Introduction
The Brazil of 2016 is once again wrapped in a political crisis in which democratic values quickly lose their protagonism while political parties cannot bear relationships involving representativeness. In this context, despite unexpected, some may be surprised that Health Reform has been indelibly linked to the Brazilian Communist Party; that, though the reform has not been characterized as a mass movement, it has been typical in social movements; and that the Unified Health System (SUS) is, in fact, a socialist proposal.
Such surprises - or, according to many, such redemptions - may help explain the reasons why one of the paradoxes hinders the non-implementation of the right to health in the Country: while all political parties, all candidates for any elective office, strongly advocate a 'health of quality' in their campaigns, the resources invested in health policies by those elected hardly enable the implementation of those promises. If such speech-practice detachment is exercised by those who are periodically submitted to popular scrutiny, it tends to be even stronger when accrued from those not needing to be accepted by the population, which results in even more drastic proposals, such as to limiting public investment budget for ten or twenty years.
The purpose of this interview is to contribute to the rescue of SUS and Health Reform recent history. Antonio Ivo de Carvalho took part in much of that history. In some periods as protagonist and in others as militant, a role he never ceased to play. His speech full of hope shows us the difficulties of doing politics during the hardest period of the military dictatorship, of belonging to a political party relegated to illegality, of opting for illegal and armed political ways, of being arrested for expressing his opinion; tells that Health Reform lived its dilemmas and mishaps, and that, above all, renews the pleasure of doing politics, of searching for consensus and of strengthening democracy.
Marcelo Rasga Moreira: The Health Reform is, in a way, an answer that stands up to a time of economic and political crisis produced by the military dictatorship. How that crisis reverberated in health sector?
Antônio Ivo de Carvalho: In the late 1970s, there was a widespread but not radicalized effervescence around the theme health. It was mainly a struggle for access to health services, then controlled by Inamps (National Institute for Medical Assistance of the Social Security), which was already much deteriorated at the time.
This effervescence was present in 'the mass', in the population... here in Rio de Janeiro; the struggle existed even before Famerj (Federation of Dwellers' Association of Rio de Janeiro) creation. In Nova Iguaçu, where we were located, a movement pro health was organized. Then, it expanded as a neighborhood movement. In São Paulo' Southern and Easter zones a strong movement also occurred, much supported by the left-wing militating in the Catholic Church.
It was not a struggle politically planned that carried an ideal of health. It was a struggle just to be taken care by the health service! People were not serviced by the health service and responded, sometimes, with a general breaker. The Church played a very important role in the mobilization and organization of those people. Urban social movements were more present than the unions in those fights. Unions demanded the expansion of rights by means of health plans. Urban social movements called for access to a system that did not yet existed.
And it was through the relation with those urban social movements that health reform was being built. Health Reform was not a mass movement, but it relied on and was inspired in that spontaneous movement, especially on the outskirts of São Paulo, where people arrived but were not serviced, so they reacted and protested.
That pressure had an impact on the military government - that felt the social security deficit already at the end of the 1970s -, which started making concessions. Those concessions and Inamps over deterioration led to a self-reform. The Conasp (National Council of Welfare Health) plan represented the institutional face of that process, generating a 'white universalization'.
MRM: Explain how that 'disguised universalization' happened.
AIC: As for Inamps services, the person only received attention if she could prove to be a worker, although it happened oppositely in municipal and state services. While these latter services operated in idle capacity, Inamps was overwhelmed.
José Mendes Ribeiro: Rio de Janeiro' municipal and state networks were important, offering health centers, municipal hospitals... a broad network.
AIC: Those networks were IAPs' (Institutes of Retirements and Pensions) legacies, offered in great quantity and the best ones, but suffering from a deterioration process. In addition, state and municipal services worked totally disconnected from hospitals and federal services. There was not a network!
Already in the 1980s, Conasp plan advanced the integration among what was then called 'various health systems' of different spheres of government. It was the beginning of a network. As for that integration, covenants were signed and manipulated by the left-wing Inamps workers so to make agreements with municipalities of more developed thinking. It was a quick process that even disrespected the State power if it refused to sign the Covenant! Thus, Inamps started to pay the municipalities for servicing. It worked as a 'white universalization'.
