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Interview with Jairnilson da Silva Paim: "Taking stock of 20 years of the Unified Health System (UFS)"/Entrevista com Jairnilson da Silva Paim: "Um balanco dos 20 anos do Sistema Unico de Saude (SUS)".

Following the interdisciplinary tradition of collective health, Jairnilson Silva Paim, physician and professor at Federal University of Bahia, is in a special position to talk about the 20 years of the Brazilian Unified Health System--SUS. As a member of the sanitary movement since the beginning of the struggle to democratize and universalize the health system, as well as a researcher in the area of collective health, he has been working on the different dimensions of health and on the building of Brazilian health system. In his more recent books, he has discussed the challenges collective health will be facing in the 21st century and analysed the political and institutional processes of Brazilian health reform.

Vaitsman, Moreira, Costa To what extent have the principles of integrality, universality, equity and social participation proposed by Sanitary Reform and expressed in the UHS been effectively fulfilled in these 20 years?

Paim It is difficult to indicate, in absolute terms, effectively fulfilled principles. In the same way, Brazilian Sanitary Reform that is, a "totality of changes" as Sergio Arouca used to say, is not restricted to a health sector reform in the UHS. Simply in relative terms, I could say that important steps have been taken towards social participation and universality and others, to a lesser degree, towards equity and integrality.

If it can be said that Law 8142/90 guaranteed channels for institutionalized social participation through health conferences and councils, at the same time, there has been an ebb in the sector's social movements as well as obstacles to reaching full citizenship, compromising the quality of this participation in terms of representativeness and legitimacy, including the colonization of these spaces by party, corporate or group interests.

While there are no longer formal barriers to guaranteeing health services for all, there are still great difficulties in access and continuity of care, due to problems linked to service organization (absence of a regionalized and hierarchical network, regulation deficiencies, reference and counter-reference mechanisms, among others). And most of all, the question of financing is still not resolved, especially for investments to expand the infrastructure of the public health system.

Equity was taken up in the hegemonic discourse of health sector reform promoted by international organisms in opposition to universality or, at the most, as a stage to achieve it. This fallacy, in reality, represented an ideological justification for the implementation of focused programs. The Family Health Program (PSF--Programa de Saude da Familia) expresses these contradictions because, as a strategy for reformulating the health system based on Primary Health Care (PHC), it would increase access for this level and redirect referrals to other points on the network, rationing the consumption of services and gaining in scale. But when it presents low coverage in towns with more than 100,000 inhabitants and concentrates on the pockets of poverty, it ends up recreating, in a concrete manner, the inverse of universality.

Integrality is the most neglected principle within the UHS. In the early 1990s, concern with it was limited to a few academic centers and municipal experiments, since political emphasis was concentrated on financing and decentralization matters. It was only with the expansion of the Family Health Program and its political reorientation as a strategy, from the second half of the 1990s, that it became possible to emphasize proposals such as territorialization, public health surveillance, reception, connection, programmatic actions, organized demand, among others, taking up again the discussion raised by Sanitary Reform. More recently, there has been a certain concern with integrality, with efforts of both academic groups and health professional staff of UHS services, especially through the Research Program of UHS (PP-SUS--Programa de Pesquisa do SUS).

Vaitsman, Moreira, Costa In what areas of the UHS have there been the greatest advances and the greatest problems?

Paim If we consider the five big areas of a health service system (infra-structure, financing, organization, management and service providing) we can say there have been advances and problems in all of them. Even for financing, admittedly one of the greatest obstacles for the development of the UHS, it is impossible to ignore that just in the federal arena the resources, in absolute terms, quadrupled from the start of the last decade to the present time: from about 12 billion, the budget went to 48 billion reals. Of course this quantity is not enough for a system that intends to be universal and integral, with a population that is undergoing a demographic transition, with significant changes in the epidemiological profile and with an expectation of medical services consumption that possibly equals rich countries.

I think that one of the UHS's great advances lies in a political engineering work that permitted, in less than two decades, decentralized management for states and towns in a country with a continental dimension, with more than 5,500 towns, great regional and social inequalities and a complex and specific federation. The spreading of the right to health consciousness among the population, even recognizing the distance between its legal formalization and the concrete guarantee, could be seen as another advance, capable of starting new struggles and initiatives in the Brazilian Sanitary Reform process.

As for the greatest problems, apart from the bottlenecks of financing, restricted infra-structure, the unresolved question of human resources, the persistence of the hegemonic medical model and the deficient organization between Primary Health Care (PHC) and medium and high complexity services, we should note the impasses resulting from management tied to partisan interests, a situation where people's health becomes an object of clientelism and a political exchange currency. This fact compromises the legitimacy of the UHS in public opinion, the professionalization of management and the continuity and efficiency of administration.

