The Forum for Defence of the Brazilian Unified Health System ( Sistema Único de Saúde ) and its role in building community participation in the fight against the privatization of health

Introduction

The Brazilian sanitary reform offered theoretical-legal subsidies for the right to health to be inserted in the Federal Constitution of 1988 (Casa Civil Brasil, 1988) creating a health system based on the principles and guidelines endorsed by the population (Fundação Osvaldo Cruz, 2014). Health public policies in Brazil are the responsibility of the state, in opposition to the hegemonic model that existed up to the 1980s which was based on private care and directed only to workers in the formal market. The structuring of the public system was grounded on the constitutional assumption that health is a fundamental right of every human being and that the state must provide conditions to ensure it. However, private initiatives can participate in the Brazilian Unified Health System (Sistema Único de Saúde (SUS)) in a complementary form; consequently, there are two subsystems – the public (state-owned) and the private (profitable or philanthropic). They are only formally separated, because in practice, it is through the SUS services that the private sector enables its actions (Cohn, 2008).

As we take a closer look at health public policies, it is possible to see a mixed scenario of public and private subsystems and it is almost impossible to recognize what is state-owned and what is profitable and philanthropic. This mixture between terms and the intertwining between fields is easily perceived, even if the social movements reinforce the need of ensuring state ownership, excluding what is private so as to guarantee the quality and gratuity of health services.

Community participation is one of the principles and guidelines established by the law that created the SUS (Casa Civil Brasil, 1990a) that ‘establishes the conditions for health promotion, protection and recovery, the organization and the functioning of the corresponding services among other measures’. Since the institutionalization of the SUS, by means of organized collectives, segments of the population were represented in the collegiate instances of the health system – Health Conferences, Health Boards and Management Boards (Casa Civil Brasil, 1990b).

However, community participation is not only about the institutionalized places for the participation of the population in health policies but it is also a locus of experience that produces the subjects that are affected by these policies as protagonists of the health policies. It is a locus of experience that produces them as social citizens, as active subjects in the dynamic that disseminates social rights as an ideal capable of assuring better life conditions. Experience is here understood as that which produces subjects in the association between possible knowledge forms; individual behaviour normative and the invention of possible modes of existence for subjects (Foucault, 2010). The notion of experience, therefore, is an effect of the integration of these three issues that configure a singular ‘historical experience’ in which the subject thinks about himself and takes form as an object of moral action (Lopéz, 2011). This conception of experience is geared to a history of thought, an analysis of the locus of experiences constituted in the association between knowledge, power and subjectivity (Foucault, 2010). Hence, the notion of experience de-centres the meaning of subjective knowledge by referring it to a field of relationships constituted by collective events and practices. In this sense, the subject is neither cause nor origin, it is always form. Experience is an event, and as such emphasizes the discontinuity, unexpectedness and randomness of history (Prado Filho et al., 2014).

Community participation is a locus of experience in the SUS that emerged as in the area of health in the context of the battles carried out against the military dictatorship in the process of democratization of Brazil, epitomized by the Sanitary Reform Movement and the defence of a public health system. In this scenario, social movement in health was a resistance to the totalitarian forms of government and the vertical ways of producing health.

The social movement in health emerged in Brazil in the decade of 1970 from popular dissatisfaction with the dictatorship’s policies for health. This dissatisfaction created the conditions for the emergence of the Sanitary Reform and, therefore, the formal structuring of Public Health (Nunes, 2006). The health worker’s movement made alliance with other social movements and researchers to fight against and to question the military regime and its policies (Luz, 1991). At present, health social movements see themselves as guardians of the ideals of the Sanitary Reform and are organized in several entities to act on institutionalized instances of social control as well as on non-institutionalized spaces of participation.

The contemporary locus of the experience of community participation crosses over and constitutes a diversity of social movements in the area of health. In this article, we analyse the presence of this locus of experience in a specific social movement, the Forum for Defence of the SUS in Rio Grande do Sul. ¹ This is an independent, collective movement that includes trade unions, various social movements and professional categories. Its main agenda is the defence of a public SUS, state-owned, under direct management of the state, free and open to all citizens.

