that runs against capitalist logic, and in particular against the hegemonic model of neoliberalism which protects profits and the interests of health care businesses. After the capitalist system’s crisis of 2008 and the international bourgeoisie’s break with the social model of the social welfare state, we have seen numerous European countries recoil from building and strengthening their universal public health systems. They instead move ahead with austerity projects that reduce public health funding, create instruments to transfer public spending to the private health sector, and strengthen private health plans.

To get an idea of the impact that the 2008 economic crisis had on the health care sector, you only have to look at one of the most robust universal health care systems in the world, Britain’s National Health Service (NHS). In 2012, it underwent a reform that increased the percentage of user contributions, fragmented the health care system, abandoned the concept of territory, adapted to market concepts of supply and demand, and directed public resources to the private sector. The result is that 11% of British people have moved over to private health plans, something which was unimaginable 20 years ago. And these moves from the austerity playbook of the Troika (the International Monetary Fund, European Central Bank and European Commission) were also implemented by the governments of Portugal, Spain, Italy, and the Nordic countries.

The case of Brazil

There have been unquestionable advances in public health indicators since the SUS was created and public health services were expanded. Even with its underfunding, the SUS has seen infant mortality fall, the vaccination of the population expand and the eradication or significant reduction of diseases such as poliomyelitis (infantile paralysis) and measles, the implementation of transplant policies and the control of chronic diseases. All of this has made possible an increase in the life expectancy of the Brazilian population from 66 years (1990) to 75 years (2020).

Worth highlighting here is the fact that the main beneficiaries of these achievements were the most precarious and impoverished parts of the working class, which includes a large part of the oppressed sectors, such as blacks, women, and LGBT+ people. For these sectors, access to an effective public health service not only makes a better quality of life possible, it is also often decisive for the preservation of life itself.

Nevertheless, the Brazilian public health system’s three decades have been accompanied by growth in the private health sector, the consolidation of public-private partnerships, and the expansion of non-public management instruments, all of which have facilitated the diversion of funding and jeopardized the sustainability of health services such as not-for-profit Social Organizations (OS). These are the overriding factors that have led to an SUS that is now underfunded and falling apart. The public health system cares for the health of 75% of the Brazilian population, but even with it serving the majority of the population, it is private health plans that in 2016 had a per capita income 2.55 times higher than that of the SUS.

What challenges does the defense and construction of the SUS face?

This situation became even more serious after the Constitutional Amendment 95 (which instituted the Spending Ceiling on public services) was approved by the government of Michel Temer in 2016. The damage inflicted on the SUS, combined with its underfunding, strengthen the narrative that the state is in no position to finance the health system, and that health demands can only be met with proposals such as private health plans, the indirect management of individual health units, and the use of market logic.

The conselhos de saúde (health councils) are collegiate decision-making forums that were created and designed to strengthen the SUS, and which are supposed to function as spaces in which health care users and workers can play a political role. But over the last 30 years, these councils have fallen into the hands of managers with interests in privatization, and have lined up with the privatization agenda of mayors and governors. These councils were drained of political debate and the vanguard of the health system abandoned these spaces as they became increasingly less viable instruments for the construction and political contestation of working class interests.

In the midst of the pandemic, the Bolsonaro government is trying to move further down the road of public health privatization and empty out the public instruments of health management. We know that public-private partnerships and indirect management are often used at the state, district and municipal levels. But the Bolsonaro decree, drawn up by the economic team around Paulo Guedes, proposes federal-level privatization, a reduction in the autonomy and role of the Ministry of Health, and the weakening of Atenção Primária à Saúde (APS – Primary Health Care), one of the few sectors that maintain majority public control.

The SUS and the fight against COVID-19

From 2018 to 2019, the SUS lost R$22.5 billion (US$4.5 billion) in funding. The COVID-19 pandemic saw this loss reversed in 2020 with an emergency budget increase of R$35 billion (US$6.5 billion). It was precisely in the fight against the pandemic that the SUS showed its strength, endurance, and resilience. Brazil, a developing, continent-sized country, has accounted for fewer COVID-19 deaths than the United States, which is a great economic power, but possesses a private health care system that excludes an important part of the population because it cannot afford to pay for health care.

The political decisions of states and municipalities regarding the use of the budget for COVID-19, decisions such as investing billions in temporary hospitals that are managed by third-party companies, that favor remedial actions over monitoring and preventing coronavirus contamination, demonstrate that public money is being used to finance the private sector (often connected to corruption schemes), and is being inefficiently invested in ways that do not strengthen the public SUS. Furthermore, the federal government has reduced the role of the Ministry of Health, turning it into a warehouse for the storage of COVID-19 tests and turning into little more than an advisory body. In this way, the staff and accumulated knowledge of the SUS, which would be decisive for the formulation of an effective national plan to fight COVID-19, are entirely underutilized. Instead, it is left up to mayors and governors to decide on actions that determine the outcome for people’s lives during this pandemic.