Vaitsman, Moreira, Costa The problems of managing the health system and services are often considered the main bottlenecks that need to be resolved in order to improve quality. There is a very strong ideological debate about the reasons behind the system's low effectiveness and the poor quality of UHS services. One position advocates reforming the management mechanisms, including human resources, as well as the rules for the organization of services. Another position states that it would be possible to solve these problems within the current management model, as long as there was greater investment in Primary Health Care (PHC), working conditions and pay for health professionals and social control. How do you see this debate?

Paim The UHS is powered by people. As long as the question of the people who work in it and fulfill themselves in it as civil subjects is not laid out, there will be no miracles in management. Similarly, a Fiscal Responsibility Law, which is socially irresponsible, compromising the expansion of a system with an intensive work nature, coupled with the broad reproduction of a set of bureaucratic ties that, with the pretext of fighting corruption, paralyzes administration, damages the flow of vital materials for the care of people and treats the complexity of the health system as if it were just another sector that buys pencils and paper. This situation cannot be ignored as one of the major reasons for the "low resolvability of the system and the poor quality of UHS services". The logical debate should give way to health policy evidence based referrals and not on beliefs. The decisions should be informed by case studies about disastrous experiences, whether by the direct administration or from outsourcing, as well as comparative studies of municipal and state management, as well as management of other health establishments that adopted other legal entities for state action, such as, special autarchies, state foundations, public companies, among others. The constitution establishes that health is a universal right and a duty of the state, but it doesn't at any point condemn the UHS to be a hostage of direct administration. New institutionalities for the UHS could be conceived and researched within the scope of indirect administration which, as well as ensuring the greater effectiveness and quality of the services provided, also protects against colonization by political-partisan and corporate interests in the management of the system and of programs and services.

Vaitsman, Moreira, Costa In spite of the improvement in consumption indexes and a lower concentration of wealth these last few years, the social conditions in which the majority of the Brazilian population lives is still the main challenge facing our society. Up to what point is the UHS able to absorb the problems that result from this situation? Is it possible for the UHS to be efficient and effective in a society with the levels of inequality, poverty and violence that ours has?

Paim The final report of the 8th National Health Conference (8th NHC--8a. Conferencia Nacional de Saude) and the Organic Health Law highlight that health depends on the way that society organizes its production. Although the economic dimension is not the only one to be considered in the social production of health, the issue of the main social determinants of health cannot be evaded. The UHS is only the institutional and sectorial dimension of a broader social reform, that is, Brazilian Sanitary Reform. This hasn't exhausted its agenda, even though its process is confronting some structural elements of Brazilian society. Even if the UHS can absorb certain problems linked to the population's way of life, through alternative care proposals or new technological intervention models, it seems to me that it is impossible to be "efficient and effective in a society with the levels of inequality, poverty and violence that ours has". Thus the pertinence of revisiting Brazilian Sanitary Reform and broadening our social and political bases in the sense of radicalizing democracy and fighting for the "totality of changes" promised by its project.

Entrevista com Jairnilson da Silva Paim: "Um balanco dos 20 anos do Sistema Unico de Saude (SUS)"

Medico sanitarista dentro da tradicao interdisciplinar da saude coletiva, e professor titular da Universidade Federal da Bahia, Jairnilson Silva Paim tem um lugar privilegiado para falar dos vinte anos do SUS. Como participante de primeira hora do movimento sanitario na luta pela democratizacao e universalizacao da saude e como pesquisador da area da saude coletiva, possui vasta producao sobre diferentes dimensoes da saude e da construcao do sistema de saude brasileiro. Em seus livros mais recentes, dedicouse a reflexao sobre os desafios que se colocam a saude coletiva no seculo XXI e a analise dos percursos politicos e institucionais da reforma sanitaria brasileira.

Vaitsman, Moreira, Costa Ate que ponto os principios de integralidade, universalidade, equidade e participacao social propostos pela Reforma Sanitaria e expressos no SUS conseguiram, nesses vinte anos, ser efetivamente cumpridos?

Paim E dificil indicar, em termos absolutos, principios efetivamente cumpridos. Do mesmo modo, a Reforma Sanitaria Brasileira, isto e, uma "totalidade de mudancas", como afirmava Sergio Arouca, nao se restringia a uma reforma setorial expressa no SUS. Apenas em termos relativos, eu poderia afirmar que foram dados passos importantes voltados para a participacao social e a universalidade e outros, em menor grau, para a equidade e a integralidade.

