Políticas de salud en Brasil (2016-2022): neoliberalismo, pandemia y amenazas al Sistema Único de Salud

Machado, Cristiani Vieira; Lima, Luciana Dias de

doi:10.1590/0102-311XEN228525

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ARTICLE • Cad. Saúde Pública 42 (suppl 1) • 2026 • https://doi.org/10.1590/0102-311XEN228525 linkcopiar

Políticas de salud en Brasil (2016-2022): neoliberalismo, pandemia y amenazas al Sistema Único de Salud

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Resumen

Este artículo analiza las políticas de salud en Brasil entre 2016 y 2022, un período marcado por una inflexión política nacional y la pandemia de la COVID-19. Se examina la gestión federal de la política de salud en los Gobiernos Michel Temer (2016-2018) y Jair Bolsonaro (2019-2022) según el contexto, el proceso político y el contenido de las políticas, así como los diferentes momentos de la respuesta a la pandemia. Con base en el institucionalismo histórico y en el concepto de coyuntura crítica, el análisis explora continuidades, cambios y disputas en torno al Sistema Único de Salud (SUS). Este estudio se fundamentó en investigaciones documentales, artículos periodísticos y en la literatura sobre el tema. Los resultados revelan que el período se configuró como una coyuntura crítica, con efectos inmediatos y graves en la gestión de las políticas y la respuesta a la pandemia. Hubo limitaciones en el financiamiento sectorial, retrocesos en políticas específicas, debilitamiento institucional y formas de resistencia dentro del Estado y la sociedad. Durante el período estudiado, no se observaron cambios radicales en la dirección del sistema de salud brasileño a causa de factores estructurales, de densidad institucional del SUS, de la disputa entre proyectos, de la interacción de coaliciones de actores con intereses variados o incluso su corta duración. Sin embargo, comprender el impacto de esta coyuntura crítica que aún es reciente requiere investigar sus repercusiones a mediano y largo plazo, a nivel global, regional y nacional.

Palabras-clave:
Política de Salud; Pandemia de COVID-19; Sistemas de Salud; Sistema Único de Salud; América Latina

