by Alexandre A. Martins, Ph.D.
Imagine an effective and efficient universal health care system that delivers care to low-income families. Now imagine dismantling that program to further marginalize those same families. This scenario raises questions of global health disparities that threatens justice. Removing access to care for low-income families is a problem in the U.S. where Medicare work requirements restrict access and where efforts to undermine the Affordable Care Act mean fewer people can sign for insurance. Globally, the same problem is occurring in Brazil with implementation of neoliberal policies that foster the expansion of a private healthcare market where health becomes a privilege, similar to the failing U.S. system. In Brazil, these policies have weakened the public health system, threatening the health of millions of people.
After years of dictatorship, the re-democratization of Brazil has moved side by side with the development of its public health system. The Unified Health System, known as SUS (Sistema Único de Saúde), was created following the new Constitution of 1988 that established health as a right of all and a duty of the state to provide. In its 31 years, SUS has improved the country’s health. However, this system always has faced challenges from neoliberal polices that were against the right to health. Federal administrations cannot end the SUS, but they can work to weaken it, especially through policies oriented to favor a health market led by private institutions.
The last [Brazilian] federal administration, which came to power after a controversial process of impeachment, and the current one have moved to oppose the right to health care. While no administration has the authority to end the SUS, with the support of the majority of the policymakers in the House of Representatives, the executive can undermine it. In its place is support to create a private sector health market that would move support and funding away from the SUS. For example, a constitutional amendment (95/2016) defunds public health by decreasing public expenditure and investments in key social areas for 20 years to come, including education and health care.
In theory, neoliberal policies may keep the federal administration acting in accord with the Constitution as Article 196guarantees the right to health. However, Article 199 states, “health assistance is open to private enterprise.” Thus, one could say that the government is not ending the right to health and is following the Constitution. However, the federal government is inverting the priority that the Constitution gives to public health (SUS)—that the State is the first to be responsible for “social and economic policies aimed at reducing the risk of illness and other hazards and at the universal and equal access to actions and services for its promotion, protection and recovery” (Art. 196)—and instead is favoring article 199 that allows private institutions which should only “participate in a supplementary manner in the unified health system, in accordance with the directives established by the latter, by means of public law contracts or agreements, preference being given to philanthropic and non-profit entities” (art. 199, parag. 1).
This policy and others that favor the expansion of the private health sector move the priority of health care away from the Constitutional duty of the State to be the main public provider of the right to health and replaces it with an uneven, and often unfair, market driven system. Supporters of this shift argue that the State is still guaranteeing the right to health because they are not ending the SUS even though this move seriously undermines the system. A private marketplace cannot guarantee the full realization to the right to health with universality, integrality, and equity. A broken, and smaller SUS that mainly provides primary care to the poor, is not a public health care system for all with universal and equal access. This shift is against the principle that grounds the right to health, that is, that health/health care is a human right as enshrined in the Brazilian Constitution and the U.N. Declaration of Human Rights. Policies prioritizing and fostering the growth of the private health sector move health care away from a human rights perspective to adopt the commodification of health care as the basic orientation of healthcare services under a neoliberal market. As a result, health ceases to be a right and becomes a privilege. This move is philosophically inconsistent and requires that all of us involved in health care demand this sell off of the public good cease immediately.