Public healthcare in Brazil

Formal job, private assistance, charity or death

Not so long ago, the biggest economy in Latin America was involved in projects to launch satellites to the space, but it had no public healthcare system yet. A typical paradox of a country shaped by three centuries of colonial history and almost four centuries of slavery, forging a society market by absurd heterogeneities, and the dialectics of a modernization process embedded in strong conservatism and elitism.

In the 1980s, health assistance in Brazil was assured by the National Institute of Social Security Medical Assistance (IAMSPE) for all Brazilian citizens… who had a formal job. The only caveat is that almost half of the labor force was informal or non-remunerated. Besides IAMSPE, high income people could afford for a private treatment, and all others should try their luck to find a place in the hospitals sponsored by the church. For those who could not make it, no treatment at all.

1980s: chaos, defeats and victories

This decade was characterized in Brazil by deep socioeconomic crises (high unemployment rate, extremely high inflation levels) and important social contestation. Under the terrible repressive apparatus created by the military dictatorship – brilliantly exposed by the recent Oscar winner film “I’m still here” [^1] –, diverse social movements were actively struggling for re-democratization and the constitution of a new society. Many defeats, but some important victories.

One of the most important movements was the “Sanitary Reform Movement”, that reunited health workers, university scholars, and people – especially women, historically associated to care – from the left-wing group of the Catholic church named Liberation Theology. Stemming from this alliance between great theoreticians and popular struggles, the movement’s motto was as simple as powerful: “health is a right for all”!

“Health is not a commodity”
Photo by Gabriella Zanardi

Alexandre De Conti, a medical school student at that time – and later a worker at SUS –, tells us that some professors started teaching this precept, that was considered by many as an unattainable utopia. Transiting from theory to practice, these professors and some students rented with their own resources a house in a poor area of Florianópolis (a city in the Southern part of Brazil), furnished it with old furniture they collected in the storeroom of the university, and started treating patients for free.

“We didn’t need high technology equipment, because our treatment was based in the ‘technology of care’”.

Professors and students of the medical school at the Federal University of Florianópolis (UFSC) renovating a rented house to use it as a health center for free treatment to the population (mid-1980s) Source: personal archive.

Isolated initiatives such as this one started popping out all over the Brazilian territory, and gradually were incorporated by progressist mayors in some cities.

From social struggles to constitutional rights

A watershed in this process was the 8th National Health Conference, held in 1986, in Brasília, and counting on more than 4000 participants. The meeting culminated in the approval of the guiding principles of the future Brazilian health system: universal access with equity, comprehensive care, community participation. Important premises came from the Declaration of Alma Ata [^1] (endorsed at a conference jointly convened by WHO and UNICEF in Kazakhstan, in 1978), but with a strong influence coming also from UK’s National Health System (NHS), from the system created in Cuba after the revolution, and from the “barefooted doctors” in China.

8th National Health Conference, which laid the foundations for the conception of the SUS.
Source: Fiocruz archive.

This whole discussion gained momentum in a context in which the Brazilian society was fully involved in the debates for the promulgation of a new National Constitution, that would replace the one adopted after the 1964’s military coup d’état. According to Maria do Carmo Carpintéro, former Secretary of Health in the city of Campinas (state of São Paulo), “SUS’ history is mixed with the history of resistance to the Military Dictatorship”.

Demonstration for the re-democratization and a health reform
Photo by Erik Barros Pinto (Fiocruz archive).

In 1988, the new Constitution was approved, and the Sanitary Reform Movement managed to include an article which recognized health as a right for all and a duty of the State, erecting the legal basis for the upcoming system.

The institutionalization of the Unified Health System (SUS)

In 1990, Laws 8080 and 8142 institutionalized the Unified Health System (SUS in the acronym in Portuguese for “Sistema Único de Saúde”), defining (Law 8080):

Art. 2. Health is a fundamental human right, and the State must provide the conditions necessary for its full exercise.

§ 1. The State’s duty to guarantee health consists of formulating and implementing economic and social policies aimed at reducing the risks of disease and other health problems and establishing conditions that ensure universal and equal access to actions and services for its promotion, protection, and recovery.

In a radical shift in regard to the previous system, it means therefore that all human beings have the right to obtain a free treatment at SUS, regardless of the nationality, the income, the fact of having or not a document, or any other condition. The website of the Brazilian Ministry of Health informs that:

“No one is left without care in the SUS. For indigenous populations, riverside communities, nomads, foreigners in transit, and homeless people, it will be possible to maintain records without a CPF [the Brazilian identity document], as long as they are justified in the appropriate field in the system”.

What seemed as a dream, became reality.

SUS: more than just free treatment

According to Mauri Bezerra, executive director of the Union of Public Health Workers in the State of São Paulo (Sindsaúde-SP) and general secretary of the National Confederation of Social Security Workers of the Brazilian Union Central CUT:

"SUS is Brazil’s largest public policy today. It’s present in everything, from the water we drink to organ transplants. It’s not just a medical appointment; it’s an entire system that benefits all Brazilians, directly or indirectly. Today, 76% of the population—more than 150 million people—rely directly on the SUS for appointments, exams, treatments, and hospitalizations". [^1]

Very importantly, the institutionalization of SUS had an impact over the medical school curriculum, opening space – especially in the public universities – for discussions on collective health, and assuring that internships could be done also in the public sphere.

The future: threats and resistance

In the moment it celebrates its 35th anniversary, the system still faces important adversities to operate, in particular provoked by underfunding. Yet, its principles are fantastic, revealing the potential of strong social struggles, that were able to create a socialist policy in a country in the periphery of the capitalist system. This immanent contradiction gives rise to a permanent tension, provoked by the everlasting threat of those who do not see health as a right, but rather as a commodity. Nonetheless, the mothers and fathers of SUS are still active, joining forces with new generations and organizing resistance against these threats. In particular, the “Front for Life” [“Frente pela Vida”], created during the pandemic, is currently an important alliance to keep the battles in defense of SUS. [^1]

May the same impetus exhaled by the Sanitary Reform Movement maintain the social struggles, protecting the Brazilian SUS and inspiring other countries to also erect universal systems – assuring that health is neither a commodity, nor an object for charity, but a right for all.