Workers’ Health as a Human Right: The foundations of the Brazilian Sanitary Reform

ABSTRACT

Reaffirming workers’ health as a human right finds solid grounding in the 1988 Brazilian Constitution, which enshrined the term ‘workers’ health’, recognizing the centrality of labor in shaping the health-disease process. Despite the prominent position attributed to labor in the constitutional text, this recognition did not translate into the provision of adequate instruments or an appropriate standing within the administrative hierarchy of the health system. As a result, the necessary dialogue and interactions with other domains of health surveillance, as well as with healthcare and assistance services, have been compromised - an issue particularly critical given the inherently cross-cutting nature of workers’ health actions. It is therefore imperative to recover the foundational values that guided the Brazilian Sanitary Reform to reestablish the connection between the working class and the health sector. This involves valuing not only labor union representations but also broader social movements, particularly through mechanisms such as Popular Health Surveillance. Strengthening surveillance strategies by improving data collection within the Notifiable Diseases Information System and fostering data integration across the labor and social security sectors represents a crucial initiative. This is especially relevant in the face of contemporary challenges posed by new forms of labor relations, where understanding patterns of illness and their distribution is essential for addressing the health impacts on the working population.

KEYWORDS
Occupational health; Human rights; Health conferences; Public health; Health-disease process

RESUMO

Reafirmar a Saúde do Trabalhador e da Trabalhadora como Direito Humano encontra respaldo na Constituição Federal de 1988, que constitucionalizou o termo ‘saúde do trabalhador’, valorizando o trabalho na determinação do processo saúde-doença. A posição destacada do elemento trabalho no texto constitucional não garantiu à área os instrumentos e a posição adequada dentro da hierarquia administrativa do sistema de saúde, comprometendo as interlocuções e interações necessárias com as demais instâncias de vigilância em saúde e com a atenção e a assistência, essenciais para a execução das ações de Saúde do Trabalhador e da Trabalhadora, caracterizadas pela transversalidade. Resgatar os valores que nortearam a Reforma Sanitária Brasileira é essencial para a reaproximação da classe trabalhadora da saúde, valorizando-se não apenas as representações sindicais, mas também os movimentos sociais, por meio da Vigilância Popular em Saúde. Reforçar as estratégias de vigilância, aprimorando a captação de dados no Sistema de Informação de Agravos de Notificação e promovendo o compartilhamento de dados com os campos trabalho e previdência, é estratégia que merece atenção, especialmente no contexto desafiador das novas relações de trabalho, nas quais compreender os padrões de adoecimento e sua distribuição é essencial para o enfrentamento dos impactos na saúde da população trabalhadora.

PALAVRAS-CHAVE
Saúde do trabalhador; Direitos humanos; Conferências de saúde; Saúde pública; Processo saúde-doença

Introduction

The period leading up to the health conferences, marked by the intense activity of municipal, state, and independent meetings, serves as a moment of profound reflection. The theme proposed to initiate discussions at the 5th National Conference on Workers’ Health (CNSTT) raises a thought-provoking question: Workers’ health as a human right. If health has long been recognized as a fundamental pillar of human rights - enshrined in Article 25 of the 1948 Universal Declaration of Human Rights¹ - why, then, is there a need to explicitly affirm workers’ health as a human right?

Reaffirming workers’ health as a human right is particularly relevant in the face of the challenging historical moment we are currently experiencing. Confronting the pressing issues of our time is a complex task in a world strained by wars with the potential to disrupt global structures and geopolitical stability. The international context is marked by profound contrasts and contradictions, where technology is proclaimed as the panacea for contemporary challenges. Yet, behind the rapid advancement of microchips and artificial intelligence lie unresolved socio-environmental issues, such as those stemming from the extraction of minerals used in the production of these tiny processors, that remain largely obscured².

The new global society, while witnessing the progressive advance of technology, remains unable to overcome the persistent problems of hunger and malnutrition affecting a significant portion of the world’s population. It observes the increasing frequency of climate-related disasters driven by a severe environmental crisis yet continues to rely on fossil fuel exploitation and the extraction of non-renewable minerals - practices that deplete the planet’s remaining green reserves and profoundly alter the lives of traditional communities. At the same time, it closely follows the rapid expansion of artificial intelligence but fails to guarantee basic education for the very children who will one day be expected to manage and regulate these technologies.

