Challenges lie ahead for health in Brazil

Progress in protecting public healthcare under the Lula government in 2023, yet challenges loom ahead

December 28, 2023 by Peoples Health Dispatch
Rosana Onocko-Campos (Photo: Abrasco)

Rosana Onocko-Campos, the president of the Associação Brasileira de Saúde Coletiva or the Brazilian Association of Collective Health (Abrasco) and one of the organizers of the Frente Pela Vida (Front for Life), reflects on the most significant events in healthcare in Brazil in an interview with Outra Saúde.

Although several positive developments have been noted since Nísia Trindade assumed the leadership of the Ministry of Health during the Lula government, Onocko-Campos cautions that more obstacles and threats to the Sistema Único de Saúde or the Unified Health System (SUS) could be on the horizon.

Outra Saúde: In a sense, 2023 has felt like a longer year than usual. We could say it began in November 2022, with the formation of the transitional government and disputes over the budget. How do you believe this impacted health programs in 2023?

Rosana Onocko-Campos: There were a series of decisions and measures implemented at that time that ensured the survival of the health sector throughout this year. If there hadn’t been an effort within the transitional government to secure sufficient funding, I believe we would have been in a very poor situation. The start of the year was also marked by a coup attempt, which was highly dramatic for all of us. On the other hand, we found the transitional team to be well-assembled, particularly in the case of the Ministry of Health. It acknowledged the necessity of having both a technical and a political component, and I think that was also a positive aspect of the beginning of the year.

OS: How would you assess Nísia Trindade’s first year at the Ministry of Health? What were the highlights, and what challenges did she face this year?

ROC: I believe the highlights are closely tied to the minister’s background, particularly her humanistic training as a sociologist and her prior leadership at Fiocruz. It seems to me that she has a comprehensive understanding of science and research derived from her personal history. She’s a good manager, in the sense that she knows how to engage with people, see people and listen to them. I used to joke with her that as soon as she arrives somewhere, people start clapping – they simply like meeting her. She’s a minister who empathizes with the sector, a crucial quality during these challenging times, as it can open doors.

As I mentioned earlier, establishing the Ministry required respecting technical qualifications and considerations, but the process also reflects the minister’s career path and Fiocruz’s values. For instance, there is a clear emphasis and commitment to the Health Economic-Industrial Complex (a program fostering collaboration between government bodies to enhance Brazilian research, development, and production for the benefit of the SUS). Additionally, the minister is dedicated, very clearly, to vaccine-related issues, such as expanding immunization campaigns and local production.

Another commitment aligned with her humanitarian and empathetic approach is addressing urgent bottlenecks. This involves increased fund transfers to Santas Casas (non-profit health providers, largely charities) and specialist services to tackle the queues for elective surgeries that accumulated during the pandemic—this is a problem that existed before, but worsened during the pandemic. The boost of the Mais Médicos (More Doctors) program is another good example, where a crucial decision was quickly implemented. 

Throughout the year, we’ve witnessed significant steps in structural policy. For the first time, policies have been introduced for medical specialties and reintegration, which will bring a tangible increase in investment in primary care, with higher amounts allocated per team. These announcements are very important and relevant, but they alone may not be enough for the next three years.

OS: What difficulties and challenges will the health sector face in the upcoming period?

ROC: I’ll begin with the broader issues and then delve into more specific ones.

First and foremost, my major concern on a general level is how the Ministry of Health will navigate its dialogue with other ministries to uphold what we refer to as One Health. This becomes crucial as we witness the Poison Bill (Bill 1459/2022, which allows for a more relaxed use of pesticides) advancing through Congress and we encounter setbacks regarding the demarcation of indigenous lands and environmental preservation. We can no longer address health, particularly prevention, without simultaneously addressing environmental and agricultural issues. The Ministry must assert itself here, and the minister should leverage the direct communication she maintains with President Lula to persuade him on the importance of specific vetoes. Even if some of these vetoes continue to be overturned in Congress, certain cases may need to be brought to court again, as this Congress is jeopardizing Brazil’s future—not just ours but that of our grandchildren. It’s an awful situation.

