When the foundation Integrated Health System (SUS) Launched in 1986 in Jakarta 8th National Health Conference, dr. Gastão Wagner de Sousa Campos completed his master's degree in preventive medicine. The title of your dissertation – "Doctors and health policy: between nationalization and entrepreneurship in health services"- coincides with the professional path that I will take from there; his doctoral dissertation was retained one year after the creation of SUS, set in 1990, two years after Citizens Constitution.
Since then, Dr. Gaston accumulate the duties of doctors and teachers Unicamp with militancy for public health. President of PT Brazilian Collective Health Association (AbrasionUntil last year, he continued to fight for eternity SUS, which, despite suffering from lack of resources since its founding, is responsible for one of the largest public health scopes in the world.
"If the Brazilian people don't fight for it SUS in everyday life, when choosing and choosing who supports SUS, if professionals do not defend SUS, he is far more threatened. In studies conducted by politicians and sociologists – for example, from the English language system, much older than us, already 90 years old – which makes the main defense SUS English It is professionals, health workers, who seek support in the community and find it. If it depends on the authorities, then I'm pessimistic, "he said when asked about the future of the health system that serves 160 million Brazilians and vaccines and universal treatment against AIDS and some cancers.
Read the interview and find out why the increase in adult deaths over the past five years and that child deaths over the past three years are directly related to the decline in resources for SUS, which tends to worsen in this government, with measures proposed by the Minister of Economy, Paulo Guedes.
Note: The interview took place last week, before the action was announced yesterday by the government. Bolsonaro.
The interview came from Marina Amaralpublished by The agency Public11-14-2019.
Here is the interview.
What is the current situation of SUS and what impact can Guiana's health have on action?
Over 32 years, SUS always underfunded, i.e. there are insufficient resources to meet the health needs of the population, SUS. But it has gotten worse, especially since the constitutional amendment of the expenditure ceiling was approved, because about five years ago the federal health budget for SUS, it doesn't even reset the value of inflation, and then we get fixed around 210, 216, 220 billion [de reais], which in practice is reducing health spending. This, of course, has consequences; We already have epidemiological studies that indicate an increase in adult mortality in the past five years, including articles published in international health journals. Why that SUS reduce the ability to buy insulin for diabetes, drugs for hypertension. And those who depend on SUS, which constitutes 70% of the Brazilian population, has an increased risk of hospitalization, exacerbating this chronic illness and death. We have lowered life expectancy objectively for adults. And I already have an analysis of the past three years that shows improvement Dead childish after 25 years it fell quickly. We have curve inversion in ribbon mortality under 1 year and also under 5 years. So the financing problem is very serious, concrete.
And the purpose of the minister Paulo Guedes is to further reduce spending on health and education. He must withdraw from the proposal Ministry of Economy sent to Congress the inclusion of pension costs for workers and health professionals in mandatory expenses [com saúde], because of the president Room Federal and from Senate they warned that they would not support. This will reduce about 18 to 20% of expenditures that are already insufficient. But they insisted on a proposal to reduce the index of government spending on health and education, which would also be a disaster; The investment volume in SUS will be in accordance with the policies of each mayor and each governor. It is therefore anticipated that in a minimum of 15% of their budget required for health, they cannot include pension payments for employees, waste collection, even though all of this is indirectly related to health. It's 15% tight on SUS, in health care, prevention and care. And states are required to spend 10% of the state budget. And this is what the Minister of Economy wants to change, with the idea of reducing public spending at any cost, at the expense of human lives. The problem for him – and the solution for us – is that he needs an amendment to change Constitution, approval of two-thirds in Congresswhich is much more difficult.
Do you think a campaign against public health that supports privatization is underway, where SUS is said to be a non-functioning white elephant …
There is a general movement to deconstruct public policy. The idea is that each turned on the market. This is a tragedy that was announced in a very unequal country, and Brazil is one of the most unequal countries in the world. that SUS It has greater resilience despite all its problems than other public policies. State universities, science and technology policies are far more stricken than health. Is that deconstruction SUS produces what we call barbaric sanitation: in a very short time, many people die. Of all vaccinations in Brazil, 80% of people go through cancer treatment SUS. So reducing it politically is very complicated.
We saw reports showing hospital lines, difficulty in examinations and operations. Does this not make Brazilians believe that SUS is a non-functioning system?
