a decree signed by President Jair Bolsonaro on Monday (10/26) it left the primary public health sector in an uproar and aroused fears about the possibility of privatizing services in the Basic Health Units (UBS). On Wednesday afternoon (28), after negative repercussions, Bolsonaro announced the revocation of the measure.
The decree, published on Tuesday in the Official Gazette of the Union, said that “within the scope of the Investment Partnerships Program (PPI), the policy to promote the primary health care sector is qualified, for the purpose of preparing studies alternative partnerships with the private sector for the construction, modernization and operation of Basic Health Units in the States, Federal District and municipalities “.
The UBS are the gateway to the SUS (Unified Health System), whose gratuity to the population is provided for in Article 196 of the Federal Constitution, which says that “health is the right of all and the duty of the State”.
The government decree was signed by Bolsonaro and his Economy Minister Paulo Guedes, without mentioning the Ministry of Health or the role of the municipalities, which manage the UBS.
This Wednesday, in order to contain the negative reactions to the text, the General Secretariat of the Presidency of the Republic even affirmed that the measure still depends on “technical studies” that “may offer different options for dealing with the issue”.
And the government’s special PPI secretary, Martha Seiller, told CNN Brasil that the partnerships eventually derived from the decree would maintain “this public and free system for 100% of the population. (…) What you have is a very strong will to use best practices to attract private investments to provide better services “.
Around 5:40 pm this Wednesday. the president announced, through social media, that the decree had been revoked. Bolsonaro argued that he never considered privatizing SUS. “The spirit of Decree 10.530, already revoked, aimed at ending these works (in health units), as well as allowing users to seek the private network with expenses paid by the Union,” he wrote.
“If there is a future understanding of the benefits proposed by the Decree, it may be reissued,” added Bolsonaro.
The decree, considered vague, aroused harsh criticism.
The president of the National Health Council (linked to the Ministry of Health), Fernando Pigatto, said in a video that it is “arbitrary with the intention of privatizing basic health units”.
In the Chamber of Deputies, at least five draft Legislative Decrees were presented to suspend the effects of the text signed by the president. One of them was presented by Congresswoman Maria do Rosário (PT-RS), who argued that “private health management transforms what is a right into a privilege for the few, those who can afford it”.
The National Council of Health Secretaries (Conass), which brings together the state secretariats, debated the issue in an assembly this Wednesday. The organ’s president, Carlos Eduardo Lula, who is Maranhão’s health secretary, said on Twitter that “we will not allow any setbacks in health”.
In a note sent to BBC News Brasil, Conass stated that the decree left “serious doubts as to its real purposes. Prepared without debate, the text mixes different aspects, such as the construction, modernization and operation of UBS. to SUS management are not taken unilaterally, they must be the result of a consensus between the federal, state and municipal levels, under penalty of absolute nullity. (…) The decree presented does not deal with a governance model, but it is an imposition of a business model “.
Public-private partnerships already exist in health
In itself, the text of the decree does not allow to conclude that there would be the privatization of public primary care, but, because it is so vague, it leaves room for loopholes – many of which may not necessarily result in improving the service provided to the public. The evaluation is by Ana Maria Malik, coordinator of the Center for Studies in Health Planning and Management at FGV-SP.
“The most worrying thing is that Health has not been heard so far,” Malik tells BBC News Brasil.
It is worth remembering that the use of public-private partnerships is already made in Brazilian public health. The main example is that of Hospital do Subúrbio, in Salvador, considered the first to test the model in the country – and under a PT government, that of Jaques Wagner, in 2010.
The management of the state hospital was under the concession of a private consortium through an auction held at BM&F Bovespa. “The State built the physical infrastructure and the consortium equipped, equipped, furnished and manages the hospital”, informs the Bahian government.
The Bahian model is considered successful and received international awards, but Ana Maria Malik recalls that additive terms (that is, more State spending) were needed to cover costs that were not initially provided for in the contract.
Conass himself points out, on his website, that “this type of (public-private) partnership has grown in recent years and is concentrated in areas whose financing cannot be fully funded by the State, either due to the increasing complexity or the high investment of financial capital “.
However, existing examples so far focus on hospitals, not basic health units, as this week’s presidential decree predicted.
A major challenge when granting health administration to the private sector, says Malik, is to draw up contracts that are careful to protect the interest of the citizen using the service, with clear definitions of the duties of private entities and close supervision – to guarantee not only gratuity of the service, but “the type of care the user will receive and what he will be deprived of.”
“It cannot be just to get rid (of the management of health units) or to reduce costs. It is not a question of spending less, because we already spend less than we should on health. It is trying to spend better”, he tells BBC News Brazil.
An October 2019 study by the Institute for Health Policy Studies (Ieps) estimates that health spending in 2060 will need to reach 12.8% of GDP (Gross Domestic Product, or the wealth produced by the country), against 9, 1% that were in 2015, according to IBGE data.
In the opinion of Ana Maria Malik, from FGV-SP, in addition to increasing funding, a key issue in basic health remains a series of bottlenecks that accumulate.
“It is not a question of having or not a PPP, but of solving bottlenecks – of access (to the health system), of emphasis on health (preventive) and not only in the disease, in the offer of good quality care, in the network patient support. (…) Whether this will improve or worsen with a PPP, it will depend on the management. “
A group of researchers from Fiocruz argues, in an article, that public-private partnerships “should play an increasingly relevant role, emerging as an important alternative” in public projects.
However, say the four authors, “especially for public health, PPPs will not always be a good alternative, since there may be a distortion of the agenda that defines health needs, favoring the interests of companies”.
They state that “public agencies can benefit from collaboration with the private sector in areas where there is a lack of specialization, such as research and technology development. Even in these cases, the roles of each institution must be well defined, so that they do not there is a conflict of interest. This can be a challenge when it comes to the formulation of public and regulatory policies. (…) Engaging with the private sector, without compromising the integrity of government actions, requires broad discussion on the part of the actors public health, for clear reasons of conflict of views and scopes between corporations and public health. “
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