Later, the creation of AIS (Integrated Health Actions) transformed the white universalization into an opened one. Integrated actions had the purpose of utilizing the idle capacity of states and municipalities, increasing the public serviced. Federal health service was overloaded and spent much money in accrediting and contracting private providers, a malefic process that helped proliferating 'swindling clinics' that received public funds for services of low or no quality.
To cope with this issue, the group then in charge of Inamps, which included Aloísio Salles, Temporão, Eleutherius, Noronha... already impregnated with the Health Reform ideals - in 1979, at the symposium Health and Democracy, held by the Chamber of Deputies, Arouca and the Health Reform elite, basically pertaining to the 'Big Party' (Brazilian Communist Party), advocated a single system, although named differently, based on a health conception inspired in Alma-Ata and in the participation - conceived the AIS, which was succeeded by Suds (Unified and Decentralized Health System) and then by SUS (Unified Health System). It was a kind of self-reform.
JMR: Did it start at Inamps?
AIC: Yes. And it reverberated onto the health reform. Already during Sarney government, a significant dispute occurred within the health movement: what constructing strategy of the unified system to apply? The unification would be carried on by the Ministry of Health or by Inamps?
That decision separated the two main leaders, Arouca and Hésio. Those who worked at Inamps, along with Hésio, Temporão and Noronha, argued that decentralization should be made by means of the extinction of Inamps followed by the transference of services to states and municipalities, in an incremental decentralizing process of the Institute network and resources.
And there was the left communist group who worked at Fiocruz (Oswaldo Cruz Foundation) and at Cebes (Brazilian Center for Health Studies), led by Arouca, who argued that decentralization should be made by the Ministry of Health, which, at that time, had no power but held both the health programs and the sanitary conceiving.
It was an internal issue, blankly out, although a hard one. But the problem was being solved within the political process. Inamps lost the power to pay AIHs (Hospital Inpatient Authorizations), i.e., to be the private provider's buyer. After SUS creation, the AIHs issuing was transferred to SAS/MS (Secretary of Health Care to the Ministry of Health), which took a prominent role even before Inamps extinction, what suddenly occurred during Itamar Franco government. That was an important split in the communist bloc.
MRM: And what was the idea behind the Health Reform Party?
AIC: That was the denomination given in the late 1970s, when the movement, not even called a reforming movement, criticized the system starred by Inamps. In the 1970s, there only existed local experiences, including the Arena (National Renewal Alliance Party): Montes Claros, Niterói, Paulínea... experiences involving universities extension campuses, preventive medicine. Alternative practices were applied mainly concerning the rendering of services to the population as a way to take health in hands, as well as innovation, both related to the organization of services. Scheduling was not used to be made with such anticipation, the ready care. It began to make part of the system reforms' idea. But the care system, which was wasteful, giving rise to deepening the criticism on 'swindling clinics', maternity wards, which, in Caxias, for example, were a complete nonsense. In São Paulo, it happened in urban areas.
The situation began to shape the idea of reform. Before thinking on a Reform agenda, the identification of people who were taking part in or developing innovative proposals was started. That's when the name Reform Party emerged, helping people integration. It carried a supra-party character, brought together people of various hues, including from the right political thinking. In the State of Santa Catarina, some Arena party supporters carried innovative experience on local management.
In 1976, Cebes was created to aggregate an advanced thinking on health area, being Abrasco (Brazilian Association of Collective Health) created in 1978. Teachers, mayors, academics congregated... Arouca may have generated the idea of Reform Party, which later contributed for the Constituent process to ensure SUS creation.
MRM: What was the importance of PCB (Brazilian Communist Party), proudly known as 'Big Party' in Health Reform?
AIC: Conceptually, Health Reform is born from within the 'Big Party'. The criticism of a system centered in hospitals, spendthrift, that was bankrupting due to Inamps, comes from there, the Party, from its contacts, members and sympathizers, from the population struggling to access the system.
In late 1970s, PCB Party, within MDB (Brazilian Democratic Movement), developed a strong health movement that was fed in the late 1960s by the process of community medicine, by the people of the cities of Montes Claros, Paulínea, Niterói... which was based on Alma-Ata and on the universalization of primary health actions. That was the so-called left-wing heath. Arouca, an inspiring of the Health Reform process was part of the left-wing heath, of the 'Big Party'.