Se e possivel afirmar que a Lei 8.142/90 assegurou canais para a participacao social institucionalizada em conferencias e conselhos de saude, constatam-se, ao mesmo tempo, um refluxo dos movimentos sociais no setor e a existencia de obstaculos para a realizacao de uma cidadania plena, comprometendo a qualidade dessa participacao em termos de representatividade e legitimidade, inclusive com a colonizacao desses espacos por interesses partidarios, corporativos e de grupos.

Se ja nao existem barreiras formais para assegurar servicos de saude para todos, permanecem grandes dificuldades no acesso e na continuidade da atencao, por causa de problemas vinculados a organizacao dos servicos (ausencia de rede regionalizada e hierarquizada, deficiencias da regulacao, mecanismos de referencia e contra-referencia, entre outros). E, sobretudo, a questao do financiamento ainda nao esta resolvida, principalmente no que se refere aos investimentos para expansao da infraestrutura do sistema publico de saude.

A equidade foi assumida no discurso hegemonico das reformas setoriais promovidas por organismos internacionais como oposicao a universalidade ou, no limite, como etapa para alcancar esta ultima. Essa falacia, na realidade, representava uma justificativa ideologica para a implantacao de programas focalizados. O PSF expressa essas contradicoes, pois, enquanto estrategia de reformulacao dos sistema de saude a partir da atencao basica, ampliaria o acesso a este nivel e reorientaria os encaminhamentos para os demais pontos da rede, racionalizando o consumo de servicos e ganhando em escala. Mas quando apresenta baixa cobertura em cidades com mais de 100.000 habitantes e se concentra nos bolsoes de pobreza, termina por reproduzir, concretamente, o inverso da universalidade.

A integralidade corresponde ao principio mais negligenciado no ambito do SUS. No inicio da decada de noventa, a preocupacao com o mesmo limitavase a alguns centros academicos e experiencias municipais, posto que a enfase politica concentravase em questoes de financiamento e descentralizacao. Somente com a expansao do PSF e a sua reorientacao politica enquanto estrategia, a partir da segunda metade da decada de noventa, foi possivel enfatizar propostas como territorializacao, vigilancia da saude, acolhimento, vinculo, acoes programaticas, oferta organizada, entre outras, retomandose a discussao posta pela Reforma Sanitaria. Mais recentemente, constata-se certa preocupacao com a integralidade, a partir da conjugacao de esforcos entre grupos academicos e instancias do SUS, especialmente atraves do PP-SUS.

Vaitsman, Moreira, Costa Em que areas do SUS houve maiores avancos e maiores problemas? Paim Se considerarmos as cinco grandes areas de um sistema de servicos de saude (infra-estrutura, financiamento, organizacao, gestao e prestacao de servicos), poderiamos admitir avancos e problemas em todas elas. Mesmo o financiamento, reconhecidamente um dos maiores entraves para o desenvolvimento do SUS, e impossivel ignorar que apenas no ambito federal os recursos, em termos absolutos, foram quadruplicados entre o inicio da decada passada e o momento atual: de cerca de 12 bilhoes, o orcamento passou para 48 bilhoes de reais. E claro que esse montante e insuficiente para um sistema que pretende ser universal e integral, diante de uma populacao que passa por uma transicao demografica, com mudancas significativas no perfil epidemiologico e com uma expectativa de consumo de servicos medicos, possivelmente, equivalente a dos paises ricos.

Penso que um dos maiores avancos do SUS reside numa obra de engenharia politica que possibilitou, em menos de duas decadas, uma gestao descentralizada para estados e municipios num pais com uma dimensao continental, com mais de 5.500 municipios, grandes desigualdades regionais e sociais e com uma complexa e especifica federacao. A difusao da consciencia do direito a saude na populacao, mesmo reconhecendo a distancia entre a sua formalizacao juridica e a garantia concreta, poderia ser considerada um outro avanco, capaz de ensejar novas lutas e iniciativas no processo da Reforma Sanitaria Brasileira.

Quanto aos maiores problemas, alem dos gargalos do financiamento, da infra-estrutura restrita, da questao nao resolvida dos recursos humanos, da persistencia do modelo medico hegemonico e da organizacao deficiente entre a atencao basica e os servicos de media e alta complexidade, cabe destacar os impasses decorrentes da gestao e gerencia atreladas a interesses partidarios, situacao em que a saude das pessoas transforma-se em objeto de clientelismos e moeda de troca politica. Tal fato compromete a legitimidade do SUS perante a opiniao publica, a profissionalizacao da gestao e a continuidade e a eficiencia administrativas.

