Public health and communication: impasses facing Brazil’s National Health System in democratic public opinion formation

This article discusses the political relations between construction of Brazil’s national health system (SUS) and communication. Understanding communication as an underdeveloped field of citizens’ rights in Brazil, it proceeds on the hypothesis that the democratic formation of public opinion regarding the SUS is hindered by a media oligopoly in the telecommunication and journalism system. This affects relations between the forces in dispute over construction of the SUS. Drawing on analysis of opinion polls and studies of Brazilian media coverage of the SUS, it argues that communication is a key political determinant in building a social base in support of the SUS and overcoming the impasses identified by the literature. It concludes that the relationship among communication, politics and democracy challenges the SUS to dispute the formation of a public health awareness in the daily lives of Brazilian citizens, as expressed by Giovanni Berlinguer to Brazil’s nascent health sector reform movement in the 1970s.


Introduction
and its ability to convince the public's judgement is weakly formed, it will feel its authority to be dependent, vulnerable and not stably constituted over time 6 . Fontana 7 argues that the unstable interaction among processes that form power relations and build consensuses constitutes the very nature of power.
This article explores the understanding of public communication not as government communication, but as an institutive component of politics, bound up with the construction of the public interest, inscribed in power relations and thus central to the republicanisation of rights, particularly in representative democracies. On that theoretical basis, it argues that, for the SUS to become fully established, it is necessary to form a social support base constituted on the strength of a public health awareness 8 and that the existence of an oligopolistic media system works to the detriment of that process.
The first section sets out the theoretical debate underlying this argument and warranting the claim that public communication is a fundamental sphere of political power, particularly as regards the construction of rights in democracies. The next section offers an analysis of opinion polls regarding the SUS conducted by various different institutes in recent decades. By that route and considering the complex nature of the formation of public perceptions, the section discuss the meanings of Brazilians' opinions of the SUS and how the private communication system interferes in their formation. Lastly, the article concludes that the lack of democratic public opinion formation is important to understanding the impasses facing the SUS. As a constituent of the very nature of political power, communication acts on the correlation of forces that dispute the directions of the public system, precisely because it affects the formation of civic values that determine public deliberations.

Communication, democracy and legitimation of the SUS
Politics understood in terms of publicly shared ideas and values is a topic in Machiavelli's discussion of the very nature of political power; it is also established as a classic theme in republican political thinking 5,7,9 . To that tradition, laws, institutions and economic choices are shaped by, and embody, public moralities formed through conflict in different historical contexts. In contrast with elitist theories of democracy, which deny that popular sovereignty is relevant to the course of history or make it conditional exclusively on the interests of parliamentary oligarchies, economic elites and intellectual vanguards, republican thinking regards the popular presence as founding the very meaning of power in modern politics, even if not necessarily in an active and sovereign sense 7,10 .
In this tradition of political theory, the public judgment of common citizens regarding the course to be taken is central to establishing and maintaining political power, especially in democratic regimes. As the construction and preservation of a social support base are essential conditions for any political agenda -from tax matters to education policy, from public health to social security affairs -the public's judgement is an indispensable component of politics 7 . Even scholars who consider institutions to be central to the dynamics of politics incorporate public opinion as a domain that has been important to containing the dismantling of Social Welfare States since the 1980s 11,12 .
Framed differently, there had been a return to studies of political culture -civic culture -with a view to understanding contemporary risks to democracies. These studies indicate that a considerable degree of public acceptance and approval is required in order for democratic institutions to become established and endure 13 . By and large, these interpretative approaches reinforce the notion that formation of a social base to support policy programmes and agendas is constitutive of representative systems. Nonetheless, when considering the political nature of public opinion and its importance to institutional dynamics, they do not incorporate the understanding of public opinion as a political variable institutive of citizenship. This leads to an analysis of the conditions in which the communications media are organised that underestimates their influence and their impact on the democratic formation of public opinion.
