The coalition of health entrepreneurs and their proposals for the reform of the Brazilian health system: political and programmatic setbacks (2014-2018)

Abstract

With the aim of systematizing the health private sector proposals related with the reformulation of the Brazilian health system, as well as contributing to the understanding of its meaning, an essay was carried out, based in documents from the Health Coalition Institute (ICOS) published in the period from 2014 to 2018. The document content analysis was carried out guided by some concepts of Bourdieu, Coutinho and Labra. With the change in the correlation of forces resulting from the 2016 parliamentary coup, the private health sector’s proposals gained visibility, which initially seemed to correspond to an update of its historical agenda, but which are progressively changing to suit the new political and economic scenario. From then on, conditions of possibility were created for the protagonism of these entrepreneurs in the field of power in relation to sectoral reform and the formulation of health policies, with consequences related to the disruption of the Brazilian Unified Health System (SUS). The contradictions between the discourse of defense of SUS by the entrepreneurs, and the privatizing concrete proposals may reveal a search for the symbolic profits associated with the defense of the public interests and of the universal.

Key words
Health Policy; Private Sector; Privatization

Resumo

Com o objetivo de sistematizar as propostas voltadas para a reformulação do sistema de saúde brasileiro, oriundas do setor empresarial da saúde, bem como contribuir para a compreensão do seu significado, foi realizado um ensaio apoiado na análise sobre o conteúdo dos documentos elaborados pelo Instituto Coalizão Saúde (Icos), no período compreendido entre 2014 e 2018. Para tanto, tomou-se como referências conceituais e metodológicas os estudos de Bourdieu, Coutinho e Labra. Com a mudança na correlação de forças decorrente do golpe parlamentar de 2016, ganharam visibilidade as proposições do setor privado da saúde, que inicialmente pareciam corresponder a uma atualização da sua agenda histórica mas que vão progressivamente se transformando para se adequarem à nova conjuntura política e econômica. A partir de então, foram criadas condições de possibilidade para um protagonismo desses empresários, no âmbito do campo do poder, em relação à reforma setorial e à formulação de políticas de saúde com repercussões relacionadas à desestruturação do Sistema Único de Saúde (SUS). As contradições entre o discurso de defesa do SUS, por parte dos empresários, e as propostas concretas privatizantes podem revelar uma busca dos lucros simbólicos associados à defesa dos interesses públicos e do universal.

Palavras-chave
Política de Saúde; Setor Privado; Privatização

Introduction

In Brazil, President Dilma Roussef’s growing loss of governability – evident from her second term of government and aggravated by both the unfolding international economic situation and the fiscal adjustment measures internally adopted since 2014 – resulted in the parliamentary coup¹ and her impeachment in 2016. Then, with ex-Vice-President Michel Temer’s rise to power, the crisis was accentuated by changes in the country’s institutional situation, represented by the political and economic measures that were applied then.

These measures, materialized in CA 95, froze the maximum federal investment limit in health spending and had a direct impact on the unfinancing of the Brazilian Unified Health System (SUS), imposing severe limits on the services offered to the population. In the political scenario, the approval by the Legislative and Executive of the participation of foreign capital in health increased the privatization processes and the discussion of popular plans^2,3.

This process disseminates in the institutional deconfiguration of SUS when it reverses some of its structuring policies, such as the National Primary Care Policy⁴, the National Program of Immunization⁵, the National Mental Health Policy⁶, the Popular Pharmacy Program⁷ and the More Doctors Program. Particularly, deleterious effects of this institutional crisis have been felt on the “mood” of the workforce, demobilizing it in relation to investments in the organization of SUS and with consequences for the formation of several health professionals in Collective Health.

On an international scale, threats to social protection systems at times of crisis, which correspond to attacks on the principle of solidarity, drive social policies into disrepute, pave the way for privatizations and make people stop claiming their rights and exercising pressure on the State⁸.