I think this is a paradox: strength SUS is its existence and weakness SUS it is a gap in care, bureaucracy, inequality: in one city there is a queue for cancer like that, in another city there is another, in other areas there is no access to cancer care. that SUS Very heterogeneous and has many problems. It is important to invest to correct this deficiency, but we make this problem worse. That's just slow deconstruction, you know? City, federal and state politicians don't have much courage to live with this cover hospital; They do it strategically, using ways that make it difficult for the population to understand, like the Economy Minister's proposal. And all this liberal radicalism against public policy, civil servants, opposing universities, achieving goals SUS. And then into resistance, public policy cannot go forward, renewing itself. So that SUS have this ambiguous situation. People complain, but they don't want them to take back what they already have.
Compared to other countries that have private health systems, what about public services like SUS? Is this really inefficient? What about countries like Britain, which has a public system too?
In comparison, countries with a dominant private health system such as Union Unite, loss: expensive, lower productivity. Unlike other areas – for example in telephony – markets produce cheaper and more productive; In the field of health and education there have been studies that show that this is not the case. Public systems are better spent and have greater coverage, greater inclusion, greater access to drugs, vaccines. And compare SUS the public health system in other countries is difficult. There are 160 million people who only use it SUS in Brazil. This is a lot, bigger than the UK population. Enter English96% of people – or enter Portugal98% of Portuguese – use the national health system, which is SUS theirs. Enter Brazil, regularly 60% to 70% use SUSHowever, because we have small resources, our scope is smaller and very heterogeneous. In cities Northeast, access to SUS worse than here at SUS of Southeast. If inside SUS from Southeast If you take a city like São Paulo, central and middle-class neighborhoods have far better access than tip, than the suburbs, where 40% of São Paulo's population lives, where 40% of Campinas's population lives. that SUS This is a public system that has to turn to the most needy and vulnerable, but it happens very slowly. I looked at cancer death statistics in Brazil: the poorer the higher the mortality rate; the lower the income, the higher the cancer mortality. Like this.
And this is due to lack of access to drugs, therapy, surgery? What is the knot?
Lack of access to health care. Who has access? that SUS guarantee chemotherapy, ensure medication, don't miss it. But if the person is poor, he goes to a health clinic on the outskirts, and the staff there, doctors, nurses, are suspicious of breast cancer: access to mammography is difficult, disorganized, you cannot go on scheduled appointments accordingly. Expansion SUS not occur according to population vulnerability; it happens according to the capacity of political pressure. We have hospital concentrations in several cities and, within cities, in several regions. In the prevention section, SUS universalization of some things, regardless of income, social class. Vaccines, for example, SUS This has been universalized and democratized: vaccine coverage is high, and today the upper middle class is refusing to get the vaccine. Now there 30 million people in Brazil who don't have clean water to this day, 50% of the population without sanitationo – open sewers – and not only in rural areas, in cities as well, in work, slums. So in the end it has a difference in prevention too.
This economic, social, cultural, political imbalance is disturbing. Another area that is preventive and provides care at the same time is that SUS universal: AIDS policy. We see no difference in mortality between people living with AIDS between those on low incomes and middle class or high income populations. Because SUS go after access, diagnosis and guidance of treatment and prevention, almost universal. For cancer, this is no longer the case, though several [tipos de câncer] they almost become universal, like cervical cancer, which depends on preventive care, on pap smears. And it can be universalized because we fight on SUS so nurses can do it too, but doctors don't want to. Even doctors forbid it, nurses do it, and about 70% or 80% of Brazilian women do pap smears. And we have fallen all over Brazil, more prominently in some areas, which has caused almost the disappearance of uterine cancer through prevention and treatment from the start. Cancer, the faster it is treated, the better it is necessary to universalize access. Inequality is detrimental in the area of prevention and care.
Brazilian doctors fight for their privileges. Many of them, for example, oppose Cuban doctors, and now we see that the government cannot fill all vacancies. What is the impact on public health?
If you do not have More doctors, must have policies that guarantee the function, expansion, access and quality of primary health services, these health networks – health centers, basic health units, where vaccines are made, diabetes care, hypertension, prenatal care for children. Many health problems throughout the world are currently solved in primary care. And we have difficulty putting doctors in primary care, Brazilian doctors wanting to be specialists, working in hospitals. And service, that is SUS, has never developed a proper attention policy. Even with More Doctor, we have coverage for only 55% of the population. Recommended coverage for follow-up and primary care is 80% of the population. Now it has dropped to around 40 percent, and with the federal government budget cuts and the city budget crisis – which employs primary care mainly in the city – there is a serious decline in care everywhere. In the city of Rio de Janeiro, the mayor closed down basic health units, fired doctors and nurses, a crisis in the scope of primary care, which had gone forward and backward. It also explains the increase in mortality in children under 5 years, under 1 year and in adults with chronic diseases.
