‘Enterprise-Mode’ and Sparks of Resistance on the SUS Shop Floor in Brazil

Beginning in the 1980s, as a response to the capitalist crisis that had deepened in the previous decade, many countries successively adopted budgetary measures known as austerity. These policies centered on reducing public spending, retracting social programs, and shifting the costs of the crisis onto the most vulnerable sectors. ¹ Hard-won social rights were curtailed even as private companies increasingly competed for public funds. The state was expected to be minimal in social policies, while continuing to subsidize private enterprises. Neoliberal discourse discredited public administration while extolling private initiative.

This article examines one dimension of that strategy, drawing from original research that reveals how private logic came to occupy public space. It does so through testimonies and narratives of lived experiences from the researchers themselves in their workplaces: public mental health services located in Brazil's largest municipality.

By briefly contextualizing the Brazilian health reform movement and the creation of the Unified Health System (Sistema Único de Saúde [SUS]), alongside the trajectory of the Brazilian psychiatric reform, this study highlights the mobilization of privatizing social forces advocating a neoliberal counterreform. This is followed by narratives from workers/researchers on their daily labor and the impacts of the privatization of service management by organizations known as Social Health Organizations (Organização Social de Saúde [OSS]), which have resulted in precarious employment, workplace tension, and distress among workers.

The Brazilian Health Reform: in Dispute with Neoliberalism

In the historical context of Brazil's re-democratization after 21 years of military dictatorship (1964-1985), the Brazilian health reform movement (Movimento da Reforma Sanitária Brasileira [MRSB]) advanced a critical vision of health as a social right enshrined in the constitution. Its central proposal was the creation of a national public health system—the SUS—founded on universality, comprehensiveness, and equity in access to health care. The movement was composed of social segments that included community leaders mobilized for better living conditions and against the rising cost of living in the outskirts of major cities, as well as union leaders, political representatives, student movements, and university intellectuals. Despite strong resistance in the 1987 Constituent Assembly, particularly from lobbying groups representing private health care interests, the 1988 constitution incorporated contradictory provisions: health was defined as a right of all and a duty of the state, yet simultaneously opened to private enterprises. ² The law allowed private companies, whether or not qualified as philanthropic, ³ to participate in the SUS in a complementary capacity. As a result, the SUS inherited the strong presence of private initiative in health care service delivery from the pre-constitutional period. ⁴

Faced with the new constitutional recognition of social rights, unprecedented in Brazil's history, private interests reacted swiftly. Among the measures that undermined the full realization of SUS principles were chronic underfunding and the weakening of public management.

One of SUS's key guidelines is community participation in service management. ² However, this democratic principle has been repeatedly disregarded by successive governments. Although Brazil briefly resisted the neoliberal wave that swept through many countries ⁴ in the late twentieth century, due to the strength of the re-democratization movement various forms of privatization gradually gained ground, much as occurred with the United Kingdom's National Health Service.^5–7 A state reform consistent with neoliberal policies, approved in 1995 under President Fernando Henrique Cardoso, amended the constitution and was followed by a series of laws that introduced private management into the SUS through so-called Social Health Organizations (OSS), private organizations that are only formally non-profit, guided by managerialism^8,9: ‘In response to the exhaustion of a state of bureaucratic crisis, ultimately manifesting in inefficiency, [the reform] brings forward the concept of managerial public administration [managerialism], based on efficiency and quality, decentralized actions focused on the citizen.’ ^{8 (p94)}

These OSS receive public funds yet operate under market conditions; they employ a workforce with high turnover, refer to employees as ‘collaborators,’ and frequently engage in ‘fourth party outsourcing,’ subcontracting other companies for secondary activities.^10,11 Moreover, behind some OSS are major private health care corporations, including Brazil's largest private health company. ¹²

Aligned with this state reform, the 2000 Fiscal Responsibility Law, whose major aim was to control public spending by reducing expenditures on public personnel, discouraged civil service exams and encouraged outsourcing. Expenditures on personnel outsourcing are excluded from personnel cost calculations. ¹³