Returning to the case of Brazil, the changes imposed by the economic situation and caused by the displacement of power that occurred in the period analyzed in this article, opened up space for the emergence of proposals from certain business sectors for the reformulation of the entire health system. Representatives of hospitals, the pharmaceutical industry, and health insurance companies, among others, until then limited to sectoral and segmented claims, as well as specific associative entities (Chart 1), have joined around the Coalition Health Institute (ICOS) since 2015, and now appear as representatives of the population’s interests⁹.

Chart 1
Associations and companies that constitute the Health Coalition Institute, by type of activity, Brazil, 2019.

Activity type	Companies/Associations
Medical and Hospital Service Providers	Hospital Albert Einstein; Hospital Sírio Libanês; Oncoclínicas
Laboratory Service Providers	Grupo Dasa; Grupo Fleury; Grupo Sabin
Educational service providers	FFM- Fundação Faculdade de Medicina
Pharmaceutical Industry Producers	Abbott Laboratories; AbbVie; Johnson & Johnson; EMS - Indústria de medicamentos; InterSystems; MSD Brasil; Sanofi
Health insurance companies	Amil; Unimed Brasil; Healthways
Associative Entities	Abramge - Associação Brasileira de planos de saúde; Anab - Associação brasileira das administradoras de benefícios; Abimed - Associação Brasileira da Industria de Alta Tecnologia de Produtos para Saúde; Abimo - Associação Brasileira da Indústria de Artigos e Equipamentos Médicos e Odontológicos; Abramed - Associação Brasileira da Indústria de artigos e equipamentos médicos, odontológicos, hospitalares e de laboratórios; Abraidi - Associação Brasileira de Importadores e Distribuidores de Implantes; Anahap - Associação Nacional de Hospitais Privados; CNS - Confederação Nacional de Saúde; CMB - Confederação das Santas Casas e Hospitais Filantrópicos; Cbex - Colégio Brasileiro de Executivos da Saúde; FBH - Federação Brasileira de Hospitais; FenaSaúde - Federação Nacional de Saúde Suplementar; Sinaemo - Sindicato da Indústria de Artigos e Equipamentos Odontológicos; Fehoesp - Federação dos Hospitais, Clínicas e Laboratórios do Estado de São Paulo;Interfarma - Associação da Indústria Farmacêutica de Pesquisa; SindusFarma

http://icos.org.br/quem-somos/associados/

It is not that the private sector has historically been absent from the debates about the creation of SUS. Since the vote on the Health Chapter in the 1988 Constitution, the presence of entrepreneurial representatives has been noticed both in the minority votes given to the systematization committee report and in the impasse created regarding financing and the public nature of health¹⁰. Over these last 30 years, important transformations occurred with the private sector, which became more complex under the influence of the financialization process of economy, expanding its several intersections and interest relations with the public sphere^11-13.

Although other authors have discussed the protagonism of health entrepreneurs regarding the emergence of the Health Coalition movement and ICOS^3,14, as well as their articulations with President Temer’s government, as proposed by the popular health plans¹⁵, little attention has been paid to the content of the proposals aimed at the health system reform and the significance of this great articulation of the several private representatives organized around a single entity, the ICOS.

To what extent do these propositions constitute only updates of the historical claims of the private sector or proposals aimed at the dismantling of SUS and its replacement by other institutional arrangements? Why did entrepreneurs start claiming a place as representatives of the needs of the population? Aiming at systematizing the proposals of this powerful business articulation for the Brazilian health system, as well as contributing to the understanding of its meaning, the present essay, supported by documentary and bibliographic sources, formulates some hypotheses about it.

To discuss the contents of these proposals, two articles published in Folha de São Paulo newspaper were analyzed^9,16, as well as all documents produced by ICOS^17-21, from 2014 to 2018, resulting in a total of five documents; and the websites of the entity’s constitutive associations. We sought to obtain the following information from the documents: authorship, objectives, conception about the SUS; diagnosis of the health situation and the health system; proposals for changes in the health system. Moreover, the analysis was supported by Bourdieu’s concepts and formulations^22-24 on field, interests and the universal, as well as on Coutinho’s considerations^25-27 about the category of interests.