The article is divided in three parts: on the first, we present the methodological procedures for the analysis of this forum. In the second, we discuss some aspects of the health privatization process in Brazil – using the United Kingdom’s model as a parameter – and the community participation on this process. In the third part, we analyse community participation in the daily politics of the Forum for Defence of the SUS.

The methodology pathway

Our insertion in this research started when one of the authors was appointed as a representative of the Psychology Regional Board of Rio Grande do Sul (CRPRS) in the state’s the Forum for Defence of the SUS during the period between November 2011 and July 2013. The research procedures involved following the activities of this social movement in their regular meetings, at public demonstrations, seminars, national meetings, law sessions and through the analysis of the documents they produced. These activities were also documented in the researchers’ field diary which, in this article, were used as a support for the discussion of the Forum’s documents.

The investigation was based on the theoretical–methodological perspective of constructing a history of thought. According to Foucault (2010), the history of thought involves a different exercise from that used in the history of mentalities being situated in ‘axis that goes from the analysis of actual behaviours to the expressions that may accompany these behaviours, preceding, following, translating, prescribing them, concealing, or justifying them’ (p. 4). It also differs from an analysis of representation functions that attempt to understand the ‘role that representations may play, with regards to the objects that are represented or in relation to the represented theme – let’s say, an analysis of ideologies’ (Foucault, 2010: 4). From Kant onwards, a history of thought understands modernity as the moment in history when human beings became the object and subject of examination. Kant’s writing, for Foucault (1984), marks the emergency of a philosophy that questioned its own time and existence, that is, that opened itself to the theme of a genealogy of modernity. It is, therefore, an analysis of the locus of experiences that constituted us as subjects of knowledge and, at the same time, as subjects that questions their reality and the ways of governing life that pertain to it, in this case, through the experience of community participation in the area of health.

In this article, this exercise of thinking the present stems from an exercise of dislodging the place of community participation; therefore, of suspicion about the political practices in health that remove it from a place based on historical evidence and relocates it in a place of social construction. Sanitary Reform and community participation are events in the field of health that establish the need for building a public health system. The Sanitary Reform institutes community participation as a locus of experience that produces subjects as an active political force in formulating and implementing public health policies.

However, this analysis is not a history that tells everything that can be said about this locus of experience, rather, it has the objective of charting some of the operatory elements of the constitution of this experience in health policy. Therefore, its aim is to set some anchor points that enable us to compare what we know now with what the Sanitary Reform produced regarding social activism (Foucault, 2006) as a process that defines the place of the population and forges activism in health as a new economy of the relationships within the field of state action. As such, the corpus for analysis was built through the attentive reading of the documents produced by the forum and of entries in the field diary. In this process, raw data were turned into useful data making the information manageable for understanding the reality under study and to define the anchor points which allowed us to map the rationalities that sustain the locus of experience of community participation.

Privatization of health in Brazil

The fight for better health conditions in Brazil through the creation of a public health model, universal and free of charge, found its inspiration, initially, in the construction of the welfare state in the European context, as in the United Kingdom, where the National Health Service was created in 1948.

The emerging neoliberal thinking had the welfare state as one of its targets. It defended the need for an economy free from state bindings and for setting limits to state control. It proposed a policy of permanent intervention, extremely watchful, that allowed for the total regulation of political power based on market economy principles. However, these interventions do not happen directly on the economical market; rather, they are directed to the factors that condition market economy – the population. It concerns a generalization of the ‘business enterprise’ format to the social body, by means of a rationalization of daily life, treating each individual as business units. These interventions take place on people’s behaviour, as in the rationalization of investments in children’s education that sees future success as fruit of the investments made during their first years of life (Foucault, 2008).

It is a model that, in order to grant the generalization of the economical order, allows people to have access to institutional resources that go against the public sector. It uses the very notion of rights and the universal declaration of rights as the basis for these regulations. It intervenes with the objective of granting social rights because these have become part of the universal rights guaranteed by previous battles. So, the novelty in the neoliberal model, regarding the living conditions of the population, is the use of a discourse on human rights and people’s fights for their guarantee as an element of interventions in society (Foucault, 2008).