The recognition that public values are a key component of the nature of political power is precisely what makes it important to discuss the democratic formation of public opinion. The democratic sense of communication as a common good rather than an individual or property right is concerned with 'equal power to speak' and thus calls into question the distribution of means and resources for conveying and constructing worldviews. From this republican democratic perspective, unequal distribution of the power to communicate ideas and points of view on matters that are important to collective living is equivalent to censorship and, in many cases, marks the very distinction between democracies and non-democracies. As expressed by Guimarães & Amorim 6 , when that good is corrupted, when the power to speak and gain audience in public matters is unequal, it is the meaning of democracy that becomes uncertain (p. 14), because not even freedom of expression is guaranteed. Following the principle of republican theory, this corruption is better understood as the private, mercantile appropriation of a public good, rather than as exclusively a phenomenon of the State. It is thus a process in which private interests relegate, and prevail over, public interests and constrain popular sovereignty.
The debate over democratic public opinion formation centres its analyses not only on the public regulation of communication in opposition to any private, mercantile oligopoly, but also on the control that these latter interests manage to gain of that regulation itself. This situation constitutes an antidemocratic veto to any dialogue on the subject, preventing public agencies, for example, from demanding diversity and plurality of information from radio, TV and print media concession holders.
In Brazil, the concentrated and mercantile nature of telecommunications, built up at odds with even the minimum 'symmetry of voice' , indicates that the republican meaning of communication is strongly repressed. Media Ownership Monitor Brazil reports that the country's 50 most important media vehicles are concentrated in 26 communication groups or companies. Five of these groups or their individual proprietors control more than half of Brazil's media vehicles, commonly through 'cross ownership' of radio stations, TV channels and newspapers. Brazil's media proprietors are active in other sectors of the economy, including the financial, real estate, agribusiness, transport and health systems, constituting clear conflicts of interest 14 . In this anti-republican environment, the business circuit -because it is oligarchic -comes to set the public agenda: it has the power to omit or understate facts and also to transform part-truths into overblown realities, to suit its interests.
The struggle for citizenship in the twentieth century can be understood as the endeavour to have education, social security, work and health recognised as public rights and States' duties. The path taken by communication in Brazil stands in striking contrast. Despite the dispute waged by Roquette-Pinto, beginning in the 1920s, for communication to gain a public, educational and cul-tural sense -which is central to health issues 15 -, what has prevailed, particularly since the 1940s, has been its commercial sense 3 . Universal rights are widely accepted to be the principle guiding democratic struggles; this contrasts radically with what has become established in the communication field. In that field, the private-property sense of freedom has predominated to such an extent that any discussion of public legislation to regulate entrepreneurship in the communications media is generally framed as acute aggression and in violation of the very notion of freedom of expression 6 .
That interpretation rests on the orientation dominant in the tradition of political liberalism, which sees State regulation of communication as a direct risk to the private, civil freedom to think without constraints, to express a plurality of perspectives with no outside interference 16 . In this connection, the concept of 'public opinion' itself is generally associated with a uniformity of views or partial opinions transformed by authoritarian means into public truths. Guimarães & Amorim 6 explain that, to this liberal canon, the individual sense of freedom of communication is in tension with the very idea of republican, symmetrical rights and duties that should shape citizenship.
This restricted sense that communication has come to gain in Brazil clearly converges with this liberal political paradigm. In that interpretative matrix, any attempt to debate the de-concentration of the power of the communications media is framed by the media oligopolies as an oppressive, authoritarian adventure by either the State or political factions. Political action to perpetuate this oligopoly by the businessmen who control the traditional media system, although unconstitutional, has proven highly effective. Examples of this are the boycott of the 1 st National Communication Conference, held in 2009; the refusal to discuss the timeframe of the 1960 Brazilian Telecommunications Code; and the repeated efforts to veto any regulation of the rules in the complementary legislation on social communication pending in the 1988 Federal Constitution 17 . Lima wrote "concerned to maintain the incredible privileges they have won over time and in a reassertion of their rejection of democratic negotiation, these groups discuss, hear and promote only their own voices" 17 (p. 9). In opposition to any distribution of the opportunity 'to speak' and 'to be heard effectively' , what holds is the 'market of ideas' and its asymmetries.