The emergence of the Health Coalition Institute (ICOS) and the lack of dialogue with the Brazilian Health Reform movement

In 2014, a manifesto was launched by doctors Giovanni Guido Cerri and Claudio Lottenberg¹⁶, entitled Now it’s the Time to Debate Health, explicitly aimed at influencing the second round of that year’s presidential election and claiming they represented the health business sector. That movement defined itself as a collaborator of the government and society.

In the manifesto, the importance of health was justified both by being pointed out as the main problem of the country by voters, and by being involved in the movement of 9.2% of GDP. The central criticism it contained focused on reducing federal resources for health and defended the use of 10% of the gross current revenue for the SUS budget, an agenda which, at that time, was supported by several other movements and entities representing health¹⁶.

In 2015, the movement was consolidated with the creation of ICOS, which was defined as “a representative of the health sector’s production chain, intending to contribute, purposefully and pluralistically, to the debate and the search for new advances in health, in response to the population’s demands and the needs of the country”¹⁶. It was intended to act as a reference for thinking and formulating innovative health policies. Since then, this entity has been producing and publishing a set of executive documents and reports, which detail its proposals and strategies to transform the Brazilian health system. In 2016 and 2017, the following documents were released: Proposal for the Brazilian Health System¹⁷ and An Agenda to Transform the Health System¹⁸. ICOS executive summaries for this period^19,20, as well as the book of proposals published in 2018²¹, has allowed one to apprehend the evolution of its formulations.

In the set of documents released by ICOS^17-21 there is not what is called “health system”, objectively speaking. Sometimes it can be understood that the reference is to the entire health system, when it intends to “bring together public and private institutions interested in contributing to the improvement of the Brazilian health system in its public and private aspects”¹⁹; in others, it seems to specifically mention the private sector: “we believe health is good business, where everyone gains”¹⁹; and in some others, the reference is explicitly to SUS: “the defense of the Unified Health System, as well as the recognition of private initiative as complementary to it, should motivate the improvement of models that have already been successfully implemented, such as the public-private partnerships”¹⁷.

Perhaps this ambiguity is due to the private companies’ demanding agenda for more resources and less control, with the innovative objective of managing the SUS and appropriating the entire “market” with which it articulates, keeping in the back what is left of SUS to take care of what is not the most profitable part.

Some authors³ understand that the ICOS priority agenda is based on propositions that aim to transform “the public and private health systems or simply the Brazilian Health System (and no longer SUS)”. For that purpose, private sector entrepreneurs in their demanding agenda reinforce strategies for strengthening free market mechanisms and a new governance model that broadens the participation of private health care providers in the definition of health policies.

Thus, in these documents, the defense of SUS does not appear as a defense of the public but, recurrently, as an “incentive to strengthen public-private partnerships (PPPs), giving them more legal support and encouraging the Social Health Organizations (SHOs) and Product Development Partnerships (PDPs)”¹⁹. Another part states that ICOS “can improve the interaction between the public and the private so that we have a health system of which costs fit into people’s pockets, so that it becomes a thriving area and satisfactorily provide services for individuals and the companies”¹⁹.

This statement extrapolates the historic and permanent agenda of the private health sector for more profit-making space within the public sphere through the PPPs and sales of care services. It explicitly reveals that the current ideological political project related to health policy, proposed by this large business conglomerate aims, in practice, to destroy the public, universal and integral feature of SUS. This purpose was synthesized by Mathias¹⁴ in the formulation, according to which the aims of ICOS would be to make “SUS fully integrated to and coordinated by the private sector. A SUS that continues to be SUS even though it is no longer so”.

It is in this context, of unquestionable favoring of the political protagonism by entrepreneurs in the health policy arena, that the commercial logic and its known consequences for human health intends to reconfigure the medical-care and sanitary organization of the country, pushing aside a broadened perspective of Health.

In this sense, the prevailing discourse of ICOS is that the public and private sectors must work in synergy aiming to guarantee the population’s interests. In several excerpts of the aforementioned documents, the expression “demands of the population and their health needs” appears, without any explanation regarding the “unavoidable conceptual complexity” of these questions²⁸.