In neoliberalism, the government’s failure in achieving its interests must be remedied through the invention of new strategies of government. In this same line, the reactions and resistance by the population are solved. Individuals are understood as ‘subjects of responsibility’, autonomy and choice. Neoliberalism uses this experience of accountability by the subjects as a government strategy, hoping to exert influence through modelling and the use of their liberty (Miller and Rose, 2012).

In Brazil, neoliberalism has a history with different paths and timings even though it has been influenced by the processes in the European context. We did not live the consolidation of a welfare state; between the decades of 1950 and 1980, very little was accomplished in the consolidation of social rights. The establishment of the public health model happened at the same time in which emerged the debate about redefining the state’s role in the area of health and in the types of interaction between state/market/society. The institutionalization of a public health system coexisted with the tendency for privatization of health policies in Latin America and European countries (Menicucci, 2010).

Resonances of this coexistence were present in the Federal Constitution of 1988, which guaranteed the right of private initiative to take part in the SUS (Menicucci, 2010). This context allowed for a constitutional arrangement of a mix of public and private within the public health system that reshaped each of them and put them side by side in the implementation of public health policies. It is an arrangement that creates legal feasibility for different components of public/private subsystems and promotes the blurring of legal borders that separate these dichotomous elements.

The complex relationships between public and private within the health sector and the technical vocabulary adopted are no longer based on the opposition between public/private; instead, the new label speaks of the relationship between state and market. Thus, the label public/private is no longer adequate to describe the relationship that the private and state-owned sectors establish in health given that private establishments can be found in the public network and state-owned institutions can integrate the private network (Bahia, 2010).

In Brazil, the construction of a public model of health care services was concomitant with the country’s opening to neoliberal policies. The growth of the private sector happened before the liberal reform of the 1990s and got stronger thereafter (Menicucci, 2010). The situation can be interpreted as a step towards the institutionalization of a dual system, private/public, since it generates an irrational situation of dual health insurance systems that shapes the experience that we live in Brazil: the poor population has access to state-owned health and those who can pay have access to private plans (Laurell, 1996).

In the aftermath of the creation of the SUS, the offer of philanthropic services and the offer of state services increased and resulted in a reduction of the hiring of private services. However, the forms of contracting services did not change, and the previous model of purchasing services was simply updated (Fleury, 2008). Accordingly, different ways of mixing state and market services were created and matured afterwards.

In this perspective, the fight to guarantee of health rights and the political activism of communities that demand public ownership of services are incorporated into neoliberalism as strategies for strengthening the economical model. When the demands of the community are incorporated into governmental technologies, they become instruments to maintain the human capital and handle it according to market needs. One of the effects of this arrangement is the activation of subjects to adhere autonomously and with satisfaction to the needs of the market, believing that claiming for rights and for economical expansion is a synonym of freedom and emancipation (Foucault, 2008). By intervening to guarantee social rights, neoliberalism used the criticism made by the social movements – in this case, the sanitary movement – about the ways of governing people’s health in order to expand its investments and as a way of encouraging consumption and managing the population’s behaviour.

The Forum for Defence of the SUS and community participation

The Forum for Defence of the SUS was created in 2008 as part of the movement that made the Sanitary Reform possible and that found a new battle for fight in the new neoliberal arrangements of privatization. It performs, now, the experience of community participation in the fight against privatization when the SUS was institutionalized and attempts to make public the private aspects that permeate health policies (Fórum em Defesa do SUS do RS, 2013).

The discourse of this social movement is centred on the distinction between public (state-owned) and private sectors as a fundamental criterion to ensure the quality of health services. The distinction between public (state-owned) and private, with the suppression of the private, is considered by the movement as an essential element to prevent the interests of the private sector threatening the guarantee of social interests.

Governments invest little in health; besides, most of public funding of health is destined to private sectors, through subcontracting and through the government’s exemption of assuring the right to health! Private companies manage the public resources with reduced inspection and social control, hire workers in precarious conditions, entail high turnover and dismissals, impairing the bonding of professionals with the community as well as the quality of service (Fórum em Defesa do SUS do RS, 2014: s/p).