In republican language, private domination of communication systems, legitimated as the property of a restricted circle of large entrepreneurs, constitutes a serious obstacle to the democratic formation of public opinion 6 . In such a scenario, private conglomerates wielding asymmetrical power to convey outlooks and to influence public choices should be regarded as true political agents. If the plurality of perspectives is constrained, a privileged capability to interfere in democracy enables a veritable militancy to be deployed in the form of journalistic material in favour of specific guidelines and agendas. This overstatement of certain specific points of view also works to silence and obliquely criticise their opponents.
As discussed in this section, the concept of democratic public opinion formation considers freedom of communication to be a social practice; as such, it is conditional on equal power and ability to exercise that freedom. As with other citizens' rights, such as health itself, freedom of communication is recognised, pursuant to the Constitution, as a public good that finds full individual realisation when its collective, shared, non-oligopolistic value is acknowledged. The distance explored here between expressing ideas and their having the power to spread defines the very nature of democracy or the corruption of public opinion. That corruption may take forms that induce partial views and perspectives as representing universal truths.
Construction of a broad social base in support of the SUS, as a constitutive component of political power, is unavoidably bound up with public debate. In that regard, communication stands as a decisive political determinant of the construction of the public health care system, and its democratisation can be a fundamental component in counterbalancing the pressures on the political system from entrepreneurial private health care concerns 18 . An examination of processes of public opinion formation reveals the communication media in their full political sense; their democratisation is a precondition for building a health system grounded in the public interest.

the SUS and opinion polls
The SUS, now under construction for more than thirty years, has substantially transformed the scope of Brazil's health services. Even considering all the limitations of its network of care, prevention and other services, Brazilians' outstanding health gains have upgraded the health scenario in the country. Examples of recognition for these results are publications such as the WHO Bulletin ("Brazil's march toward universal coverage") 19 , the British Medical Journal editorial 20 and the 2011 special issue of The Lancet 21 .
In an issue commemorating 30 years of the SUS, Ciência e Saúde Coletiva journal brought together studies by more than a hundred researchers to present a balanced discussion of the challenges facing the system and its undeniable contribution to the improved health status of millions of Brazilians. Those studies are well synthesised in the words of Campos, who wrote there is a wealth of evidence of the superior effectiveness and efficiency of universal, public systems as compared with market models 22 (p. 1708).
In the light of these assessments and assuming that public legitimation of the health system is a central political determinant in establishing health as a right, this study attempted to ascertain Brazilians' perceptions of the SUS by analysing opinion polls taken by various different research institutes between 2000 and 2020. Note that opinion polls offer snapshots of specific points in time and are susceptible to biases, such as the mood of the moment, the sampling method and even how the questions are framed. In addition, as they use differing methodologies, it was not possible to compare them as regards changes in public perceptions of the system. Despite these limitations, analysis of these polls did yield important food for thought about relations between public health and communication in Brazil. These included: (1) the differences between assessments by 'direct users' and 'indirect users' of the SUS; (2) the differences between assessments of SUS services actually used (experience) and 'overall' perceptions of the public system; and (3) the level of knowledge of the SUS among the general public.
The poll by Vox Populi in 2003, held at the request of the National Council of [State] Health Officers (Conselho Nacional de Secretários de Saúde, CONASS), found that 45.2% of 'exclusive users' of the SUS said that the public health system functioned 'well or very well' , while among 'non-users' the approval rate fell to 30.3% 23 . In a subsequent poll, the Institute of Applied Economic Research (Instituto de Pesquisa Econômica Aplicada, IPEA) identified a similar scenario: among those who had experience of SUS services in the prior 12 months and those who did not, the proportion of opinions that these services were good or very good was greater among the former (30.4%) than among the latter (19.2%) 24 (p. 9).
In that same direction, the series of polls by Datafolha (2014-2018) also identified differences between assessments based on experience of SUS services and those constructed indirectly. In 2018, among interviewees who had used a SUS service in the two years prior to the poll, 22% classified them as poor or very poor and 39%, as good or excellent. When the question related to health care in general in Brazil, the negative assessment rose to 55% of interviewees [25][26][27][28] .