In these documents, health needs are defined only as access to and use of care services. The debate regarding the concept of health needs, which is very important to public health, has revealed the analytical and practical importance of considering that needs not only express the biological aspects of the issue, but also other dimensions (social, cultural, economic ones). These dimensions will conform to their diversity from the insertion of different social groups in the specific production processes of each society, processes that generate different health conditions²⁹.

In the statements, even when living conditions are mentioned, it is based on a social homogeneity that ignores the patterns of inequality of the Brazilian society, widely analyzed by several authors^30-32, as if under this structural condition “a very healthy way of living” could be available to everyone at any historical and social situation: “the expectation is that people can experience a very healthy way of living, that they can live to the fullest”¹⁷.

In An Agenda to Transform the Health System¹⁸, despite the unfounded criticism of the “Brazilian system”, which supposedly gives priority to “acute” diseases of the past, there is an attempt to better characterize the health situation based on the formulation of the existence of a triple burden of diseases: chronic, infectious diseases and those caused by external causes.

However, this diagnosis is made without any reference to the literature specialized on the topic that analyzes the evolution of health problems of the Brazilian population and has identified a much more complex picture than the summarized one^33,34.

The country’s epidemiological transition, which started in the 1970s, seems to be a current or future problem. The cited sources are sometimes major press reports or statements by Specialty Societies, nor is there any reference to existing policies for the control of chronic noncommunicable diseases, for which there is also a bibliography with which the document does not establish a dialogue.

The Institute disregards in its bold project for the transformation of the Brazilian health system, an important set of epidemiological studies developed both by researchers in the field of Public Health and by the technical areas of the Ministry of Health. After all, how can one formulate health policies without the adequate basis of the social-health picture?

Finally, it should be emphasized that all spaces of social participation are ignored, with ICOS’s proposal showing only the supposed “population’s empowerment”, which would occur as of the publication of data and the permission for “inspection of institutions, with patients/citizens making more informed choices”²¹.

Associativism, fields and interests

What is new in this private sector movement in health starting in 2014? At least three phenomena have been identified. The first one consists in the creation of an inter-category and segment association of the so-called health production chain, overcoming, albeit temporarily, the internal contradictions between insurance companies and insurance, service providers and supply producers. The second comprises the preparation of propositions aimed at the public and the universal that would surpass the immediate interests of these agents, even if only in discourse. The third, takes shape in the disputes about the proposals for the reform of the Brazilian health system, that occurs inside the field of power, according to Bourdieu²⁴.

In Brazil, the associativism of health business groups is a phenomenon dating from the 20^th century. It was discussed by Labra³⁵, when studying the relations of society with the State, pointing out that sometimes the detected transformations and processes appear as initiatives and concessions of the State, and sometimes as social achievements.

But, as the author well recognizes, political systems are more complex than this polarity and, therefore, the accommodation of negotiated interests and concertation policies highlights the importance of interest associations as manifestations of social agents that must play a decisive role in public policy-making processes.

This discussion is important for the understanding of a frequent phenomenon in the process called “political concertation”, which expresses the clashes permeated by a high degree of political and ideological dispute between the members of antagonizing groups.

The lightness of these considerations should not hide the problem of the representation of interests when considering their extreme variety according to the country to which one refers to. Therefore, attention should be paid to the complex coalitions present in different government structures where, in principle, representatives of labor, capital and the State should be present to ensure policies of interest to the concerned parties.

Yet such configuration no longer seems to account for the enormous variety of “sub-interests” detectable in public policy spaces when a large fragmentation of the State seems to be drawn into a mosaic of multiple departmental interests. As mentioned by Labra³⁵, “in these cases, policy-making would tend to be carried out between fractions of the State and clientelistic interest groups”.

In the case of associativism in the private health sector, as early as in the first half of the 20^th century, the corresponding corporate arrangements were present. Labra³⁵ names several associative entities – some of them persist to this day – to highlight at least two aspects that may inspire the effort to understand this phenomenon nowadays. She calls attention to the fact that, even in the 70s, the associations went through “a process of concentration and hierarchization of representation at the national level, without, however, establishing an organization that aggregated all entrepreneurial interests”³⁵. She also points out some factors (which today are certainly insufficient to understand the problem), to which she attributes the effect of the rather heterogeneous private market being “in the process of functional specialization and regrouping/mutation of interests”³⁵.