The complexity of issues surrounding the labor market and the health of those who work involves not only social, but also environmental, technological, political, and economic issues. Solutions should come from understanding the complexity of the problem, rather than relying on linear solutions.

Establishing workers’ health as human rights in the current context has the potential to position it within this broader and complex spectrum, thereby promoting and reinforcing disciplinary stability around the topic. The consolidation of workers’ health as a distinct field remains an ongoing process - one that has yet to be fully resolved within the framework of public health as outlined by the 1988 Brazilian Federal Constitution (CF/88)^3,4.

This opinion article seeks to engage with the reflections prompted by the 5th National Conference on Workers’ Health (CNSTT). Initially, through a retrospective examination of the Brazilian Sanitary Reform (RSB), it provides a legal analysis of the status of workers’ health within the 1988 Constitution. Subsequently, considering the key discussion themes, it offers reflections on the current challenges faced by the discipline. Finally, it offers considerations on possible pathways for the continuous improvement of health policies dedicated to this field.

Workers’ Health as a Human Right

From a legal standpoint, it is well-founded to argue that Brazil already positions workers’ health within the framework of a human right. This is not a recent development, but rather the outcome of a long-standing struggle led by social and labor movements, culminating in the achievements of the RSB. As a result, health was elevated as a right of all and a duty of the state in Article 196 of the 1988 Constitution. This constitutional provision emerged from a broader process of social construction driven by the mobilization and advocacy of social and labor movements, particularly during the 8th National Health Conference and the 1st Workers’ Health Conference, both held in 1986⁵.

Significantly, the so-called 1988 Citizen Constitution went beyond affirming health as a right of all and a duty of the state; it also mandated the creation of the Unified Health System (SUS), whose scope of action was explicitly outlined in the constitutional text itself. In this way, health not only emerged from the Constitution as a subjective right of all Brazilian citizens concerning the state, but the organizational structure through which this right should be implemented was also established - namely, through the SUS.

However, that was not all. The Federal Constitution also introduced a new legal foundation for health, making it essential, in this context, to understand the conceptual scope of the right to health as outlined in Article 196⁴, which reads as follows:

Health is the right of every individual and the duty of the state, ensured through social and economic policies aimed at reducing the risk of disease and other health-related harms, and at guaranteeing universal and equitable access to actions and services for its promotion, protection, and recovery.

In Brazil, the right to health - beyond being recognized as a subjective public right - brought about a substantial transformation in the very concept of public health. With the promulgation of the 1988 Constitution, the understanding of public health, which had previously been limited to activities aimed at preventing and controlling the spread of diseases posing risks to the population, was significantly broadened. The state thereby assumed the responsibility not only for delivering public health services focused on the promotion, prevention, and recovery of health, but also for formulating and implementing economic and social policies as essential components of guaranteeing this right. As Santos³ emphasizes, the epidemiological perspective on the health-disease process - which prioritizes the study of social, environmental, economic, and educational factors that may lead to illness - has been incorporated into the understanding of the right to health.

It can therefore be said that the 1988 Constitution did not limit health to just biological aspects of disease; instead, it recognized that the health-disease process is also influenced by social and economic factors that interact throughout its course. In doing so, it acknowledged the concept of social determination in the health-disease process and emphasized the significant influence of social, political, and economic dynamics on health outcomes. The 1988 Constitution elevated workers’ health explicitly, including the term in the constitutional text (Article 200, section II)⁴. Furthermore, it recognized the need for the health sector to contribute to the promotion of more balanced environments, including the work environment, as provided in Article 200, section VIII)⁴. The scope of action for workers’ health and environmental health was later defined by Law No. 8,080/1990⁶, the Organic Health Law (LOS).

Accordingly, workers’ health (STT) is acknowledged in Brazilian law as a human right. However, a substantial gap remains between this legal recognition and the realities experienced in practice - a gap that must still be addressed. This discrepancy is revealed in the persistently high rates of occupational accidents and work-related illnesses. While it is true that we have shed the unenviable title of the country with the highest number of workplace accidents in the world, a mark reached in 1975⁷, the fact remains that the decrease in cases has not yet placed us in a comfortable position. People continue to die, suffer mutilations, and fall ill at high rates in Brazil. In 2024 alone, the Social Security system received 742,200 reports of workplace accidents, while 494,422 severe work-related accidents were registered in the Notifiable Diseases Information System (SINAN)⁸.