TYPE	AUTHORSHIP	IDENTIFICATION	DATE	THEME	DESCRIPTION
Constitutional Amendment	House of Representatives/ Federal Senate	Constitutional Amendment n. 86	17/Mar/2015	Federal funding	- Makes the execution of the parliamentary amendment schedule mandatory, limited to 1.2% of the Executive’s budget project, half allocated to health (“mandatory nature of budgetary amendments”) https://www.planalto.gov.br/ccivil_03/constituicao/emendas/emc/emc86.htm
Party document	Ulysses Guimarães Foundation /PMDB	A Bridge to the Future	29/Oct/2015	Proposal for national reforms	- Emphasizes economic reforms guided by fiscal adjustment, spending restraint, incentives for the private sector, and pension reform https://www.mdb-rs.org.br/fl_adm/uploads/documentos/Uma_ponte_para_o_futuro.pdf
Constitutional Amendment	House of Representatives/ Federal Senate	Constitutional Amendment n. 95	15/Dec/2016	Federal funding	- Imposes limits on public spending, affecting the health budget (“spending cap”) https://www.planalto.gov.br/ccivil_03/constituicao/emendas/emc/emc95.htm
Ordinance	Brazilian Ministry of Health	Ordinance n. 1,482	25/Oct/2016	Mental health and drugs	- Includes therapeutic communities in the National Registry of Health Establishments, so that they can receive resources from the Brazilian Unified National Health System (SUS, acronym in Portuguese) https://bvsms.saude.gov.br/bvs/saudelegis/sas/2016/prt1482_25_10_2016.html
Ordinance	Brazilian Ministry of Health	Ordinance n. 2,436	21/Sep/2017	Primary care	- New National Primary Care Policy - Changes rules regarding the composition of teams; a minimum number of community health workers (CHW) per team is no longer required https://bvsms.saude.gov.br/bvs/saudelegis/gm/2017/prt2436_22_09_2017.html
Ordinance	Brazilian Ministry of Health	Ordinance n. 3,588	21/Dec/2017	Mental health and drugs	- Changes rules relating to the Psychosocial Care Network, giving greater prominence to specialized psychiatric hospitals https://bvsms.saude.gov.br/bvs/saudelegis/gm/2017/prt3588_22_12_2017.html
Ordinance	Brazilian Ministry of Health	Ordinance n. 3,992	28/Dec/2017	Federal funding	- Reduces blocks of budgetary transfers from the Brazilian Ministry of Health to two expense groups - operating costs and investment - replacing the linkage to health programs https://bvsms.saude.gov.br/bvs/saudelegis/gm/2017/prt3992_28_12_2017.html
Technical Note	Brazilian Ministry of Health	Technical Note n. 11	4/Feb/2019	Mental health and drugs	- Changes the National Mental Health Policy and the Guidelines of the National Drug Policy; compiles resolutions from the Tripartite Interagency Committee (CIT, acronym in Portuguese) and ordinances from the Ministry published between 2017 and 2018 that alter these policies https://cetadobserva.ufba.br/sites/cetadobserva.ufba.br/files/nota_tecnica_-_esclarecimentos_sobre_as_mudancas_da_politica_de_saude_mental.pdf
Decree	Presidency of the Republic	Decree n. 9,759	11/Apr/2019	Collegiate bodies	- Extinguishes and establishes guidelines, rules, and limitations for collegiate bodies of the federal public administration https://www.planalto.gov.br/ccivil_03/_ato2019-2022/2019/decreto/d9759.htm
Decree	Presidency of the Republic	Decree n. 9,761	11/Apr/2019	Mental health and drugs	- Approves the National Drug Policy https://www.planalto.gov.br/ccivil_03/_ato2019-2022/2019/decreto/d9761.htm
Ordinance	Brazilian Ministry of Health	Ordinance n. 188	3/Feb/2020	COVID-19	- Declares a Public Health Emergency of National Importance due to COVID-19 https://bvsms.saude.gov.br/bvs/saudelegis/gm/2020/prt0188_04_02_2020.html
Law	Presidency of the Republic	Law n. 13,979	6/Feb/2020	COVID-19	- Provides for measures to address the Public Health Emergency of International Importance https://www.planalto.gov.br/ccivil_03/_ato2019-2022/2020/lei/l13979.htm
Ordinance	Brazilian Ministry of Health	Ordinance GM/MS n. 2,282	27/Aug/2020	Women’s Health/Sexual and Reproductive Rights	- Amends procedures for authorizing the interruption of pregnancy in the SUS, in cases permitted by law - Physicians, healthcare professionals, or those responsible for the establishment must report cases of suspected or confirmed sexual violence to the police - The medical team must offer the pregnant woman the opportunity to view the fetus or embryo via ultrasound https://www.in.gov.br/en/web/dou/-/portaria-n-2.282-de-27-de-agosto-de-2020-274644814
Ordinance	Brazilian Ministry of Health	Ordinance GM/MS n. 2,561	23/Sep/2020	Women’s health/Sexual and reproductive rights	- Replaces Ordinance 2,282/2020, after receiving criticism and contributions - Maintains the guidance for reporting sexual violence to the police https://bvsms.saude.gov.br/bvs/saudelegis/gm/2020/prt2561_24_09_2020.html
Report	Federal Senate	Final Report of the Pandemic Parliamentary Commission of Inquiry.	26/Oct/2021	COVID-19	- Points out errors and omissions by the Federal Government in addressing the pandemic and recommends the indictment of President Bolsonaro and other government officials for crimes of responsibility, as well as proposing new legislative measures https://legis.senado.leg.br/atividade/comissoes/comissao/2441/mna/relatorios
Ordinance	Brazilian Ministry of Health	Ordinance GM/MS n. 715	4/Apr/2022	Maternal and child care	- Establishes the Maternal and Child Care Network, which replaces Stork Network (Rede Cegonha) https://bvsms.saude.gov.br/bvs/saudelegis/gm/2022/prt0715_06_04_2022.html
Ordinance	Brazilian Ministry of Health	Ordinance GM/MS n. 2,228	1/Jul/2022	Maternal and child care	- Addresses the accreditation and financing of the Maternal and Child Care Network https://bvsms.saude.gov.br/bvs/saudelegis/gm/2022/prt2228_01_07_2022.html
Ordinance	Brazilian Ministry of Health	Ordinance GM/MS n. 4,809	30/Dec/2022	Collaboration with society for the Economic-Industrial Complex of Health	- Establishes the Permanent Forum for Articulation with Civil Society - Criticized for being published in the final days of the government, without sufficient debate and without the inclusion of the National Health Council https://bvsms.saude.gov.br/bvs/saudelegis/gm/2022/prt4809_30_12_2022.html
Court Decision	Supreme Federal Court (STF, acronym in Portuguese)	STF Judgment - Criminal Prosecution (AP) 2,668	11/Sep/2025	Attempted coup d’état	- Judgment of the STF’s decision in AP 2,668, which, by majority vote, convicted eight defendants in the indictment related to the attempted coup d’état, including former President Jair Bolsonaro and former high-rank officials of his government https://noticias-stf-wp-prd.s3.sa-east-1.amazonaws.com/wp-content/uploads/wpallimport/uploads/2025/10/22075642/downloadPeca.pdf
International agreement	World Health Organization	WHO Pandemic Agreement	20/May/2025	Pandemics	- Multilateral agreement approved at the 78th World Health Assembly in 2025, after three years of negotiation, with recommendations aimed at prevention, preparedness, and response to pandemics, to be followed by member states, aiming for greater global security and equity https://apps.who.int/gb/ebwha/pdf_files/WHA78/A78_R1-en.pdf

