Opinion – Public Health: SUS political challenges: how to improve the Brazilian health system?

The Unified Health System (SUS) has a good diagnosis of its problems and numerous solution proposals shared by debaters in the Brazilian health system. The solutions face a series of political challenges, which make it difficult to implement changes that could benefit the SUS. But, before entering this debate, it is necessary to summarize which proposals make it possible to improve the provision of SUS services.

But what are the political challenges that need to be overcome to enable the implementation of these changes in the SUS?

First, there is a dispute between the public and private sectors in the provision of health services. Although the Constitution establishes that we have a single, public and universal system, in practice, it seems that we have two systems: the public and the private that compete with each other. This space dispute causes waste, fragments the SUS and harms the population’s health care. A harmful effect of this competition is the culture that the “dream of consumption” of the population is to have a private health plan, the SUS does not work and that it is intended for the poor, they have no option due to lack of income. Evidence of this is the union negotiations whose priority is to guarantee a private health plan for their members. The SUS needs to be a value for Brazilian society, as the National Health Service (NHS) it is for the English population, otherwise we will not be able to overcome their shortcomings.

Brazil has a large private sector in the area of ​​health, it is the second placed in a world, behind only the USA. This is a reality that needs to be addressed in the formulation of public policies in the sector. Private sector participation in the SUS must occur within a regulation that preserves constitutional principles. The Ministry of Health needs to promote a negotiation with all those interested in the subject to clearly define the space of each one in view of the interest of SUS users, increasing efficiency and cooperation between the two sectors.

Possible solutions from the private sector are already born with a defect of origin, since only the interest of expanding its market on top of the SUS needs is it clear whether the solution improves or not the access and quality of health services in the country, according to the constitutional precepts. This is the case of recent proposals for the creation of health plans or the network to provide consultation services, which increase waste and disintegration of the system, contrary to what their proponents advocate.

In this debate between the public and private spaces, some use the simplistic argument that the larger the private sector, the lower the demand for SUS. It doesn’t work that way in countries that have a public and universal system. The private sector is complementary to the public sector. In addition, the population does not have the income to pay for health insurance. Data show that 75% of Brazilians depend solely on the SUS and, in the northern region of the country, this number reaches 90%. Improving access to health services is not a simple matter, as this argument makes it seem. On the contrary, it will have to go through the reduction of the size of the private sector and, consequently, the growth of the public sector.

However, the debate that interests the population and the Ministry of Health should lead is about how we are going to organize the provision of services that meet the health needs of citizens throughout their lives, in all regions of the country, according to the principles constitutional laws and with the participation of all who can collaborate.

The second challenge is the lack of administrative continuity when government changes occur. This exchange does not normally guarantee the continuity of public policies. My experience at the head of the Espírito Santo State Health Department (SESA-ES) between 2005 and 2010, leads me to say that if three sequential governments at the federal, state and municipal levels maintain a policy that faces the structural challenges of SUS listed above, we will be able to take a leap in quality in the provision of services to the population. In other words, to build effective and structural solutions, it takes 10 to 15 years of continuity in public health policies.

The third is the population’s short-term expectation. Millions of people seek SUS services daily and need an immediate solution to their health problems. This huge short-term demand and difficulties in accessing services guide the political debate. Therefore, in order to obtain the support of the population and politicians to advance the necessary changes, we cannot just think about structural changes in the medium and long term. Short-term initiatives are needed to meet the needs for consultations, examinations and surgeries, such as the tried-and-true policy of collective efforts. However, structural changes need to be implemented at the same time as short-term changes, otherwise we will continue to delay overcoming difficulties in accessing health services.

Structural changes also generate immediate results, but on a scale. At first, few users will be served by the new model, but over time all will be served by it.

The fourth challenge refers to the multiplicity of actors in society and at all levels of government, which interfere in health policies and their budget. I highlight, above all, the Judiciary, the Public Ministry, the Audit Courts, the Legislative branch, professional councils, associations of people with diseases and unions. Some controlling bodies have the legal authority to determine expenditure outside the Executive’s planning and others control management based on an emphasis on processes rather than results.

Articulating this set of political, economic, institutional and corporate interests is not an easy task for the public manager. Even more, when for the population and the media, by a simplistic assessment, there is only one person responsible for the difficulties in accessing health services, which is the public manager on duty. However, if we have political leadership with clarity on what needs to be done, it is possible to build political support to produce short-term results and advance structural changes. Public policies that work, in various governments and across the country, demonstrate this.

This complexity caused by the existence of multiple actors and their interests is little considered in the public debate, despite its relevance, since it imposes restrictions on the speed of improving the quality and efficiency of health services. On the other hand, it imposes a democratic and transparent governance that is a strength of SUS. The legal norms that regulate the control relationships between public entities need to be improved in order to facilitate the production of results in health care for the population.

In summary, in order to guarantee public and universal access to health services, it is not enough to just create the constitutional right, it is necessary to overcome the political challenges to implement it.