The recorded data do not account for issues related to underreporting, nor the fact that SINAN covers a broader scope, including all types of employment arrangements and age groups. Nevertheless, the figures remain alarming and reveal that a culture of prevention has yet to reach a level of health awareness among companies, the healthcare network, and the general population sufficient to transform working conditions. The fact that these data predominantly represent severe workplace accidents further exacerbates the situation; they do not reflect the total occurrence of accidents or work-related illnesses, revealing only the tip of an iceberg of a broader landscape or underreported problems. It is essential to emphasize that workplace accidents are preventable and that many lives can be saved through more effective policies that recognize the value of traditional knowledge and the importance of more democratic relationships in addressing this avoidable public health issue.

Thus, the question remains pertinent: what measures can be taken to improve the health status of the working population? Building upon the discussion themes proposed by the National Health Council (CNS) for the 5th National Conference on Workers’ Health (CNSTT), this article aims to engage with these reflections and contribute to the dialectical and dialogical process that underpins the democratic environment of the conferences.

National Workers’ Health Policy

Ordinance No. 1,823/2012⁹, which established the National Workers’ Health Policy (PNSTT), is a significant milestone in positioning workers’ health within the SUS itself. The PNSTT emphasizes the activities of Workers’ Health Surveillance (VISAT), highlighting the strategy of monitoring work environments and processes (Art. 2), and reinforces the understanding of work as one of the determining factors in the health-disease process (sole paragraph of Art. 3)⁹.

A relevant historical precedent to be considered is the publication of Decree No. 7,602/2011¹⁰, issued in the year before the establishment of the PNSTT. The decree addressed the National Policy on Occupational Safety and Health (PNSST) and, as its very title makes clear, is grounded in the perspective of Occupational Safety and Health (OSH). However, the strategy of inter-ministerial coordination in the field of occupational health and safety failed to materialize. This effort did not lead to the development of an operational plan defining institutional responsibilities, resolving conflicts related to surveillance and inspection activities, or addressing the differing conceptions of social participation. Nor did it result in overcoming the institutional tensions necessary to advance subsequent stages toward integrated action in the field of health and labor among the ministries involved. The policy outlined in the PNSST, although it included the participation of the Ministries of Labor, Health, and Social Security and aimed to overcome the fragmented actions of these federal executive bodies, clearly failed to achieve its objective. It was limited to specifying the responsibilities of each ministry and did not demonstrate progress toward fostering a more synergistic approach among the institutions involved.

Resuming the discussion on the PNSTT, it can be said that the establishment of this health policy in the year following the issuance of the PNSST was beneficial not only in providing greater detail regarding the health sector’s responsibilities concerning workers’ health but also in offering clearer direction for the integration of the issue within the health system itself. This strategic orientation is reflected in Article 8¹⁰, which defines the policy’s objectives. Key among them are the strengthening of Workers’ Health Surveillance (VISAT) and its integration with other areas of Health Surveillance; the promotion of health within safe and sustainable work environments and processes; and the assurance of comprehensive healthcare for workers. These objectives recognize the cross-sectoral nature of workers’ health initiatives and highlight the need for coordination across the various levels and services within the SUS health care network.

Moreover, by establishing these objectives, the PNSTT reaffirmed the understanding that workers’ health must be approached from a cross-cutting perspective, recognizing work as a key determinant in the health-disease process. For this reason, it must be taken into account in health situation analyses and health promotion initiatives.

To achieve these objectives, strategies were outlined in detail in Article 9⁹. Among these strategies was the emphasis on fostering collaboration between Workers’ Health Surveillance (VISAT) and the other branches of Health Surveillance - namely Epidemiological, Sanitary, and Environmental Surveillance. Particular attention was given to establishing effective communication and cooperation with primary health care through joint planning, co-creation of protocols and technical guidelines, capacity building for health teams, and the standardization and integration of tools for recording and reporting occupational injuries and diseases.