Concerning the SUS, another issue that causes concern is whether the minimum budget levels will be met. This year, there have been attempts even from within the government itself to say that the minimum budget level does not necessarily have to be adhered to. This is a matter of great concern within the health movement.

Additionally, within the SUS, we are eager to witness significant strides in the next three years toward establishing permanent policies in three key areas. Firstly, there is the issue of funding – how it will be allocated, in what quantity, and based on what calculation.

Secondly, decentralization is a concern because of the approach undertaken until now. Because there has not been any thoughtful structure, this matter is being left to the states and regions, leading to diverse consortia and forms of privatization across the country. We believe a legal framework is essential to strengthen the public component of the SUS, but this has to be built at the regional level. I often joke that today, the regions are like the Queen of England—they need the ability to govern themselves, to have financial and administrative autonomy, and determine the allocation of resources. This represents an important bottleneck in the current state of the SUS.

Finally, another issue we have been attempting to address is that of the health workforce. While the More Doctors program has proven effective in addressing a significant deficit of health workers, it alone is not enough to support the whole SUS. No country that is committed to financing provision of health services through a universal health system has achieved this goal without a solid workforce policy that considers positions, salaries, and career paths. This is an issue that needs immediate attention. There are various proposals that we can discuss, and while personal opinions may differ on which is better or which modifications are necessary, the crucial point is that resources must be allocated to this part of health policy. Currently, there are none. Each municipality operates independently, resulting in Social Organizations (OSs) making work more precarious and compromising the quality of SUS outcomes.

This needs to be said because otherwise, there’s a risk of portraying those in the health movement as outdated individuals seeking traditional public careers, like they had just fallen off the 20th-century truck. That’s not the case. There are valid reasons behind advocating for a system that prioritizes efficiency and effectiveness. When there is a lack of sustainability in health education due to frequent personnel turnover, strained relationships, and the exploitation of workers to the point of burnout and suffering (as observed frequently among health workers), it becomes evident that discussions about careers and hiring are not merely a “leftist frill.” Instead, they are essential conditions for the proper functioning of the system.

OS: What policies do you believe have the most potential for 2024?

ROC: I see some glimmers of hope, I would say. For instance, there is an initiative led by the Secretariat of Work and Education Management (SGTES), to promote training programs in Family Health, interdisciplinary professional master’s degrees, and other training initiatives. I believe that the efforts made by this Secretariat throughout 2023 will bear fruit next year. This is significant because we went through six years without substantial investment in training and education. This is very important.

I discussed this at the National Mental Health Conference recently. There are also strategies that need to be revisited, such as the humanization of hospitals and the discussion of clinical-institutional supervision within psycho-social care networks. These are workplaces where the psychological suffering of workers quickly transforms into bureaucratization, and bureaucratization serves as a barrier for users. It’s essential to recognize that bureaucratization is an institutional illness, but it can be treated. The remedy involves providing the necessary support in terms of training, management, and clinical-institutional supervision for workers. Without this support, we risk forfeiting a good resource that directly influences what I refer to as the effectiveness of the system: how our patients are received, the eye-to-eye contact that someone who has been suffering will experience at the health center, psycho-social care center, or any outpatient clinic.

OS: Specifically in the realm of mental health, what would you say about the government’s actions in this first year?

ROC: I believe there was a significant effort to address the backlog. Six years ago, new mental health services were not established, and in the last government, there was a clear attempt to revert to hospitalization measures, including compulsory hospitalization.

However, a critical issue lies with therapeutic communities, and it seems no one is addressing the core of the problem. These communities were removed from the purview of the health sector, but there hasn’t been any action taken outside the health sector either. We witnessed the distressing news recently about a girl who was killed in a therapeutic community. Even such horrific incidents are not sufficient to put a limit on the voracity of certain political sectors, including the Centrão and the churches.

This highlights a point where health intersects with politics, raising significant concerns about the Brazilian political landscape. It’s unrealistic to think that the Ministry of Health or Social Development can tackle this issue alone. It’s a discussion that Brazilian society can no longer afford to overlook. At some point, there needs to be a societal response to the regressive nature of this Congress.