Building a program for the strengthening and expansion of the public SUS

Since 2010, the World Bank and the IMF have been informing health policies across the globe. They have guided public financing towards private popular health plans and established service charters that leave the least profitable health activities (prevention and health promotion) to public management while handing over the high profit generating sectors to private companies. Therefore, any program for the defense of the public SUS must make it clear that health care is not a commodity and so cannot be submitted to the rules of the market.

In order to facilitate the privatization of the health sector, the business media and the bourgeoisie construct their discourse about the efficiency of the private sector, and this narrative is strengthened among those in the population that have negative experiences of seeking care in the public health system. A central element that strengthens the discourse around privatization is the underfunding of the SUS. The Law of Fiscal Responsibility (LRF) leads to mechanisms that reduce public management and establish budget rules for the states and municipalities which limit investments in public health construction and expansion while allowing for unlimited public-private partnerships. Additionally, the spending ceiling established by Constitutional Amendment 95 does not allow for health investment to keep pace with the country’s growing population. What the health sector needs is a Law of Social Responsibility which prioritizes the allocation of budget resources to public services, strengthens the instruments of public management, and enables the appointment of public servants and the construction of public health units.

Pointing to the serious need for a financial framework such as this must be complemented by a discourse that highlights the quality of the public health system and promotes the need for greater investment for the proper functioning of the SUS. We have thousands of examples throughout Brazil where the public SUS system works well, provides quality care, and meets with user satisfaction. This is especially so among the black and poorest parts of the population, who are the main victims of the country’s social inequality and structural racism.

The dubious quality of the private sector, with its interest in profits that overrides the interests of the health of the population, must also be denounced. The conflict of interests between the patient and the large private health sector businesses is irreconcilable and we must be absolutely upfront about this problem. On one hand, the private sector seeks profit, which leads to procedures that are sometimes unnecessary and risky, but profitable. On the other hand, the interest of the patient is in the resolution of their health problem, which sees them place confidence in the procedures indicated.

Beyond this, it is not enough for the SUS just to be public. The biomedical model, with its exclusion of psychological, environmental, and social factors, a model that has shown itself to be inefficient in meeting and solving the population’s different health demands, must also be addressed. Instead, we need to emphasize the need for multi-professional health teams made up of nurses, physiotherapists, pharmacists, physical educators, nutritionists, psychologists, social workers, dentists, and physicians; the need to make prevention and the promotion of health their priority and who put patients in control of their own health and arm patients with enough knowledge so that they can make their own choices.

To this end, it is essential to bring the need for higher salaries and better working conditions for health professionals to the fore. It is also important to emphasize the importance of public tenders for hiring public health professionals to supply the demand in hospital services, health centers and home care. Developing this social dimension of the discussion around health further, it is also necessary to point out that the winning of better health also crosses over into issues such as access to employment, income, basic sanitation, quality food, education and many other rights for an active, healthy and independent life. That is, the full realization of the right to public, universal, free and quality health care goes over into the need for the construction of another social and economic model, a socialist model.

Another important point is the need for health activists to occupy the places of political debate around public health care. We need to strengthen the present health councils and occupy these spaces, because with the institutionalization of debate around public health, these councils offer the possibility of forming a new vanguard of medical professionals that defend the public SUS. Furthermore, it is essential that social movements, unions, left-wing parties, residents’ associations, among other social and political organizations, embrace the defense of a public, free, universal, and quality SUS for all, and promote united struggles under this banner.

In short, the COVID-19 pandemic has facilitated intense debate about the health care system among workers. The repeal of the Bolsonaro decree for the privatization of Primary Health Care (APS) shows that the population is willing to defend public health. Therefore, it is necessary to strengthen the fight in defense of SUS and build strong resistance to all plans for the privatization of the Brazilian health care system.


Robson Bonin, “Para 67% dos brasileiros, saúde preocupa mais que situação financeira” (For 67% of Brazilians, health concerns them more than their financial situation): https://veja.abril.com.br/blog/radar/para-67-dos-brasileiros-saude-preocupa-mais-que-situacao-financeira.

Jairnilson Silva Paim, “Os sistemas universais de saúde e o futuro do Sistema Único de Saúde (SUS)” (Universal health systems and the future of the Unified Health System (SUS)). Saúde Debate (Health Debate). Rio De Janeiro, Vol. 43, No. Special 5, pp. 15-28, December 2019: https://www.scielo.br/pdf/sdeb/v43nspe5/0103-1104-sdeb-43-spe05-0015.pdf

This article is an English translation of “Saúde para garantir a vida dos explorados e oprimidos”, [https://esquerdaonline.com.br/2020/11/09/saude-para-garantir-a-vida-dos-explorados-e-oprimidos/], Esquerda Online (EOL), 09/11/2020

Translation: Bobby Sparks