Opinion – Public Health: Efficiency in the SUS

In 2022, Fiocruz launched the book SUS: The debate around efficiency, by Alexandre Marinho and Carlos Octávio Ocké-Reis, in which the efficiency of the Unified Health System (SUS) is discussed. This is an important clarification on how to address the debate on efficiency in health policies. In summary, the authors state that: “Strictly speaking, efficiency is a necessary, but not sufficient, condition to achieve the efficacy and effectiveness of public health actions and services. In other words, it is not enough to be efficient if the results are not achieved, nor if the health needs of the population are not met.”

In the presentation the authors explain the objective of the book ” […] our interest in examining efficiency in the Unified Health System (SUS) is justified by the fact that such an argument is systematically used to defend its commodification and privatization. This hides, under a technocratic bias, an attack on the democratization of access to health promoted by the practice of the Brazilian health reform”. instrument to define attacks on public health policies sponsored by the Brazilian State. The frequent accusation of inefficiency intends to delegitimize the SUS before the popular and middle classes, through the corporate media, alongside the accusation of corruption.”

Throughout the book, several arguments are discussed considering their impact on efficiency, such as the issue of rising health costs, chronic underfunding, the various types of efficiency calculation (technical, allocative and scale) and, mainly, that the evaluation of quality of health expenditure must also take into account the concepts of effectiveness (meeting the health needs of the population) and efficacy (objectives and intended results).

For this reason, the authors do not accept that the efficiency criterion is used as a justification for determining cost cuts in the SUS and emphasize that the fulfillment of the mission of the Brazilian health system to guarantee universality, completeness and equity in the health care of the population does not can only be achieved with efficiency in work processes.

It is difficult to disagree with the authors’ statements for those who follow the public debate and have worked in the formulation and implementation of health policies. Many debaters compare the efficiency of public service delivery with that of the private sector as if that were possible. As the purposes are different, while one aims at profit and the other fulfills a social function, this implies completely different management models and values. In addition, they are subject to very different management and control rules.

Despite this, these differences do not prevent public organizations that provide health services from working with the concept of efficiency, although with practical applications different from the private sector. It is constitutionally determined (Article 37) that public administration be guided by the principle of efficiency, a fact recognized by the authors, so that any resource made available to the health system must be spent in the most efficient way possible.

However, in the case of public health, the provision of public services cannot be compared, not even between States, since, for example, the difficulties of health care in the Amazon are much more complex than in the southeast of the country. One solution might be to compare each state with itself and follow the evolution of its indicators over time.

A few years ago the SUS developed an index, the IDSUS, which made it possible to compare the performance of states and municipalities considering the specificities of each one, but unfortunately the project was discontinued, instead of being improved. This index could enable a concrete debate on the difficulties of each state and municipality in the provision of health services, providing relevant information for planning and for the allocation of budgetary and financial resources, in addition to increasing transparency for society about the situation of care. of health in each entity of the federation, thus facilitating social control. In the country we already have a successful example in Education that uses the Basic Education Development Index (Ideb) to assess the quality of educational services and meet these objectives.

The authors consider that underfunding does not allow evaluating the efficiency of the application of resources in the SUS. At this point, I distance myself from their vision. In my experience at the head of the Espírito Santo health department – reported in the book “Gestão Pública e Saúde” (FGV-2020), I learned that it is possible for each state, municipality or health unit to define its planning, indicators and goals, considering the existing resource, technical, and policy limitations, and periodically monitor and evaluate them. This practice allows for an improvement in the provision of services to the population and makes transparent to society both the lack of resources and other existing restrictions (political, institutional, management and control) for citizens to fully exercise their constitutional right to health. To this end, we implemented in Espírito Santo a project developed by the National Council of Health Secretaries (CONASS) called Primary and Secondary Health Care Planning.

Society needs qualified information not only to exercise social control over the health system, but also to defend the consolidation and improvement of the SUS. This task of clarifying and mobilizing society needs to be fulfilled, mainly, by each Basic Health Unit (UBS), municipal and state secretariats, health councils and by the Ministry of Health itself.

The authors had the merit of deepening the theme of efficiency, a fundamental issue for the debate on the management, support and improvement of the SUS. This discussion is almost always very simplistic and focused on the lack of funding, which helps to strengthen those interested in weakening the system.

The SUS has financing and management problems, as with all public policies, and both must be overcome to guarantee the effective exercise of the rights to health established in the constitution.