It is also important to highlight that Article 9, Section II, Subsection ‘h’⁹ includes among the policy’s implementation strategies the assurance of worker identification, along with the recording of their occupation, economic sector, and type of employment relationship across various data systems of the SUS. This requirement also applies to systems managed by the Ministries of Social Security and Labor, including the National Register of Social Information (CNIS), the General Register of Employed and Unemployed Workers (CAGED), the Federal Labor Inspection System (SFIT), and the Annual Social Information Report (RAIS). Additionally, it involves databases from other agencies such as those responsible for agriculture, environment, industry, and commerce. These data sources support the analysis of workers’ productive profiles and health status. This measure would help collect data that would strengthen epidemiological surveillance on workers’ health, as it benefits from gathering information from various sources¹¹.

More than a decade after the introduction of the PNSTT, these objectives remain largely unfulfilled. The enhanced collaboration among state agencies responsible for health, labor, and social security - envisioned in both the PNSTT and the PNSST - has yet to move beyond the conceptual stage. It is posited that fostering greater interaction among these sectors could be effectively achieved through improved digital data sharing. Each of these entities holds a vast amount of data on the Brazilian working population, and sharing this information would be mutually beneficial. However, there is neither consensus nor initiative in the development of these databases to establish a minimum common dataset that could facilitate data sharing. Information entered in the Work Accident Communications (CAT), for example, must afterwards be duplicated in notifications to the SINAN system. The initiative to develop a data-sharing policy could originate from the Ministry of Health itself, which, according to the PNSST, has been assigned the task of ‘contributing to the structuring and operationalization of the integrated workers’ health information network’ (item VII, Subitem ‘d’ of the PNSST)⁹.

An integrated information network would be highly valuable for assessing the health status of the working population, thereby supporting the adoption of more effective measures to address issues impacting workers’ health. Furthermore, information sharing would aid in combating fraud within the social security system, for instance, based on health mortality information. Similarly, it would assist the field of labor in developing more robust regulatory standards grounded in consistent epidemiological data.

Looking again at the field of health, it is evident that within the SUS itself, more integrated collaboration between VISAT and other areas of Health Surveillance is not yet part of everyday health activities. One illustrative example can be found in the initiatives reported during the 10th Meeting of the National Network for Comprehensive Workers’ Health Care¹², also known as the 10th RENASTÃO, which celebrated the 10th anniversary of the PNSTT. This observation is not meant to diminish the value of the work presented - on the contrary, the initiatives showcased during the event panels deserve recognition for reflecting the tireless efforts of VISAT professionals at the state and municipal levels. However, these accounts also reveal a limited level of coordination among the different branches of health surveillance. This suggests that integrated action is still a goal to be achieved, rather than a strategy that has already been firmly established.

Some topics discussed at this meeting, such as ‘Worker Health Surveillance Experience in the Municipality of Brasiléia, Acre’ and ‘Worker Health Surveillance in Public Health Emergencies in Santa Catarina: investigation of deaths from diffuse alveolar hemorrhage in an apple farm’, reported successful experiences in more integrated action between VISAT and municipal health surveillance agencies and epidemiological surveillance agencies in these states. In their presentations, however, speakers highlighted the challenges in achieving more integrated collaboration with health surveillance, revealing that a cross-sectoral perspective on labor within health actions has yet to be fully incorporated into the SUS.

Another important point to note is related to the National Network for Comprehensive Workers’ Health Care (RENASTT), which is part of the SUS service network. There is no doubt that the establishment of RENASTT has significantly contributed - and continues to do so - to the development of the PNSTT. Specialized Reference Centers for Workers’ Health (CEREST) are key institutions for implementing this policy at the state, municipal, and regional levels. These centers are entrusted with important responsibilities, such as investigating occupational risk factors and hazardous situations, examining work-related diseases, health conditions, and deaths, identifying measures for the promotion and protection of workers’ health, and providing technical and educational support within their respective territories. All of these initiatives are to be developed through ongoing dialogue with social oversight bodies and the labor and social security sectors, in a participatory and territorially contextualized manner. This process must be systematically integrated with other surveillance systems, namely, health, epidemiological, and environmental surveillance, as well as with other SUS services and with sectors such as labor, environmental protection, social security, trade unions, and related areas, to enhance the overall coherence, effectiveness, and efficiency of these actions¹³.