There was also another stream in the party, not directly linked to the health sector, which focused on the 'popular upheaval', on training persons for popular struggle. And I pertained to that stream. I worked then for Fase (Federation of Organs for Social and Educational Assistance), located in Nova Iguaçu; I attended the fifth year of College and did not wish to engage the university or trade union structure, the two alternatives to keep the fight. I engaged the social movement by means of the Catholic Church and ended up getting much closer to the associative movement in the late 1970s than to the health movement. I was graduating and engaging the popular movement along with the Church. Hésio, Noronha, Reinaldo pertained to Uerj (University of the State of Rio de Janeiro) ... and were creating the social medicine. In Ensp (National School of Public Health Sergio Arouca), from Fiocruz, there existed the Pesis (Program of Socioeconomic Studies on Health), where Davizinho (David Capistrano Junior) worked. I went to Nova Iguaçu due to my engagement in the basic Christian communities. Adriano Hippolytus was the Bishop there. I used to say to him "I am a communist", to what he answered: "there are communists who are much more Christians than my Christians!" Bishop Adriano was simply a liberal. The one really engaged in the left-wing was Bishop Valdir Calheiros, from the diocese of the city of Volta Redonda.
We called popular movement to put pressure on! I remember that during dengue crisis, we connected with the people to take to the streets, to close Via Dutra (the road that connects Rio de Janeiro and São Paulo cities). At that time, I wrote a paper for the third edition of the journal 'Saúde em Debate' (Health under Debate): 'Health as an instrument of base upheaval', which saw health not as an end in itself but as a means of producing 'popular upheaval', as class consciousness!
JMR: The party had formal meetings to discuss on health sector?
AIC: No. There was not a party board responsible for gathering healthcare personnel so to discuss issues. The party had the sensibility to listen to its members and supporters and to yield alliances. All those facts to which I referred - the turmoil in São Paulo to open the health centers and the 'white universalization' in 1970s - had the participation, whether direct or indirect, of people or party supporters. And the party knew how to give to those people the opportunity to organize the social struggles according to their possibilities. That allowed the persons from the party participated, for example, in Inamps management.
When we talk about the 'Big Party' role, we should not deceive ourselves thinking that the party 'nomenklatura' was responsible for formulating it. What happened was that an organized layer of the party, moved by the ideals of communism, health as universal right, fight for access to social policies, has always been able to mobilize other actors and gather support. In SUS case, the influence took place around the PMDB (Party of the Brazilian Democratic Movement), whose leader was Ulysses Guimarães, president of the Constituent Assembly.
The 'Big Party' participated in the great struggles, in the 'great causes'. But there was a phenomenon 'Big Party' inspired others in the coalitions and in institutions it penetrated: its ideals of social justice. Since the 1922 Week, the intellectuals, Jorge Amado, Portinari... After the cold war, that becomes relative... the mistakes, the over influence of the soviet State, the Stalinism... so much that PCB collapse does not weaken the Health Reform, because it goes forward even without the party, but with its former members and supporters.
MRM: During Inamps operation, there existed the idea of taking over the State from inside?
AIC: No. It was a very technical issue. There was a group of policy makers in universities who were invited to work in the system rather based on their competence than on their politic color. In the absence of good professionals, the government had to hire experts pertaining to the 'Big Party'. It was not a party guideline that their experts joined the State to take it over, but the party had the sensibility to make the fight feasible within Inamps. As I said before, the covenants made at Inamps with the municipalities following political alliances were operated by persons directly or indirectly connected to PCB. The 'white universalization' was conceived by the 'Big Party', by its members.
MRM: And the Gramscian practice of the association between organic intellectuals and workers, forming the 'historical block'? There existed that Gramscian influence on the 'Big Party'? Arouca' statement that health professionals have to overcome the walls to understand citizens and be understood by them suggests that.
AIC: It was not a stream followed by the party. It was rather a thinking advocated by Arouca. The category 'participation' is originated in the popular movement, not in unions or in the working class. The working class followed 'factories committees' as a proposal, something that made sense in the great ABC area (car manufacturing cities surrounding São Paulo, with very strong unions), but not in urban centers in general. What happened was the expansion of that category of participation inspired in Alma-Ata. The earliest examples of participation, called popular participation, happened outside the State, to fustigate the State, then the community participation arose within the health service, and, later, the idea of social participation emerged in the structures, in the councils.
MRM: Tell me more about that praxis trajectory called 'Participation'.