Taking these perspectives as a starting point to explore the current configuration that undertakes a certain representation of the Brazilian private system, makes it possible to state an assumption that under different political circumstances, it is the manifest trends of the capitalist development of the country that have shaped the relations of the entrepreneurial health segments with the State, refuting the consequences for society, who, ultimately pays the bills.

This would be the case, for instance, of the permissibility originating from the promulgation of the Foreign Capital Law in 2015 (Law No. 13.097/15)³⁶, to guarantee and foster transactions between domestic and foreign capital in assistance, a sector previously protected by a constitutional prerogative. Since its inception, it has been responsible for mergers and acquisitions between service providers, leading to the formation of monopoly groups between hospitals, laboratories and insurance plan companies.

The social concertation resulting from these processes has been mediated by the agenda of claims and demands of business segments and marked by the power of lobbying arrangements that they can aggregate around their projects.

This has been an agile and permanent process, which already had visible particular characteristics in the first decade of this century³⁷, characteristics that have been shaping in recent years and adjusting to the political and economic transformations experienced by Brazilian society.

Prior to the emergence of ICOS, it would seem impossible for a single entity to accumulate political potential to express the demands of the most part of a sector historically pulverized into multiple interests. Moreover, a group with mercantile purposes; however, bold enough to propose representing the entirety of society, since then aspiring to build a “new national health system”!²¹. Bold, because it now manifests, explicitly, the power to decide on the creation of a public policy that has been consolidating itself for thirty years.

Moreover, another incompatibility arises in this objective, this central one, since business interests, by moving towards profit maximization, will always be foreign to the purposes of the public sector.

In this regard, the suggestion made by Coutinho^25-27 should be accepted, in his study of the representation of interests and to return to some of his leading questions: Which factors lead to the formation of a group of interests? Whose interests are represented? What is the justification for representing interests?

Bourdieu²³ also developed the idea that there are no disinterested acts. According to this author, the social world would be constituted by social fields, as spaces of relations, where particular issues are at stake, where there is interest, investment, illusion, regarding specific issues of that social universe. The associations are part of the organization of social groups in their disputes and can often constitute areas of consecration and accumulation of symbolic and political power. He studied the several social, scientific, artistic, political and bureaucratic fields^22-24. When analyzing the historical process of the genesis of the State, particularly the constitution of the bureaucratic field, he drew attention to what he considered the alchemy of the transformation of particular interests into universal interests.

Therefore, what do these agents that comprise ICOS represent as political subjects from several productive segments and organized in sectoral associations? They all need to take prominence in the market, at the same time as they antagonize each other, as multiple private clashes are established between them and in different manners, aiming at purely private interests that are competitive with each other. For the private health plans, the less consumption of medical and laboratory services, the more profit they make; as for hospital owners, the pharmaceutical and equipment industry, the more appointments and hospitalizations, the more profit they make.

Some facts are indicative of these considerations. Within the scope of private health plans, there are three entities that currently represent them in the market Brazilian Association of Health Plans (Abramge), National Health Federation (Fenasaúde) and Brazilian Federation of Health Plans (Febraplan).

The trumpeted loss of clientele over the past five years has not equally affected the affiliates of all these entities, even though the survival of like-minded entities in the marketplace depends on a dispute for clients that gets worse in a situation of economic crisis. However, the most economically sound entities have another support base, resulting from strategies other than just marketing their products. In this case, it is their material bases that allow them to invest in the financial market in search of other sources of profitability. And that is why even in a crisis scenario profits in supplementary health continue to grow.

Moreover, the conflicts between health service providers and health insurance and health plan companies reverberate the issue of unbridled increases in health care costs. The disagreements between these agents are well known, with health insurance and health plan companies on one side, and hospital providers and the pharmaceutical industry on the other side.