The Forum perceives itself as part of ‘non-formal spaces (forums, movements)’ (Fórum em Defesa do SUS do RS, 2013: 11) for community participation. Nevertheless, it holds constant dialogue with formal spaces of participation. Thus, although the Forum does not have a seat in the Health Councils, its members are delegates, elected by other institutions and social movements, in the Health Conferences and participate routinely in the municipal council of health of Porto Alegre and the state council of health of Rio Grande do Sul, representing other social movements and bringing their demands to the meetings since they understand that ‘the definition of health policies and its inspection is a task of the health councils. Only the social control by organized popular participation will transform this right in reality’ (Fórum em Defesa do SUS do RS, 2014: s/p).

For this social movement, the mere existence of health councils does not assure that the sanitary ideals will become reality. Popular participation is needed to transform this right in reality, and this was one of the reasons that led to the foundation of this social movement.

The Forum of Entities for Defence of SUS acts in an articulated manner in themes considered controversial by the Municipal Council of Health. It operates autonomously and without the participation of managers or providers: it a non-institutionalized movement. It is in this scenario that workers and users of SUS in several states and towns overcome obstacles and build different strategies, with the support of its representatives, for stopping government’s attempts of privatization of the Unified Health System. (Terres, 2014: 7–8)

The locus of experience of community participation is anchored on institutionalized spaces within the decentralized and participative system of the SUS. However, the Forum for Defence of the SUS has suspicions regarding the private interests that are present in public management. Their members stress that participation is made ‘autonomously and without the participation of managers or providers: it is a non-institutionalized movement’, fostering the ability of workers and users to stop the attempts to privatize the SUS. This is presented as a guarantee that the movement will not be institutionalize, therefore putting managers and providers of services under suspicion by allocating to them the institutionalized position. This locus of experience produces workers and users as agents in defence of the public system that are provided with instituting power. This exercise of instituting citizenship is not possible for all of the population: it is directed to those who are perceived as not being institutionalized inside the power structures of the State.

Besides this preoccupation with non-institutionalization, we detected reservations with regards to the possibility of exercising an instituting citizenship. This refers to the fact that there is no guarantee of autonomy for popular movements and trade unions in the contemporary context: according to the Forum for Defence of the SUS, social movements have become tied to economic interests that can be found throughout the governmental management and the provision of private services to SUS. The Forum reinforces the importance of the National Front against Privatization of Health as a rallying point for the forces that intend to fight the scenario of ‘passivity and cooptation’ in social movements – a reference to the criticism that such movements are receiving because of their proximity with the Workers Party (PT) at federal government.

The National Front against Privatization of Health is becoming an important space of agglutination of forces in a scenario of passivity and cooptation of popular movements and unions. This is our fight, to constitute resistance. This is the only way we can fight with unambiguous conceptions. This has been our form of acting. This is today’s goal. (Fórum em Defesa do SUS do RS, 2013: 4)

The election of Lula (2003–2010) represented a political milestone for the country, because for the first time, a president who represented the working class was elected. It created the expectation that the SUS would have more investments and the country would indeed have conditions to implement the health system (Batista Junior, 2014).

PT’s various governments, frustrating all expectations, advanced towards the privatization of health services and actions by contracting private services as a substitute to public services (Batista Junior, 2014). The frustration with the PT government and the accusations of ‘passivity and cooptation’ of social movements reinforced their own perception that Forum has an activist role and is able to join the fight against the ‘privatization agents’. The experience of community participation places on the government the impossibility of defending the SUS and tries to move community participation away from of the places of power occupied by them.

As can be seen below, health conferences, for this social movement, become fundamental places for the defence of the SUS. The citation below endorses the achievements obtained in two decades of the implantation of the SUS as a result of the people’s fight, reinforcing the view that the construction of the public system was a result of popular fight and of the collective consensus. It is a speech that creates a field of truth that anchors SUS as a ‘public heritage’ conquered by popular power in the fight against hegemonic groups which do not want its full development. It also highlights the importance of each person’s contribution for insuring improvements of the system.