AIC: The 1982 AIS, in Conasp, advocated that the signing of agreements between the Union, states and municipalities had to include health councils. In the State, there existed the CIS (Inter-institutional Health Committees). When signing of covenants those things were built within the state apparatus. Then, the culture of participation was being created, as well as the presence of the population representatives in the co-management structures of the State. Thenceforth, the co-management started. It actually comes from the local Cuban health system, in which it is obliged to integrate a network, joining representatives from the various networks - federal, states and municipal ones - and from the population.
So, it was created in Niterói, by means of the 'Niterói Project', which had Gilson Cantarino as its first President, and Moreira Franco, who pertained to AP (Popular Action), as Mayor. Here in Rio de Janeiro, there was a collegiate for each programmatic area that pertained just to the board, and the participation occurred around it. But in Nova Iguaçu, the council was external to the government. Here in Rio it became institutionalized, which shows that different ways were tried out and, for that time, innovative as for participation.
MRM: In the Eighth (VIII National Conference on Health, in 1986), the participation and the councils happened externally to the State.
AIC: Yes! The State was the decision-making committee of the bourgeoisie! This also corresponds to a temporal, cyclical sequence. Is typical of the 1970s, when everything was quite closed.
The participation in the Eighth also was a way to translate the State that exited the dictatorship, and would not be able to ensuring SUS as a universal right. The external participation is almost a safeguard designed to call the population for the political struggle.
After that it was becoming weakened by the democratization and by the ideas of community involvement advocating that institutional spaces should also be occupied so to increase the system quality and democratization.
JMR: That also corresponded to a transition from the international left-wing, European, to the participation coordinated by the intellectual elite within the State apparatus.
AIC: Yes. The Brazilian communism followers had the idea of making an up-down change, much influencing on heath. Conasp itself had the idea of changing laws as a reason to change the system.
Until today, SUS carries the mark of being designed by a heath elite originated in the left-wing. In the Constituent Assembly, the unity driving SUS idea was quite larger than today.
JMR: So, talk about SUS.
MRM: Do you advocate a SUS managed by the State? A system carried out only by the State, without the private sector?
AIC: No, I do not. I advocate that the private sector has a place in the system. This is an issue under debate by the Eighth. There was a segment advocating the SUS management by the State and the expropriation of the private offer. There was another that advocated the private offer. Neither of the two was de winner. The Constitution text prevailed: the supplementary character of the private sector. That argument, at the same time that sought to limit, legitimized what came first, the agreements and contracts. No following government wanted to touch it.
I am not for a SUS entirely managed by the State, but I wonder things would work better whether the private sector did not deserve so many subsidies!
Besides, there are no proposals articulating private and public offerings! There is no synergy, a minimum articulation between private and public networks. It is a distortion that grew up in the shadow of the constitutional prediction and government policies.
That should be accounted to governments' attitude of loosening the relations with the private sector. Perhaps that explains, I am not quite sure, the royal treatment health plan operators have always deserved, also by receiving subsidies as by the political basis supported by the middle class.
Today, no one has the courage to propose the end of subsidies to health plans, which are outrageous. They are aggressive! No one proposes anything to reduce this shameful situation. PT (Work Party) governments either faced this issue. It has also a historical basis, as PT originated from a workers' trade union. During the 1979 ABC's strikes, Lula being ahead of the union, health plans were already a union claim. The strengthening of both Inamps and a health public network was not a request. And when the PT came to power, that historical basis remained. And the main purpose of PT governments was the worker absorption by the labor market and his/her purchasing power increase. I am not sure if it was a deliberated action, but the fact is that the income increasing and the income distribution improvement allowed the acquisition of health plans. But to consume health is not equal to consume plans; there are other products that people consume.
Popular plans have proliferated in the Country to the detriment of the coverage to access and procedures. The great victory of the plans did not occur at the individual level, it came through its insertion in the guidelines of workers struggles.
The design proposed by SUS did not overcome the mental map of organized workers, who, since the beginning, had health plan as an agenda item. It has been so since always. This is a widespread phenomenon.
The discussion is there... why health professionals do not adhere to SUS? In fact, a certain elite does not pertain to SUS! The poor does not use SUS' services by choice but because they cannot afford a plan. They do have no choice, so they choose because they do not have other choice. And so far SUS has to deal with this mental map. And, due to its scarce resources, it is unable to develop.