Moreover, they incorporated the demands from the former Workers’ Health Programs (PST) previously established in the states of São Paulo, Bahia, Rio de Janeiro, Minas Gerais, and Rio Grande do Sul, which had traditionally focused on care, assistance, and rehabilitation actions, as well as on investigating the links between illnesses and occupational hazards. Historically, the PST can be credited with bringing public health closer to trade unions and workers’ groups^5,14, some of which were transferred to CEREST.

It is important to acknowledge, however, that there is currently a noticeable detachment of trade union representatives - and even of the workers themselves - from the activities of SUS. The ongoing crisis faced by the labor union system, which has long been subjected to severe challenges to union freedom and was further exacerbated by the labor reform enacted in 2017 (Law No. 13.467/2017)¹⁵, has contributed to this growing disconnection. The labor reform led to the abrupt cut in mandatory union dues, destabilizing the union system and partially explaining the removal of these representatives from some forums. However, even in the face of high accident rates, there has been no effective rapprochement or reproachment between workers’ representatives and the SUS.

In this regard, we believe a thorough reflection is warranted concerning the absence of more consistent strategies that integrate the Workers’ Health Surveillance (STT) units of the SUS with primary health care policies or even with specialized care. The latter, which interact more directly with users, including working individuals, are still far from incorporating the strategies formerly developed by the Workers’ Health Programs. These entities, with few exceptions, have limited interaction with VISAT, the current locus of the STT. This situation is unjustifiable from a constitutional standpoint, given that work was explicitly recognized as a determinant factor in the health-disease process within the 1988 Constitution. The intention here is not to advocate for the ‘resurrection’ of the former Workers’ Health Programs, but rather to draw on their history to critically assess whether the current framework allows for the fulfillment of the constitutional value attributed to work within the health system. The current situation undermines the achievements of former programs, whose merits include bringing working people closer to the previous public health system and helping to integrate the field of labor into the Sanitary Reform Movement. This contributed significantly to securing the inclusion of workers’ health within the SUS envisioned by Constitution¹⁶.

It is therefore crucial that the implementing agencies of the National Policy on Workers’ Health (PNSTT) possess the necessary resources and tools to carry out health actions as comprehensive as the population they aim to reach, that is, the entire Brazilian working population. Thus, it is important to discuss the composition and/or rearrangement of the CEREST staff with teams that are adequately trained and sized for the work to be carried out in the territory as recommended by the National Health Council (CNS) in Table 4 of Resolution No. 603, November 8, 2018¹⁷.

The field of Workers’ Health Surveillance (STT), in addition to the constitutional provisions (Art. 200, item II)⁴, holds responsibilities not only around surveillance, but also in health promotion, care, and assistance, as provided in Law No. 8,080/1990 (Art. 6, § 3)⁶. However, this legal status, guaranteed by law and the Constitution, in our view, is at odds with the treatment that has been given to the STT within the SUS itself.

In this context, it is important to note the current organizational structure of the Ministry of Health. STT is housed within the General Coordination Office for Workers’ Health (CGSAT), which is part of the Department of Environmental Health Surveillance and Workers’ Health (DVAST). This department, in turn, is subordinated to the Secretary of Health and Environmental Surveillance (SVSA)¹⁸. This remark is offered with complete clarity and without any implicit connotation or criticism of the current secretary; nevertheless, the position presently occupied by STT is not consistent with the duties assigned to the field by Organic Health Law (LOS), nor is it compatible with the importance and status granted to it in the 1988 Constitution.

This is not a call for a higher hierarchical position, but rather an appeal for the appropriate placement of the STT within the SUS, an area entrusted with the implementation of numerous and diverse actions as established by both the Constitution and the LOS. It is extremely difficult, laborious, exhausting, and arguably unrealistic to expect that, while confined to a coordination unit, subordinated to a department within a secretary, STT, through its agents, can effectively engage in dialogue, intervene, and implement coherent policies integrated with primary health care and specialized care.

Finally, about surveillance activities in work environments and processes, we underscore the importance of including, within the teams, professionals to whom the public authorities have granted police powers - individuals who are duly vested with sanitary authority, under current legislation. Accordingly, it is essential that municipal and state sanitary codes explicitly address STT and grant it such authority. Moreover, it is crucial that public health administrators at the territorial level issue the necessary administrative acts to formally confer sanitary authority to VISAT agents.