ATTEMPTS AT COORDINATION BY THE MINISTRY OF HEALTH (JAN-APR 2020)	POLITICAL POLARIZATION: “HEALTH VS. ECONOMY” (APR-DEC 2020)	SLOW VACCINATION, HIGH MORTALITY, PARLIAMENTARY INVESTIGATION (JAN-JUN 2021)	EFFECTIVENESS OF VACCINATION VS. DENIALISM (JUN/2021-DEC/2022)
Limits of federal actions in border closures, economic and social measures Physical distancing measures depended on state and municipality decisions Initial preparation: new legislation, installation of the national Emergency Operations Center (COE, acronym in Portuguese), training of national laboratories and other Latin American countries for diagnosis Coordination efforts and daily reports from the Brazilian Ministry of Health Emphasis: hospital care Difficulties in importing supplies and equipment Conflicts between the positions of the President and the Brazilian Ministry of Health	Conflicts: President, health authorities, and experts Changes in the Brazilian Ministry of Health: two ministerial changes, alterations in leadership. Federal Government decisions not based on scientific evidence Resistance to physical distancing measures, pressure to normalize the economy Vaccines: technology transfer agreements vs. conflicts over purchases and effectiveness. Instability of national information systems Subnational initiatives (e.g., Northeast Consortium, involving governors, health authorities, partners), public organizations (Fiocruz, universities), media organizations, and social movements to provide reliable information about COVID-19 and promote other control measures	Domestic vaccine production (Oswaldo Cruz Foudation [Fiocruz] and Butantan Institute): dependent on imports of Active Pharmaceutical Ingredient (API) Gradual vaccination by the Brazilian Unified National Health System (SUS), according to vaccine availability. March 2021: changes in the Brazilian Ministry of Health Establishment of a Parliamentary Commission of Inquiry (CPI, acronym in Portuguese) into the federal government’s response (Pandemic CPI) Conflicts between government authorities and experts/scientists	Achieving high vaccination coverage in adults with the basic schedule protects against hospitalizations and deaths. Complete cycle of national vaccine production by Fiocruz Increased availability of vaccines and tests. Despite scientific evidence on vaccine effectiveness, fake news and anti-vaccine campaigns generate vaccine hesitancy and low coverage among children and lower coverage of booster doses in adults (after the basic schedule). Final Report of the Pandemic CPI points to omissions and crimes by authorities to be investigated