Vaitsman, Moreira, Costa Os problemas de gestao e gerencia do sistema e dos servicos de saude sao muitas vezes apontados como os principais gargalos a serem resolvidos para melhorar a qualidade. Ha um embate ideologico muito forte quanto as razoes da pouca resolutividade do sistema e da baixa qualidade dos servicos do SUS. Uma posicao advoga que e preciso reformar os mecanismos de gestao, inclusive os de recursos humanos, bem como as regras para a organizacao dos servicos. Outra posicao afirma que seria possivel superar esses problemas dentro do atual modelo de gestao, desde que houvesse maior investimento na atencao basica, nas condicoes de trabalho e na remuneracao dos profissionais de saude e no controle social. Como voce ve esse debate?

Paim O SUS e movido a gente. Enquanto a questao das pessoas que nele trabalham e nele se realizam como sujeitos publicos nao for equacionada, nao havera milagres na gestao e nem na gerencia. Do mesmo modo, uma Lei de Responsabilidade Fiscal, socialmente irresponsavel, que compromete a expansao de um sistema cuja natureza e trabalho intensivo, ao lado da reproducao ampliada de um conjunto de amarras burocraticas que, sob o pretexto de combater a corrupcao, engessa a administracao, prejudica o fluxo de insumos vitais para o cuidado das pessoas e trata a complexidade do sistema de saude como se fosse um setor qualquer que compra lapis e papel. Essa situacao nao pode ser ignorada como um dos grandes responsaveis pela "pouca resolutividade do sistema e pela baixa qualidade dos servicos do SUS". O embate ideologico deveria ceder lugar a encaminhamentos baseados em evidencias e nao em crencas. As decisoes deveriam ser informadas por estudos de casos sobre experiencias desastrosas, seja da administracao direta, seja das terceirizacoes, bem como de estudos comparativos de gestoes municipais, estaduais e de estabelecimentos de saude que adotaram outros entes juridicos para a acao estatal, tais como autarquias especiais, fundacoes estatais, empresas publicas, entre outros. A Constituicao estabelece que a saude e direito de todos e dever do Estado, mas em nenhum momento condena o SUS a ser refem da administracao direta. Novas institucionalidades para o SUS podem ser concebidas e pesquisadas no ambito da administracao indireta que, alem de garantir maior efetividade e qualidade dos servicos prestados, facilitem uma "blindagem" contra a colonizacao de interesses politicopartidarios e corporativos na gestao do sistema e na gerencia de programas e servicos.

Vaitsman, Moreira, Costa Apesar da melhoria nos indicadores de consumo e de reducao da concentracao de renda nestes ultimos anos, as condicoes sociais em que vive a maioria da populacao brasileira permanecem como o principal desafio de nossa sociedade, repercutindo diretamente nas condicoes de saude. Ate que ponto o SUS tem condicoes de absorver os problemas decorrentes desta situacao? E possivel que o SUS seja eficiente e efetivo numa sociedade com niveis de desigualdade, pobreza e violencia como a nossa?

Paim O relatorio final da 8a CNS e a Lei Organica da Saude destacam que a saude depende da forma com que a sociedade organiza a sua producao. Embora a dimensao economica nao seja a unica a ser considerada na producao social da saude, nao e possivel tergiversar sobre os principais determinantes sociais da saude. O SUS e apenas a dimensao institucional e setorial de uma reforma social mais ampla, ou seja, a Reforma Sanitaria Brasileira. Esta nao esgotou a sua agenda, ainda que o seu processo se enfrente com elementos estruturais da sociedade brasileira. Mesmo que o SUS possa absorver certos problemas vinculados ao modo de vida da populacao, mediante propostas alternativas de modelos de atencao ou novos modos tecnologicos de intervencao, parece-me impossivel ser "eficiente e efetivo numa sociedade com niveis de desigualdade, pobreza e violencia como a nossa". Dai a pertinencia de revisitarmos a Reforma Sanitaria Brasileira e ampliarmos suas bases sociais e politicas no sentido de radicalizar a democracia e lutar pela "totalidade de mudancas" prometida pelo seu projeto.
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Title Annotation:OPINION/OPINIAO
Author:Vaitsman, Jeni; Moreira, Marcelo Rasga; Costa, Nilson do Rosario
Publication:Ciencia & Saude Coletiva
Article Type:Interview
Date:May 1, 2009
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