Analysis of these opinion polls on the SUS found that the closer the population was to the services, the greater the positive assessment of the system. In the opposite direction, negative assessments proved to be rooted in social segments that, for a variety of reasons, had less contact with SUS services. A 2018 IBOPE poll found a stark contrast between assessments of the "public health system in the interviewee's city" and "the assessment of Brazil's public health system overall". While 16% of interviewees considered the care provided locally by the SUS to be 'good and excellent' , when asked about the SUS they had heard about, the approval rate fell to 5%. The respective assessments as poor or very poor were 54% and 75% 29 . The IBOPE itself concluded that this situation reinforced the view that negative opinions of the SUS reflected a significant information bias, indicating that the worsening overall assessment is related more to generalised dissatisfaction among Brazilians and to media-based opinions 29 (p. 6).
This situation suggests that information mediation and, above all, the approach taken by evaluations produced from that information, are fundamental components in the formation of public opinion and thus influence for or against legitimation of the SUS.
The evidence that the media oligopolies have been subjecting the SUS to a systematic process of biased reporting, overstating its weaknesses and downplaying its virtues, finds echo in other studies on the subject. Moraes, Oliveira-Costa & Mendonça 30 found that, in 2016, 66% of articles on the SUS published in the Correio Brasiliense newspaper were negative in tone, 19.9% neutral and only 14.1% positive. These surveys revealed that the construction of an almost exclusively negative image of the SUS in the media was brought about both by the 'quantitative predominance' of negative news about the system and by the use of linguistic resources that help build an image of the SUS as exclusively a problem [30][31][32][33] . That process of information distortion was found to be perceptible in both the national and local press.
Silva & Rasera 32 , who examined the linguistic and discursive resources deployed in articles in the Folha de São Paulo newspaper, found that the terms 'SUS' or 'Sistema Único de Saúde' (national health system) were consistently present in the negative news items. By contrast, in most of the articles that referred to improvements in Brazilians' health conditions or programmes and services of excellence, the terms were not prominent. Another frequent discursive strategy found in the Folha de São Paulo articles was that problems in public health care services were treated as a generalised crisis in the SUS. They concluded that these discursive mechanisms are at the root of the construction a strong image of the system as the "problem-SUS" 32 . Oliveira argued that this image of the SUS was often found in association with the purported inefficiency of the State and the incompetence of health authorities or health personnel, leading to the construction of an unthinking symbolic order with regard to the health policy field represented by the SUS³¹ (p. 72).
As these studies point out, this becomes particularly problematical when it emerges that this slanted criticism of the SUS is accompanied by a tendency to stress the value of private care 30,31 . Accordingly, while the media often paint an unflattering picture of the SUS, in parallel and in the opposite direction, they overstate the virtues of private health insurance or health service providers.
As identified by the opinion polls investigated here, levels of dissatisfaction with the care provided by the SUS are not negligible. DataFolha surveys from 2014 to 2018 [25][26][27][28] found that health was Brazilians' first priority. However, as direct contact with the SUS has been seen to foster a more favourable assessment than among those whose opinions rested on sources other than concrete experience, information mediation can be said to play an important role in the construction of public judgement of the system. In that process, the image of the "problem-SUS" is a hyperbole built on a fragment of reality and complemented by repeatedly side-lining the system's virtues.
More detailed examination of the opinion polls shows that stronger rejection of the SUS is firmly associated with income progression, schooling and having health insurance. In this respect, the 2003 CONASS report was categorical: There is a quite clear, inverse relationship between positive assessment of the functioning of the SUS and the interviewee's level of schooling. This approval comes from 64% of illiterates and 39% of those with higher education. The same occurs with income: the lower the income, the better the assessment of the SUS 23 (p. 23).
Note that the concentration of a negative view of the SUS in middle social sectors is convergent with the derogatory representation that appears in the media. This hub of political opinion contrasts decisively with the poorest sectors of the population, the 75% who have no private health insurance and are thus 'direct users' of the SUS -and who, as seen above, return the highest rates of approval for the public health services. The negative media approach also penetrates among 'direct users' , as is perceptible when they are called on to assess the 'SUS in general' . Nonetheless, that convergence is at least partly offset by perceptions derived from experience.