Some data also show an increase in maternal mortality. Do you have news about this?
So the death of the mother drops slowly, and it decreases slowly before. That is, it does not progress. Child mortality has declined rapidly, but neonatal mortality, which is the first month of life, has also declined very slowly in Brazil. Both mortality of children up to 1 month and women in labor and postpartum are high because they are related to hospital care, where SUS has little impact. Hospitals don't follow the norm SUSespecially by medical corporatism. Then everyone does what they want, the way they want and understand. And while 80% of women in Brazil do regular prenatal care with more than seven visits during the nine months of pregnancy, which is the minimum number, labor and delivery care is very bad in Brazil, and we have this problem which is an epidemic of cesarean section.
And is this directly related to maternal death? Is a cesarean section even more dangerous for the mother?
The risk of having general anesthesia surgery, having an infection in a hospital is much higher. Remarkably, if you take it based on social class, maternal mortality is as high among the rich in the upper middle class as among the poorest, because in the private sector 96% of births are cesarean section, SUS 46% – and still very high. Worldwide recommendations for WHO 20% at most. That is, there is a market mix with difficulties in normal delivery care – lower mortality, but not simple. Even though SUS pays, doctors don't do analgesia for those who are black and poor – and I talk about statistics that show that they refuse to do more analgesia in black women than in white women.
Do they refuse to do analgesics on black women?
Look for it Fiocruz"Born in Brazil," with data showing this, yes (click here to see this part of the survey). What I say about the increase in adult deaths in Brazil in the past five years is in an article that came out in November now Lancet. There are several writers, but the most famous Brazilian writer is Mauritius Barreto. And one and a half years ago an article about child mortality was published which showed the positive effects of expanding family health strategies from primary care and Bag Family.
The effect is that fast? When there is a decrease in income, an increase in unemployment, how long does it take for us to realize this in public health?
That's what I'm saying: the effect is very fast. That could be worse in five, even in three years. When there is a crisis in economic growth with social impacts, rising unemployment, falling real minimum wages, people's purchasing power, the death of parents and children is very fast. The story is that economic growth alone guarantees prosperity, that the economy needs to grow to have such public policies SUS, unemployment salary, Bolsa Familia, is wrong. Market growth tends to focus on income if there are no public policies that impose restrictions through taxes and shifting spending. It needs to have a democratic, open and transparent state, because if it has corruption, politicization and protection, public policy is included in the budget but it is not effective. We must ensure proper government management. It all depends on politics. The current Brazilian government and many press say that if there is economic growth, everything will be resolved, public transportation, housing. But this is not the case.
How did the increase in violence emerge in the death data?
A death from violence In Brazil it has grown, and 90% of these deaths have two reasons: violence in the city – drug-related killings, militias, gang conflicts and police, which mainly affect young black people – and the other main cause is traffic. We have 66 [mil] 74,000 deaths per year due to homicide and around 40,000 deaths per year from traffic. Now, besides death, imagine the number of people who need surgery, rehabilitation, prosthetics, attempted murder survivors, motorcycle accidents. This is much higher than fatalities, and more than 90% [são] treated at SUS. Because intensive care, surgery, neurosurgery, orthopedic surgery, severe traumatology all begin with SUS. And who has the agreement then goes to continue treatment.
One final question is just to close. Does SUS have safety? In your opinion, is it possible for us to maintain this public health system and work more efficiently? It's a matter of political will, a matter of budget …
We are at this, in ensuring survival SUS. Whether it will last or not, only God knows. But there are many possibilities and the needs of the country are also large. It seems that survival SUS – I want to attract attention – it really depends on the government. And that depends on the government, the public budget, the state of Brazil, the law. But it really depends, maybe even more so, on the population and society and, especially in the community, on health professionals. If the Brazilian people don't fight for it SUS in everyday life, when choosing and choosing who supports SUS, if professionals do not defend SUS, he is far more threatened. In studies conducted by politicians and sociologists – for example, from the English language system, much older than us, already 90 years old – which makes the main defense SUS English It is professionals, health workers, who seek support in the community and find it. If it is up to the authorities, then I am pessimistic.