To have conferences is of fundamental importance, since what is at stake is the survival of SUS as a public good for everyone or its privatization, as its enemies want. The SUS is a result of the fight of the Brazilian people, who managed to assert in the Federal Constitution that ‘health is a right of the citizen and a duty of the state’. After two decades of implementation, the SUS has become one of the most important health systems in the world. Indicated to be a social world heritage, it is a reference for many countries. In spite of its great achievements, SUS has big problems to overcome, with the help of each of us. (Fórum em Defesa do SUS do RS, 2011: s/p)

The move towards public management and ownership is the defence of ‘a public, state-owned SUS, able to offer quality services under state management’ (Fórum em Defesa do SUS do RS, 2014: s/p); its advocates are service users and health workers, and its enemies are privatization agents (placed at the managerial and service provider sectors). The field of dispute in which this social movement is anchored is a dichotomous scenario, in which, one side, is the group that has financial hegemony, on the other, the population. The first group harbours the ideals of privatization endorsed by economic groups and by private and public managers. The second group is comprised by the population and collectives organized for defending a common good, therefore the nationalization of SUS.

The Forum in Defence of the SUS produces the locus of experience of community participation by means of a veto of the private elements that are historically part of Brazilian public policies. It advocates for the public (state) and resists the private, doing without all that it entails: interests, management models, private health care groups, private financing, private logic, commodification and so on.

The fight against privatization is anchored in the duty of the state of granting the right to health and the refusal of its implementation by private services. Service users and health workers play a decisive role by being active in safeguarding this precept, since they are the interested part and are neutral in regards to the other players: managers and service providers.

Users and health workers organized in different groups, acting as citizens that have become political activists, guardians of public health as a way of granting better living conditions to all the population. These are social movements that strive to outline clear boundaries between the public and the private in health services, spearheaded by the person of service users and health workers: with public referring to the state and, therefore, interested in attending to the demands of the population (their social rights); private referring to private interests and their negotiations (the market relations).

By restating the duality between public/private, the Forum for Defence of the SUS asserts itself as a representative of public interests, since it manages to congregate two important elements for defending the SUS: the fact that it does not have managers or service providers among its components and is a space for the agglutination of forces against the cooptation and passivity of social movements. It asserts its existence in the need to fight for what the state is not able or willing to provide.

WE HAVE TO FIGHT TO DEFEND AND QUALIFY THE SUS! The Forum for Defence of SUS of Rio Grande do Sul (RS) fights for a public health of quality and against its privatization. We are a plural group that aggregates trade unions and professional associations, workers, users and activists around an agenda of debates and action for strengthening the quality of the SUS services for its users. Our battle flag is the defence of state-owned SUS, under direct management of the state and offering quality services. (Fórum em Defesa do SUS do RS, 2014: s/p. Highlights of the original)

This excerpt also recovers an important demarcation of the fight in which the movement is engaged when it focuses on the ‘defence of state-owned SUS, under direct management of the state and offering quality services’ reiterating the refusal of forms of indirect health management that constitute public entitlement submitted to private law, thus configuring formal privatization.

Final considerations

The fight conducted by the Forum for Defence of the SUS resumes the dichotomy between public and private, shifting some elements of the traditional definition used in the area of health. It does not portray the public as referring to the care provided by the public sector (state) or private as that offered by the private sector (free market). Even if it does not abandon these referents of public/private, by stressing the defence of a public, state-owned SUS, the Forum enlarges the debate beyond health care incorporating a diversity of components that ensure access to health, among them, in particular, the management of health services. So, for this social movement, public is a state system that is managed directly by the state. To the notion of public, it adds that it must be state-owned and managed, in order to reinforce the association of ‘public’ and ‘state-owned’ in the fight against privatization.

The experience of community participation of the Forum for Defence of the SUS creates an arena of participation and collective defence of the public system of health that crystalizes in history the values, ideas and desire that produce different suppositions about how to attain social rights through the defence of a public and state-owned health system model, submitted to public law, guaranteed by community participation in a system free of private interests and of worries about becoming co-opted.