2016: a year of perplexity

The year 2016 will forever be remembered in the history of the Brazilian democracy. Over the next few years, its effects will continue to impact the actions of Public Health intellectuals and militants who have dedicated their lives to science and to constructing alternatives for improving the population's conditions of life and health.

An economic crisis and a political and institutional rupture have demarcated a highly adverse scenario for retaining the social rights established in the 1988 Federal Constitution and for the process of constructing the Brazilian Unified National Health System (SUS). This is because, even though enormous contradictions are evident in the trajectory of social and health policies since the Constitution was enacted ^{1), (2}, the conditions which favor advancements ³ are now under threat.

From 1988 until 2016, the consolidation of a universal health system was not a central issue in the government agenda. Nonetheless, historical-structural characteristics which limit the universalization of health were counterbalanced by specific national policies. These policies boosted the expansion of public service supply and access and the reorientation of the health care model, especially in basic care, producing improvements in public health indicators ^{4), (5}.

These strongly technical strategies and interventions found varying degrees of space in the different government cycles, due to political arrangements and the actions of sectoral groups committed to health reform in the country. Of particular note were the actions of Public Health entities and related organizations (such as Brazilian Public Health Association - Abrasco, Brazilian Health Economics Association - ABrES, and Brazilian Health Studies Center - Cebes), of health administrators, technicians and professionals in the different spheres of government, of council members and health social movements and also of Health Ministry officials and Public Defenders who work in the area, who broadened SUS's support base.

However, simultaneously to the improvement in health conditions and in access to public services, the private sector gained strength in investing and providing care ⁶. Over the past few years, public expenditures with health, whether as a proportion of total expenditures or as per capita expenditures, remained below that of other middle-income countries, even when taking into account their stability and increase in the 2000s ⁷. Problems related to funding - among others, the low economic and fiscal priority of federal expenditures, which varied according to economic growth or deceleration, as measured by the Gross Domestic Product (GDP) ⁸, and the channeling of public resources to the private sectors through direct incentives and tax breaks ^{9), (10}-, benefited the expansion of the private sector.

Starting in 2016, the policies oriented by health as a universal right and a duty of the State did not find a welcoming environment in the federal Executive and Legislative. On the contrary, political decisions that compromise the protective effect granted by the Constitution and Organic Health Law, tear apart SUS's institutions and weaken its material and technical base, increasingly affected by financial issues, have advanced.

In a recent interview ¹¹ to BBC Brazil, the Health Minister himself shows his contempt for scientific knowledge, referring to health scholars as "ideologues who deal with the issue [of SUS's universality]" and qualifying the production of an area of knowledge that is both nationally and internationally consolidated as "crazy theses".

In turn, the health plans and insurance market intensifies processes of internationalization and financialization ¹², through purchases and acquisitions, changes to its accumulation regime, product diversification and search for new clientèle. Additionally, its political strength is confirmed in propositions put forward by the government and by representatives, which, by favoring the private sector through measures that involve regulating "popular plans", reproduce social stratification and health inequalities and subject the right to health to economic oscillations.

To this are added proposals suggesting, as a solution to the economic crisis, a regime of austerity and fiscal adjustment for the next 20 years (Constitutional Amendment Proposition 241/2016 - PEC 241, approved by the House of Representatives in October of 2016 and sent to the Brazilian Senate for appreciation as PEC 55), with significant cutbacks to public spending and serious limitations for guaranteeing social rights and SUS. In a political situation in which the State's role is restricted and equality and social justice lose value, the private sector tends to broaden its presence in the health system.

In this context, we close the year proposing a Thematic Section on the "fiscal austerity, rights, and health". Here, we let the experts speak. We have invited economic, social and health policy scholars to analyze, from different perspectives, the meanings and possible repercussions of these measures. With this, we hope to encourage the debate and renew our critical perspective on these issues that are so fundamental to the future of health policies in Brazil.

Enjoy your reading!

• ¹
  Viana ALD, Machado CV. Proteção social em saúde: um balanço dos 20 anos do SUS. Physis (Rio J.) 2008; 18:645-84.
• ²
  Paim JS. A Constituição Cidadã e os 25 anos do Sistema Único de Saúde (SUS). Cad Saúde Pública 2013; 29:1927-36.
• ³
  Paim JS, Travassos C, Almeida C, Bahia L, Macinko J. The Brazilian health system: history, advances, and challenges. Lancet 2011; 377:1778-97.
• ⁴
  Macinko J, de Oliveira VB, Turci MA, Guanais FC, Bonolo PF, Lima-Costa MF. The influence of primary care and hospital supply on ambulatory care sensitive hospitalizations among adults in Brazil, 1999-2007. Am J Public Health 2011; 101:1963-70.
• ⁵
  Rasella D, Harhay MO, Pamponet ML, Aquino R, Barreto ML. Impact of primary health care on mortality from heart and cerebrovascular diseases in Brazil: a nationwide analysis of longitudinal data. BMJ 2014; 348:g4014.
• ⁶
  Viacava F, Bellido JG. Condições de saúde, acesso a serviços e fontes de pagamento, segundo inquéritos domiciliares. Ciênc Saúde Coletiva 2016; 21:351-70.
• ⁷
  Servo L, Piola SF, Paiva AB, Ribeiro JA. Financiamento e gasto público de saúde: histórico e tendências. In: Melamed C, Piola SF, organizadores. Políticas públicas e financiamento federal do Sistema Único de Saúde. Brasília: Instituto de Pesquisa Econômica Aplicada; 2011. p. 85-108.
• ⁸
  Machado CV, Lima LD, Andrade CLT. Federal funding of health policy in Brazil: trends and challenges. Cad Saúde Pública 2014; 30:187-200.
• ⁹
  Ocké-Reis CO. SUS: o desafio de ser único. Rio de Janeiro: Editora Fiocruz; 2012.
• ¹⁰
  Mendes A, Weiller JA. Renúncia fiscal (gasto tributário) em saúde: repercussões sobre o financiamento do SUS. Saúde Debate 2015; 39:491-505.
• ¹¹
  Schreiber M. Sistema de saúde para todos é "sonho" e seus defensores são "ideólogos, não técnicos", diz ministro da Saúde. BBC Brasil 2016; 11 nov. http://www.bbc.com/portuguese/brasil-37932736
  » http://www.bbc.com/portuguese/brasil-37932736
• ¹²
  Bahia L, Scheffer M, Tavares L, Braga IF. Das empresas médicas às seguradoras internacionais: mudanças no regime de acumulação e repercussões sobre o sistema de saúde no Brasil. Cad Saúde Pública 2016; 32 Suppl 2:e00154015.

Publication Dates

• Publication in this collection
  2016