New Labor Relations and Workers’ Health

Brazil is a country of contrasts, where colonial and dehumanizing labor exploitation models, such as slavery and the use of Indigenous labor through the subjugation of their territories, coexist with models shaped by what has come to be known as Industry 4.0. Between these extremes lies yet another form of labor exploitation, the ones mediated by digital platforms.

Regardless of the model or the form in which services are rendered, be it formal or informal, manual or intellectual, the question persists: how do workers experience illness?

Within this context, reinforcing health surveillance strategies is essential for understanding the processes of illness associated with emerging labor relations. While the reporting of work-related accidents, illnesses, and health conditions linked to these new forms and modalities of work is important, it is evident that such reporting alone does not address the broader social and public health challenges they entail. Nevertheless, it remains a valuable instrument for improving the understanding of disease patterns and their distribution. It also makes it possible to assess the extent to which new technologies and new models of labor exploitation impact and overload the health care system.

In a universal health care system based on the principle of free access to health care services, notifications are even more important as they enable the costs of these services to be quantified by combining information within notifications with that from the Hospital Information System (SIH). There has been a clear trend toward shifting the risks and costs associated with the impacts of these labor arrangements, often operating under the guise of informality, onto the SUS. As a result, it assumes the burden of health care services and the physical and psychological rehabilitation of injured workers. These expenses, which ought to be borne by the enterprises responsible, are instead distributed across society at large.

With respect to labor performed through digital platforms, the federal government has expressed concern about the sustainability of the social security system. In an ill-conceived initiative¹⁹, the presentation of the Complementary Bill (PLP) No. 12/2024²⁰ was announced, proposing mandatory social security contributions from both the workers and the platform operators. Ultimately, the urgency designation for the bill’s consideration was revoked, as the purported agreement among stakeholders failed to materialize, exposing the vulnerability of the state in confronting this emerging context.

What can be observed from the PLP is the complete absence of any mention or reference to the transfer of costs related to the health impacts on workers engaged through digital platform intermediation to the SUS. This is an evident reality, in which we daily witness traffic accidents involving delivery drivers hired through these platforms, who invariably receive care within the SUS. Thus, quantifying these occurrences, recording such cases as work-related accidents in the SINAN data system, and estimating the costs of hospital care are essential to uncover these issues and to propose appropriate solutions involving the health sector stakeholders in this discussion.

Recognizing that the reporting of work-related injuries and illnesses is essential for the development of occupational health surveillance policies, the Ministry of Public Labor Prosecution (MPT), through the National Coordination Office for the Defense of the Work Environment and Worker Health (CODEMAT), established the National Project to Strengthen Worker Health within the SUS. One key focus of this project targets the so-called silent municipalities, i.e., those that fail to report work-related diseases and injuries to the SINAN database system. This initiative has been ongoing since 2021. In less than three years of implementation, through the collaborative efforts of the MPT, Regional Centers for Occupational Health (CEREST), and the municipal and state Health Secretaries, the number of silent municipalities was significantly reduced, from 1,100 to 238 in 2024²¹.

Despite ongoing efforts, substantial progress remains to be made. Enhancing notification mechanisms is essential to support the work of reporting units within SINAN. Isolated initiatives have emerged to streamline and simplify the mandatory reporting of work-related accidents and health conditions affecting workers, as exemplified by actions taken in the municipality of Porto Alegre. In this municipality, the implementation of the digital platform known as ‘Sentinela’ enables integration with SINAN, automatically inserting data into the database system. This platform facilitates data collection and has significantly reduced the number of fields that need to be completed in SINAN. The volume of data required to complete SINAN reporting forms has been a frequent source of complaints from reporting units. With the adoption of the platform, however, this burden has been reduced to a modest eight fields. The platform also enables integration with hospital information systems, which can then carry out direct notifications. Among the outcomes reported following the system’s implementation in July 2020 are an increase in case reporting within the municipality, the strengthening of worker health surveillance (VISAT) in the region, and the facilitation of more effective public policy development²².