The affinity between the negative media approach and the perception held by middle sectors with less contact with the SUS projects the perception of one portion of the population as being the general opinion among Brazilians. When this class bias in the media approach was documented, what public support the system does command could be seen to be silenced or side-lined. This dissonance between assessments based on direct experience and a 'generic perception' is of fundamental importance to understanding the political effects of communication on efforts to overcome the impasses facing the SUS. From the clues present in opinion polls on the system, the democratic deficit in communication can be seen to prejudice decisively any recognition of the plurality of the public interest -precisely because, in the absence of spaces for voicing favourable experiences with the system, its functioning and advances, as opposed to its limitations, the conditions required for building a public health awareness that holds the SUS to be a substantial political value for citizenship become corrupted.
On that understanding, communicationexactly for its being part of what defines the nature of power -can be said to be of decisive political importance for full realisation of the SUS. As communication is a political domain on which all other rights depend in order to take public root, 'the formation of a public health awareness' , which Berlinguer 8 pointed to in the 1970s, continues to be a key challenge for the SUS.
Despite this situation, communication's political nature as regards democratising access to health does not figure as a central object of study among the main theses concerned with the impasses facing the SUS. In the past 30 years, debates in the health field have concentrated essentially on investigating public underfunding of the SUS, public-private hybridism and management-related challenges². The political reasons why these impasses are being perpetuated have been explained, from different angles, by studying the political coalitions that determine State incentives to the health care market and by the sector's institutional trajectory². Although this framing is dominant in collective health studies, the awareness of the political terms of communication and their centrality to health are nonetheless also present in discussions in the health field. They are considered, for example, by a working group of the Associação Brasileira de Saúde Coletiva. As Araújo & Cardoso have pointed out, more democratic telecommunications are in the interests of health and should be one more area for exercising intersectorality, a concept dear to the field 34 (p. 94).
This article, in dialogue with that legacy, is concerned to show that struggles to democratise access to health will always call for strong public support and visibility. Historically, in addition to the health sector reform struggle in the constituent assembly of the 1980s, evidence of that struggle for a public voice can be seen in the movements that grew up around the provisional financial transactions tax (Contribuição Provisória sobre Movimentação Financeira, CPMF) (both when it was introduced in 1997 and when it was extinguished in 2007), the historical campaign in favour of Constitutional Amendment 29 in the early 2000s, which demanded expansion of federal health spending, and the "Saúde+10" movement in 2013.
In the context of the new coronavirus pandemic, construction of the Life on the March (Marcha Pela Vida) campaign, which was supported by more than 500 organisations working together nationally in defence of the SUS, was completely ignored by the traditional media circuits. Whether the agenda involves formulating proposals or criticisms and contestation, communication takes agonic form in the struggle for public health, rather than supporting a permanent, organic programme for forming a political citizenry. The familiar argument that tax waivers nurture the private health insurance sector 35 , or others pointing out that outsourced service provision weakens care, need to enter into the public's judgement in order to counter market reasoning. To a certain point, the success or failure of such struggles was never independent of their ability to spread and gain public legitimacy.
As a correlate to the weakening of the SUS's social support base, another consequence of communication's not being sufficiently central to the public health agenda is the deficit in the spread of public interest information on health system funding. Illustrative of this gap is the fact that in 2003 only 35% of interviewees were able to say what the expression 'SUS' meant and nearly 22% did not know that no payment should be made for SUS services at the time care is provided 23 . In an IBOPE poll in 2018, 76% of interviewees reported that they 'did not know' about the Family Health Strategy or knew about it only by 'hearsay' . Given that, by 2018, that strategy covered 64.5% of the population, it is likely that a part of those interviewees had used these services, but did not identify them as such 29 . In another direction, Camargo & Grant 36 argued that the lack of wide-ranging, democratic, public debate on health issues also leaves room for movements based on mistrust of science, such as the anti-vaccine movement, to grow and, with them, their prejudicial effects on population health.
Studies indicate that even the National Health Service (NHS) of the United Kingdom, which has enjoyed high prestige for many years, has also depended to some extent on cultivating public values in order to develop over the years. Thompson 37 argues that the public's direct contact with the NHS has proven fundamental to strengthening the system's legitimacy in the UK, given that, at first, no distinct identity was forged that would dispel public "mistrust" of previous models. Remember, however, that the UK has one of the best-structured public communication systems in the world, which certainly favoured more plural public debate of the challenges to be overcome.