OS: As the president of Abrasco and a member of the Front for Life operational team, what role do you believe the health movement played in the political debates throughout the year?

ROC: I may be biased, but I think we made a significant effort to maintain what I would describe as critical support for the government.

We understand, of course, that we emerged from the dark seas. Currently, we are sailing with some defined directions but also facing several uncertainties and perhaps impending storms—challenges that we are anticipating and attempting to address. All this is happening in a context where the governance situation is a cause for concern. I believe the movement has acted responsibly in this context.

Recently, during the Front for Life plenary, we assessed that this year we’ve made progress in approaching the parliamentary field, something that we’ve set to achieve after the election at the end of last year. Strengthening the Parliamentary Front for Health, for example, is a significant step taken by the health movement. We need Congress to address real issues affecting people once again. At times, it feels as if parliamentarians live in a bubble, lacking sensitivity, with agendas that seem entirely corporate and disconnected from the actual problems of the population.

Another noteworthy move was visiting various ministries to present ourselves as the Front for Life. To defend our lives, we approached the Ministry of Justice to request concrete measures to curb the deaths of young Black people and people from peripheral communities, and to promote social inclusion. Within this context, the discussion around the legalization or decriminalization of the possession of small quantities of drugs is crucial. It’s an issue that requires thorough debate within Brazilian society; otherwise, the country won’t have a future. It’s not feasible for Brazil to aspire to be the country of the future, as the President often asserts, while we read news stating that half of young people in the poorest 10% of families in Brazil neither study nor work. Or when we observe that demographic trends are disrupted by the premature deaths and murders of young people, particularly Black boys and boys from peripheral communities. Either Brazil addresses this issue, or there won’t be a future.

What’s disconcerting is witnessing Congress pretend that such matters are not within their purview. Our role as movements will always be to remain vigilant, spotlight these overlooked issues, engage in discussions, and push for efforts. It’s a long fight, but we cannot afford to give up.

OS: Especially in recent months, it has become evident that the dispute over funds – not limited to health alone – extends beyond a battle between the “left” core of the government and the Centrão wing. It is apparent that the allocation of federal resources creates divisions among ministers and leaders of the Workers’ Party (PT) and other parties within this more progressive faction of the government. How do you perceive this issue of budget disputes in the health sector, and what are the prospects moving forward?

ROC: I believe that politics is made by doing. It depends on us, as social movements and organized civil society, to question or drive decisions. I’m not surprised [by the disputes] because I didn’t expect a monolithic government. I also don’t believe that the Workers’ Party is a party where everyone shares the same vision. Neither the president’s party nor the front [forming the government] is set up that way. These different groups occupy different parts of the state machinery, and each operates in their own way. Politics never stops operating. When no one operates, someone else steps in.

So, it’s a field of contention, a close one given the difficult situation. It’s essential to judge how uncompromising we need to be on certain issues to prevent them from being sidelined and how far we cannot compromise on governance. This involves interpretations and positions of emphasis. Some value governance more, while others argue that governance cannot be built without social justice. This boundary is dynamic and always tense, and it’s impossible to say in advance what will happen. 

What I sense, both within Abrasco and among our partners in the health movement in the Front for Life, is that we are all united and clear in our aim to push for social justice, reparations, and the resolution of major structural problems in Brazilian society. How successful we will be, I don’t know.

The only thing that fills me with hope is that we’ve managed to restore consensus in recent years. The health movement was much more divided previously, as seen in the Lula governments before the current one. I believe this unity strengthens us and also supports the current ministry – to whom we have consistently expressed solidarity regarding the minister’s position. This is our point of hope.

The interview with Rosana Onocko-Campos was conducted by Guilherme Arruda, and published in Portuguese on Outra Saúde.

People’s Health Dispatch is a fortnightly bulletin published by the People’s Health Movement and Peoples Dispatch. For more articles and to subscribe to People’s Health Dispatch, click here.