Ultimately, understanding the health profile of workers - regardless of the nature of their employment - necessarily depends on improving the reporting of injuries and work-related accidents. Enhancing the notification system by streamlining data collection through integration with multiple sources, such as those of Social Security, the Federal Revenue Service, and others, would greatly contribute to strengthening the Worker Health Surveillance (VISAT). It is inexplicable, for instance, that the number of work-related accident reports submitted to Social Security²³ exceeds the number of accidents recorded by SINAN²⁴ as currently observed. This discrepancy is particularly puzzling given that the social security system handles notifications only for formal employment, whereas SINAN covers the entire working population, regardless of employment status. The inconsistency and discrepancy in these data highlight the need for policymakers to address this issue with greater seriousness.

Popular participation in worker health for social accountability

The establishment of social control through the representation of labor unions and social movements in participatory management and representative bodies of the SUS is a directive set forth by the PNSTT. This directive stems from the constituent process, grounded in the principles of democratization and social participation, which guided the specific focus on knowledge-sharing within educational processes, planning, and worker health surveillance. As an integral part of the SUS, institutionalized through councils, participation mechanisms, and social legitimacy - achieved through the exercise of popular power won by social strugglessocial control in health is a product of the redemocratization process that shaped the new public health framework envisioned by the 1988 Constitution. Social control is neither a favor nor a concession. It arises from a legal imperative enshrined in Law No. 8,142/1990²⁵.

Listening to the experiences of workers’ organizations in their struggle for occupational health is essential to ensure the legitimacy and effectiveness of policies related to worker health and safety. Therefore, this practice, entailing interaction with various representative groups, must become a routine part of everyday processes, rather than occurring solely within the institutionalized setting of occasional meetings such as conferences, where the debate aims primarily at securing collective approval. The participation of labor unions and social movements in the Intersectoral Worker Health Commissions (CISTT) is essential for bringing real-life issues to the table. Equally important is social participation in the development of annual and multi-year health plans, whether through conferences or workshops held within local communities. In recent years, the term Popular Health Surveillance has gained traction. Although still an evolving concept, it has been actively promoted by popular movements across the country from north to south. It is essential to facilitate and emphasize the participation of these groups as they are the most legitimate representatives to bring data, facts, and local knowledge from their communities to the formal health surveillance agencies.

In numerous territories adversely affected by environmental degradation and labor exploitation, it is crucial to empower grassroots groups arising organically to advocate for the right to a dignified quality of life within their communities, thereby advancing public health promotion. It is crucial to implement robust mechanisms that ensure the meaningful participation of these groups and provide transparent responses to their demands and concerns, whether affirmative or negative, to foster stronger participatory governance founded on mutual trust and respect for public administration.

It is important to underscore that the incorporation of demands from these groups and social movements is expressly provided for under the National Policy on Worker Health (PNSTT), which, according to Article 9, section V⁹, includes among its implementation strategies the promotion of community engagement, worker participation, and mechanisms of social oversight - without restricting such articulation solely to trade union representation. In this regard, it substantially departs from the tripartite model traditionally advocated in labor frameworks, positioning itself as a contemporary response to the challenges of our time.

It is essential to recognize and elevate the role of social movements, particularly those that arise in response to exceptional and often tragic labor and environmental conditions. A salient example is the sustained advocacy and organizational work that followed the industrial disaster in the municipality of Paulínia, São Paulo, widely known as the ‘Shell/BASF Case’²⁶. This event gave rise to the Association of Workers Exposed to Chemical Substances (ATESQ)²⁷. Notably, this very group of workers benefited from prior experiences of other labor groups in the municipality of Cubatão, also in the state of São Paulo, where the Association for the Combat of Persistent Organic Pollutants (ACPO)²⁸ was established. ACPO has played a significant role in addressing industrial chemical pollution and its impacts, particularly human exposure and poisoning, contributing to broader efforts in environmental and occupational health advocacy. Another prominent association playing a significant role in the field of labor and health is the Brazilian Association of People Exposed to Asbestos (ABREA)²⁹, which brings together regional entities from Bahia, Rio de Janeiro, Pernambuco, Paraná, and the southwestern region of Bahia. These entities collectively advocate for the nationwide ban on asbestos and provide support to individuals who, years or even decades after exposure to the carcinogenic mineral, are diagnosed with Asbestos-Related Diseases (ARD).