MRM: So we have that, from 1994 to 2014, PSDB (Brazilian Social Democracy Party) and PT, the two major political forces in the Country during the short period of democracy settled after the military dictatorship, occupied the Presidency of the Republic - always abreast of PMDB. Nonetheless, SUS did not become a political force in any of the governments?
AIC: Yes. What happens to SUS is a phenomenon that deserves a deeper discussion. What is the meaning of SUS as State policy? There is not a proposal to end SUS in the following 20 years. Serra was a SUS minister. He was not against SUS, even being a prominent member of the toucans (PSDB Party), responsible for that privatization processes. There is a tacit agreement on SUS. No one has ever stood against the idea of SUS.
See the current electoral process. No one is asking you to put an end on SUS. I am not making a moral judgment of it. It is a phenomenon. On one hand, it can be seen as an improvement, and there is a certain predominance of this vision that reinforces SUS shortcomings, but it does not propose something else. Even with this tide upstream advocating the market, SUS is never mentioned.
MRM: Does anyone speak in favor of SUS?
AIC: Yes, but not enough. Specific situations happened. HIV-Aids (Human Immunodeficiency Virus - Acquired Immunodeficiency Syndrome), Humanization, Family Health, More Doctors... The Family Health, introduced by Alceni Guerral during Collor government, was something that, by its magnitude, was significant as a SUS own policy. More Doctors was also relevant, widening access.
SUS has never managed to steady itself in the dreams, in the thinking of the population, because SUS is inefficient!
JMR: Europe has solved this issue also by keeping social security as by making private insurance unfeasible for not receiving subsidies. Those countries do not let middle class to buy plans because they do not grant subsidies. Spain and England... not only forbid subsidizing as penalize private providers. Brazil could have kept its social security.
AIC: That is what I think most impressive! The working class wants access to the doctor, not the health care system.
MRM: So, those pro Health Reform are the minority in the political scenario? If the two major parties in the Country, always anchored by PMDB, did not deploy a Health Reform, so the Constitution, those who advocate the Reform are not a minority in the political game, and therefore unable to deploy SUS?
AIC: As for the elaboration, we are the majority. But in terms of the politics, of the implementation, we are not!
The idea of SUS, of universal health, created the mental map of people in the Country, except for the politicians'. Few are those who currently oppose SUS while advocating another system. However, within the State and political arenas, there has always been the protection of market interests. Because SUS is highly expensive, financing disappear inside it. And it is not due to corruption. The cause is negligence. This mixture of private interests and the middle class willingness to have plans is a powerful obstacle.
JMR: The middle class has lost as did the public system! Health plans provide a kind of very expensive care and generate the population satisfaction, who wants to deserve the same from SUS. And it is often unnecessary to do what the private sector does, but if the private sector offers, the middle class imaginary demands SUS to offer the same.
AIC: It is the very well-known medicine prescription. And SUS, for its nature, is required to make a rational use of the resources! It is a public policy! In the private context, if the person wants to do an MRI, she does. How to do it in SUS, universal? It is only possibly to do certain exams when really necessary! So, SUS has to rationalize resources that health plans do not need to. And here there is an intersection between mental and real worlds... people trust plans - not as in the same level as in the past, but they trust -, they trust because of the hospitality, because of the feeling of receiving a personalized treatment, a set of measures.
MRM: That confidence in the private in contrast to public distrusting is analogous to the population distrust in politics and governments?
AIC: For those who can afford a plan, there is a sense that SUS is addressed to the poor. And that is the subservience of a feeling that thinks the poor is worse.
MRM: There is quite a dose of prejudice?
AIC: I think so. Odorico (a very well-known soap opera personage) had an interesting say: the poor strongly aspires, envies, those who have access to money. Interiorizing differences in class is something widespread. That lessens the hate against the middle class.
JMR: And the current government proposal, how do you see it?
AIC: It is like a radicalization towards evil. I think the current government tends to represent a worsening in SUS problems, because it takes place under the aegis of a tide upstream the market, a conception that believes in the self-regulation of the market, in the privatization! And the current government explicit represents that thinking, the privatizing alternative.
But then there are the mysteries of politics. Democracy requires participation, with or without consciousness, by voting. And the act of voting is full of symbolisms; it is a sophisticated decision of the voter. That causes the democracy to suffer a refraction of shady interests.
MRM: The political crisis is reversible?
AIC: I think it is! From here to 2018, we have a long road ahead!
Publication Dates
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Publication in this collection
Dec 2016