Outsourcing expanded in the public sector beyond OSS to include concessions, permits, partnerships, cooperatives, nongovernmental organizations, and public-interest civil society organizations (Oscips). Increasingly, public services came to be ‘delivered not by tenured civil servants, but by a wide range of precariously employed workers hired under short-term or project-based contracts without the same labor rights of a civil servant.’ ^{14 (p19)}

Currently, about 85% of SUS-provided services are delivered by private organizations, that is, organizations not directly managed by public authorities. This represents a reversal of the constitutional principle that private participation should occur only when public services are insufficient. Partnership with the private sector is therefore no longer the exception but the rule. ¹⁵ According to several scholars, the various forms of labor precarity observed in this process reflect policies in which the state itself acts as a promoter of precarious employment.^16–19

The current federal administration, led by a broad coalition government headed by the Workers’ Party (Partido dos Trabalhadores), lacks a congressional majority and has not, to date, reversed this model of management.

In the same wave of privatization, in the country's largest showcase of the SUS, São Paulo, a Brazilian municipality with 11.5 million inhabitants and capital of the state of the same name, has transferred most of the health care network, including mental health services, to private management by several OSS, fragmenting the system and undermining the democratization of management. ¹⁹

The Brazilian Psychiatric Reform

The mental health workers’ movement (Movimento dos Trabalhadores em Saúde Mental) was founded in 1979, and by 1987 the anti-asylum movement had been formally organized. The Brazilian psychiatric reform was approved by the Brazilian parliament as federal law 10.216 in 2001, ²⁰ after 12 years of proceedings. The psychiatric reform ‘represented a remarkable social achievement and a civilizational advancement.’ ^{21 (p4490)} Over three decades, the anti-asylum movements succeeded in ‘building a counter-hegemonic proposal for the National Mental Health Policy, previously centered on hospital-based care’. ^{21 (p4490)}

In 2025, the psychiatric reform celebrated 36 years of legal enforcement, having established a nationwide, albeit heterogeneous, network of community-based services to replace psychiatric hospitals. This includes psychosocial care centers (Centros de Atenção Psicossocial [CAPS]), therapeutic residential services (Serviços Residenciais Terapêuticos [SRT]), community centers, income-generation centers, and other initiatives. Psychiatric beds have also been incorporated into general hospitals while psychiatric beds in specialty hospitals have been progressively reduced.

From the perspective of the psychiatric reform, care involves the most active possible participation of mental health service users in their pursuit of better living conditions and improved care provision. It is important to highlight that ‘In Psychosocial Care, those who seek mental care, commonly referred to as ‘users,’ are seen as an integral part of a network of relationships, making them social players rather than carriers of signs and symptoms. ^{22 (p401)}

By confronting the asylum-based model, federal law 10.216/2001 redirected the structure of mental health care, ensuring as fundamental rights of individuals with mental disorders: access to the best possible treatment with humane approach and respect aiming at recovery through social reintegration in family, work, and community life; protection against abuse and exploitation; confidentiality of personal information; the right to physician presence to clarify the need or otherwise for involuntary hospitalization; free access to available means of communication; and the right to comprehensive information about the treatment. Preferably, treatment should occur in community mental health services, in therapeutic environments, and through the least invasive means possible. ²⁰

Defenders of the psychiatric reform argue that the asylum logic extends beyond the control of those labeled ‘insane.’ It encompasses ‘homosexual and transgender individuals, homeless people, drug addicts that inhabit the streets of cities and many other actors who, in each area and territory, cross over the boundaries of good conduct’. ^{22 (p404)}

Particularly since 2011, ²¹ there has been a redirection of mental health policies in Brazil, reflecting yet another mode of capital accumulation. Despite the legal advances achieved in mental health, the field has faced the same destabilization affecting the SUS: precariousness induced by neoliberal policies, especially through underfunding and the privatization of management. These processes have undermined the community-based network of mental health services, whose expansion has stagnated and now faces a serious financing crisis. ²²