As a dimension of the formation of citizenship, the right to communication has various implications for establishing the right to health. Accordingly, given that public opinion plays an important part in the dynamics of how that right is implemented, functions institutionally and is guaranteed constitutionally, the relationship among communication, democracy and public legitimation of the struggle for rights must be made a central concern of Brazil's health sector reform.

Conclusion
This article examined opinion polls on the SUS, from which it identified important differences between assessments based on experience using the system and those informed by sources other than personal experience. Note that assessments by lower-income respondents converge with the findings of prestigious health research centres in Brazil and elsewhere. Rejection by sectors that make less use of SUS services aligns with the media approach that has constructed an image of the SUS as a problem 32 , indicating that, the further from respondents' direct experience, the more the journalistic position -and its views and specific interests -takes hold.
In the context of the COVID-19 pandemic, studies indicate that this traditional journalistic framing of the health system has suffered the impact of a growing public recognition that the SUS represents hope 38 . Since June 2020, when the federal government came to obstruct access to data on the numbers of deaths and infections, what came to be called the Press Consortium (Consórcio de Imprensa), consisting of the Globo communication system and the Folha de São Paulo and Estadão newspapers, presented itself as the mouthpiece for the public interest. The Consortium, however, rarely mentions the fact that its information on the pandemic is produced by the epidemiological surveillance services of the SUS, illustrating yet another chapter in the now traditional endeavour to efface the system and undermine its credibility. That journalistic framing ignores the actions taken by state and municipal health departments to detect and monitor new cases and deaths, intensifying the relegation of the SUS as a health authority.
Health is a central concern to Brazilians, which does not necessarily indicate that they support and trust the SUS. Even the legitimacy attained by its principles of universal, free care is not to be confused with legitimation of the system itself nor with public defence of it. More precisely, this study found that the repeated and partial criticism of the SUS does not necessarily mean that its principles are rejected, but may be serving to contest their feasibility.
Latent in citizens' political identities are often opinions on fundamental issues in the nation's democratic life, such as support for political parties or rejection of reform of the State. As formulated by the republican tradition, public dispute over the meanings of shared things is intrinsic to politics, for which communication is important in forming and channelling values. As an object of politics, this means to say that the legitimacy of building a free, public health system or that of commercialising health services on the market are historical, social constructions that occur through practical politics. They depend on collectively constructing worldviews that identify health as a common good and a right or as a merchandise to be accessed through the market. This means that their continuing presence as a condition of democracy embodies a dispute that is always open to construction and persuasion.
As discussed here, Brazil's health sector reform built its critical acclaim with an eye to the various dimensions constraining fulfilment of the SUS promise. Nonetheless, there was a void in its thinking as regards the understanding that communication is institutive to the construction and maintenance of power -to constituting a health authority. As a rule, the dimensions of politics lie within the ambit of the State and of classic institutions, such as ministerial portfolios and parliaments, together with interests disputed by social movements and business corporations. What is common and recurrent in these approaches is that politics is understood to be exclusively the activity of elites and political vanguards. Contributing to this framing are undoubtedly the theories of democratic elitism underlying the argument that ordinary men and women are precluded from participating in and understanding political decision-making by its complexity, rationality and geographical scale.
Contrary to this liberal political science, the republican tradition recognises communication to be a political asset that is truly institutive of health policy, revealing that a public health awareness firmly established at the centre of Brazilian citizens' identities is part of what constitutes the correlation of forces disputing what directions the system is to take.

Collaborations
RT Santos worked on conceptualization, data collection, formal analysis, theoretical investigation, and methodological design. He also supervised the research team, drafted the first version of the article, and reviewed it; TAV Franco worked on conceptualization, data collection, formal analysis, theoretical investigation, methodological design, and writing the first version of the article and its revision; RGV Pitthan worked on conceptualization, data collection and analysis, theoretical investigation and revision of the final version of the article; LMS Cabral worked on conceptualization, data collection and analysis, theoretical investigation, administration of the research project and review of the original article; BC Gomes worked on conceptualization, data collection and analysis, theoretical investigation and review of the final version of the article; D Cotrim Junior worked on the conceptualization, data collection and analysis, theoretical investigation and revision of the final version of the article.