The work carried out by these, and other associations emerges from pain and a sense of indignation over situations that could, and should, have been prevented. These movements play a vital role in disseminating knowledge and providing emotional support to affected workers and their families, often stepping in to fulfill responsibilities that would ordinarily fall to health professionals. These organizations frequently assume responsibility for risk communication within affected populations, facilitating health-seeking behaviors and performing other critical functions. Enhancing the interface between the SUS and these entities requires formal validation of their legitimacy attained through their experiential knowledge. This recognition should be a subject of thorough institutional reflection to foster a collaborative and effective partnership that advances the health interests of the labor force.

Final considerations

The reflections articulated in this opinion article seek to advance the recognition of workers’ health as a fundamental human right, embodying both historical struggles and present-day challenges. Moreover, it highlights the pivotal role of occupational health and the imperative of implementing effective policies within the Unified Health System (SUS), especially against the backdrop of enduring historical contexts and ongoing social and environmental crises. It also draws attention to the need for comprehensive approaches that integrate health services and policies in the realization of the expanded concept of health, ensuring the protection of workers’ rights and the prioritization of their health.

In the context of the 5th National Conference on Workers’ Health (CNSTT), it is essential to promote coordination among the various sectors involved in labor, environmental, and social security matters. This collaboration fosters a holistic understanding of health, one that recognizes the workplace as a central element in shaping the health-disease process. It is the recognition of work as a central pillar of health policy as expressed in the constitutional principles, an achievement born of social movements whose struggles paved the way for these rights to be secured.

May this moment of the 5th National Conference on Occupational Health (5ª CNSTT) thus serve as a meeting point for all social actors and interested stakeholders in the right to health - workers, health professionals, and policymakers - to reaffirm their commitment to advancing workers’ health through proactive engagement and the development of robust policies grounded in human rights and the promotion of a culture of prevention, understood as a duty of the state and a right of all workers. This vision can be made a reality by ensuring that all workers are guaranteed the undeniable right to a healthy and safe working environment.

Conferences are also moments of celebration, gathering, and collective reaffirmation of the strengthening of the foundational mechanisms of public health. Furthermore, its vitality demonstrates that the field of workers’ health and safety remains dynamic and resilient despite the turbulent times we face, characterized by the climate crisis, emerging technologies that directly impact work relations, and the profound shifts in work processes and relationships brought about by the pandemic, making this a critical inflection point for the labor sector in Brazil.

The problems of our time are complex, and moments such as this are opportune for reclaiming the foundational essence of the field of workers’ health and safety. The chosen theme for the upcoming discussions was well selected, as it positions STT as a human right, just as it has been recognized in the original text of Brazil’s Constitution. It is imperative to reaffirm this stance to reclaim the values that guided the Brazilian Sanitary Reforma and the foundational principles enshrined in the constitutional text. These principles were shaped by social movements that catalyzed a pivotal shift in Brazilian public health toward the ideal of collective health, recognizing work as a fundamental determinant of the health-disease process.

It is therefore essential that the health sector reclaim these foundational values, recognizing that the dimension of labor was explicitly acknowledged and constitutionally elevated, not by chance, but as the result of social struggles. The original Constituent Power made a deliberate political choice to affirm the centrality of labor within health-related actions. This choice must guide the structuring and valorization of the field of Workers’ Health and Safety within the SUS, in a manner that enables and strengthens the necessary dialogue with other areas of health surveillance, primary care, and specialized health care services.

Workers’ Health and Safety must be integrated into health promotion and care actions, and actively engage with them. Only through this integration can it fulfill the responsibilities assigned to it by Law No. 8,080/1990 and the 1988 Constitution, which are not limited to surveillance but also encompass health care, promotion, and assistance activities. Expecting the inherent cross-sectoral nature of Workers’ Health and Safety (STT) to manifest spontaneously, while overlooking the hierarchies imposed by the administrative management structure, is to willfully ignore the problem and to dismiss the progress achieved by the RSB itself. Recognizing work as a fundamental determinant in the health-disease process is essential to honoring the constitutional rights of Brazilian workers and ensuring that health policies genuinely reflect and address their needs within an equitable and comprehensive health system.

• Financial support:
  Non-existent

Data availability:

Research data are contained in the manuscript itself

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Edited by

• Editor in charge:
  Maria Cristina Strausz

Publication Dates

• Publication in this collection
  06 Oct 2025
• Date of issue
  2025

History

• Received
  28 Apr 2025
• Accepted
  22 June 2025