Also, to strengthen the discussion, the hierarchization between philanthropic hospitals should be remembered, considering they are divided into at least two categories, with different remuneration contracts: those recognized by their certifications of quality and safety – “the hospitals of excellence” – whose special contracts with the Ministry of Health allow them to provide consultations and offer training programs to public hospitals, including the University Hospitals/EBSERH network. The others are the vast majority that provide health care services to the SUS population.

By exposing its intentions with such clarity and emphasis, ICOS defends the interests of its eminent associates, criticizing the excessive judicialization processes present in SUS or praising from the good results achieved by the SHOs, to claiming the speeding up of authorizations for clinical research²¹.

From these perspectives, it would help the health insurance and plan companies in fulfilling their interests in halting the lawsuits and the high costs involved. Otherwise, it would respond to service providers wishing to secure the lucrative possibilities offered by the unregulated expansion of SHOs³⁸ and other PPPs, as well as the expectations of the pharmaceutical industry when pushing for facilities with PDPs.

To pursue such goals, ICOS does not ignore the “lobbying” movements – the activity that has expanded the most, for instance, in the United States – when the business world started to intensely mobilize and try to control the legislative power and even try to create laws⁸.

Consequently, its leaders met “with the main authorities of the Republic taking their agenda for better and more accessible health for the population” and were received in audience by President Michel Temer¹⁷: “For the initiative to go on and the proposals can actually move forward, it has been agreed that ICOS will have regular meetings with the head of the Executive Power”.

However, ICOS also had meetings with congressmen and senators and with Brazilian Supreme Court (STF) Minister Ricardo Lewandowsky. With the latter, it particularly addressed the problem of judicialization, when the STF’s Secretary of Integrated Health Services defended the integration of public and private sector experiences: “The private sector, with its experience of managing and conducting processes, focused on quality and user attention. And the public, due to the capillarization”¹⁹.

Although the expression “civil society” appears in several passages of the ICOS documents, what can be seen in this set of particular claims is that it expresses a certain representation of interests, inherent to the productive sectors of health, but not exactly the demands of the entire civil society.

Therefore, it is clear that the interests of the several companies and business associations that constitute ICOS converge in a certain direction – translated by the pursuit of “financial sustainability,” i.e., corporate survival and profitability. As they belong to the economic field where business logic prevails, why would they give up their contradictions and internal disputes in search of a common good? The hypothesis of the search for an association for better appropriation of universal resources within the scope of the State and, thus, obtain symbolic but also economic profits, can thus be formulated.

Final considerations

The still preliminary analysis carried out in this article on the content of the ICOS proposals reveals, despite the discourse to the contrary, its ideological political project related to health policy has the potential to make the universal and public SUS unviable, in the name of the public and the universal, and, consequently, withdraw from the population its inalienable right to health.

Seeing there is an agreement among the reviewed authors on the growing hegemony of the private sector in the defense of their particular interests, it is necessary to investigate new forms of organization of the health business, as well as its strategies of approximation with the political and economic powers.

Exploring the hypothesis formulated herein requires further research to analyze the transformations in social spaces and health-related fields. This would imply an analysis of the social, political and professional trajectories of the main agents involved, together with a better identification of possible historical possibilities²².

But the gaps are not found only in the plane of knowledge. As Mattos et al.³⁹ warns, “what you can tell is that they are getting organized and that they are going to be influential”. And, undoubtedly, the president of ICOS promises that “This project will be seen, in some years, as the beginning of a profound and welcome transformation of Brazilian health system. (...) Now there is a path to follow”²⁰.

If there are no doubts about the democratizing characteristic of the Health Reform propositions, there are uncertainties regarding the strategies required and necessary for the accumulation of forces aiming to resume and expand the discursive agenda that structured SUS. Particularly at the historical time ongoing in the country, of democratic and civilizing setback.

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Publication Dates

• Publication in this collection
  25 Nov 2019
• Date of issue
  Dec 2019

History

• Received
  30 Jan 2019
• Accepted
  12 July 2019
• Published
  03 Sept 2019