DIMENSION	TEMER GOVERNMENT (MAY/2016-DEC/2018)	BOLSONARO GOVERNMENT (JAN/2019-DEC/2022)
Context	- Dilma Rousseff’s impeachment process: Vice-President Temer assumes the presidency in May/2016 on an interim basis and, in August, permanently, until the end of 2018 - Neoliberal economic policies, with an emphasis on austerity and spending cuts, guided by the “A Bridge to the Future” program - Configuration of ministries and profile of ministers: merger or extinction of ministries, predominance of white men with a conservative profile - Constitutional Amendment 95/2016 - spending cap. - Proposals for labor and social security reforms, with a reduction in workers’ and social rights - Imprisonment of Lula, who is prevented from running in the 2018 elections - 2018 campaign: changes in electoral rules, attack on Bolsonaro - Elections: Bolsonaro’s victory over Fernando Haddad (in the second round)	- Ministerial reform: reduction in the number of ministries through the elimination or merging of portfolios; creation of the super-ministry of economy (headed by Paulo Guedes) - Ministers aligned with a neoliberal and conservative agenda, and military personnel increased in strategic areas - Militarization in the occupation of civilian positions in the federal administration - Ultraliberal economic policies and measures to favor markets - Conservatism leads to setbacks in pro-diversity and equity policies - Setbacks in foreign, environmental, education, and other policies - COVID-19 pandemic severely impacts the country between 2020 and 2022: the federal response is marked by insufficient policy coordination, denialism, authoritarianism, and contradictions - Establishment of the Pandemic Parliamentary Commission of Inquiry (CPI, acronym in Portuguese) in 2021
Political process in health	Ministerial tenures: Ricardo Barros (May/2016-Apr/2018): - Civil engineer and businessman - Federal Representative − Progressive Party (PP − Paraná); former mayor of Maringá (Paraná State) - The Minister questions the scope of social rights and the Brazilian Unified National Health System (SUS, acronym in Portuguese) - Conservative composition in the Brazilian Ministry of Health’s secretariat Gilberto Occhi (Apr/2018-Dec/2018): - Lawyer and career employee of the Federal Savings Bank - Member of the PP; former Minister of Cities and of National Integration in the Dilma government (between 2014-2016) - Emphasis on budget management and administrative rationalization Relationships with other actors: - Synergy with the guidelines of economic authorities. - Favoring of private actors - Resistance from the Brazilian National Health Council and other sectoral actors	Ministerial tenures: Luiz Henrique Mandetta (Jan/2019-Apr/2020): - Orthopedic surgeon and rural landowner - Federal Representative - Democrats (DEM − Mato Grosso do Sul State) - Experience in public and private health management. - Mixed composition in the ministry, with a conservative profile and technical staff - Technical positions at the beginning of the COVID-19 response, generating conflicts with President Bolsonaro and the minister’s resignation Nelson Teich (Apr/2020-May/2020): - Oncologist and businessman - Resigned after less than a month in office Eduardo Pazuello (May/2020-Mar/2021): - Army General, without health training - Appointed as interim minister in May and permanent minister in September 2020. - Increasing occupation of Brazilian Ministry of Health positions by military personnel - Public alignment with the President’s guidelines in dealing with the pandemic, but authorization for national vaccine production by Oswaldo Cruz Foudation (Fiocruz, acronym in Portuguese) Marcelo Queiroga (Mar/2021-Dec/2022): - Cardiologist with management experience in the private sector - Alignment with the President - Continuity with the previous administration Relationships with other actors: - Support from national medical entities with a conservative profile - Scientific denialism by the President and other actors - Technical weakening and increasing militarization in the Brazilian Ministry of Health, with instability in pandemic management - Restrictions on collegiate bodies and social participation - Conflicts with specialists and other spheres of government - State and municipal governments adopt varied policies - Resistance from scientific institutions, health agencies (including within the Brazilian Ministry of Health, Fiocruz, and Brazilian Health Regulatory Agency), healthcare professionals, and social movements
Content of health policy	- Cost containment due to budgetary constraints (effects of EC 95/2016) - Proposal for popular healthcare plans for low-income populations: formation of a working group, but resistance and rejection - Changes in the rules for federal transfers, which are now divided into two blocks: operating costs and investments - Changes in the National Primary Care Policy (2017) with greater flexibility in team composition and the number of Community Health Agents per team - Changes in Mental Health and Drugs policies reinforce hospitals and therapeutic communities, criticized by experts for clashing with the guidelines of the Brazilian psychiatric reform and the advances of the mental health care model in the SUS	- Announcement of the discontinuation of the Mais Médicos program (a hallmark of the previous government) and the launch of the Médicos pelo Brasil program, requiring the revalidation of diplomas for physicians trained abroad. In practice, professionals hired by both programs coexisted in the country during this period - Changes in the rules for financing primary care, with a relative weakening of the Family Health Strategy - Specific policies affected by the government’s conservative agenda (e.g., women’s health, LGBTQIA+ population), by financial restrictions, and by reduced social participation - Changes in the rules relating to the maternal and child care network and authorization for the termination of pregnancy in cases permitted by law - Continuation of changes in Mental Health and Drugs policies adopted by the previous government, criticized by experts for clashing with the guidelines of the Brazilian psychiatric reform and the advances of the care model in the SUS - Management of the response to the 2020 pandemic: different moments (see Box 2) and contradictions; Tensions arise between technical strategies (e.g., decisions regarding national vaccine production) and measures lacking a scientific basis

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[TFN1] Source: prepared by the authors based on various sources, as indicated in the links.