During the neoliberal governments of Michel Temer and Jair Bolsonaro, from 2016 to 2022, marked by attempts to dismantle the SUS and by the counterreform of mental health policy, there was a resurgence of disputes led by business groups, disregard for decisions issued by democratization and social participation forums such as the Mental Health Conferences, the reemergence of a hospital-centered and psychiatry-focused model, and the funding by the Ministries of Justice and Social Development for private services, the so-called ‘therapeutic communities’ aimed at drug users, in which forced abstinence is one of the main measures imposed. ²²

In light of the above, this study aims to contribute to strengthening the struggle of those who defend the advances of the Brazilian psychiatric reform and the SUS.

Methods

The material presented here is part of the research project ‘Common Episodes of Uncertain Care,’ carried out by the Laboratory for Studies and Research on Health Training and Work (Laboratório de Estudos e Pesquisas de Formação e Trabalho em Saúde - LEPETS) of the Federal University of São Paulo (Universidade Federal de São Paulo UNIFESP), Baixada Santista Campus, between 2020 and 2023. Approved by the UNIFESP Research Ethics Committee under protocol no. 0398/2022, the study involved 30 researchers, public health care workers, graduate students, and faculty members.

The study explored narratives of experiences lived by the researchers themselves in their workplaces, focusing on episodes of care.^23,24 In biweekly meetings, one participant presented a written narrative, followed by reflections, commentaries, experience-sharing, and questions. The recorded discussions were read in the subsequent session, initiating a new round of analysis aimed at identifying the multiple policies, concepts, and operational modes underlying the narrated situations.

At the conclusion of the process, the complete set of materials (narratives and meeting records) was analyzed to identify major thematic fields, among them the private dimension that permeates work processes, particularly in public mental health services managed by OSS. These analyses revealed various effects on workers and on the modes of health care provision.

In a second phase of analysis, worker-researchers employed in mental health services in the municipality of São Paulo, under OSS management, examined collective dimensions within the ‘shop floor’ of public services that shaped and traversed their work processes.

Conclusion

The psychiatric reform movement and the anti-asylum struggle in Brazil are founded on the commitment to mental care outside asylums and within the community, addressing issues related to racism, gender violence, and minority populations historically imprisoned by madness, whether in old asylums or through the asylum logic currently applied. However, the corporate management models that have expanded and become normalized within the SUS operate under a specific conception of science and ethics that permeates work relations and modes of subjectivation with a force that is often paralyzing.

The Brazilian mental health field, shaped by the struggles of workers and service users, carries a kind of militance enacted daily through labor, resistance, and the ongoing health care even in the harshest conditions. This vital and inventive force, which has generated life outside the social boundaries, is now being captured by the enterprise-mode, deepening the precariousness of both work and care while shrinking spaces for collective exchange.

This article presents traces of the trajectories of worker-researchers within the SUS and their everyday labor processes. If there are limits to this type of investigation, there is also an innovative approach at its core: an approach centered on narratives that bring visibility to certain events and issues of the enterprise-mode, as confirmed by theoretical studies from several authors, but also to the different ways of resisting it. Through writing and collective analysis, worker-researchers were able to identify what is usually rendered invisible in the daily work routine: worker illness, the fear of dismissal or persecution by management for dissenting opinions, and the loneliness and anguish of being unable to work according to the principles of psychosocial care.

Above all, the enterprise-mode is not limited to the management of services by OSS, nor merely to the business model increasingly adopted by public policies. It is everywhere. As Chaui notes, ‘the factory is a company, the school is a company, the hospital is a company, the cultural center is a company. More than that. It defines the individual as an enterprise. As human capital or as a self-entrepreneur.’ ^{31 (p18)}

This article exposes the contradictions and brutalities that hover between the political aspiration to build a public, participatory, and emancipatory anti-asylum mental health system that meets the population's needs, and a work regime tied to corporate functioning, driven by power, competitiveness, and the resulting precarization of labor and of life itself. The workers of Brazil's public mental health system, those on the frontline of the SUS, continue to flash sparks that pierce through the silence.