After Outcry, Bolsonaro Revokes Decree Leading to Private Investment in Basic Health Care

RIO DE JANEIRO, BRAZIL – The Federal Government decree that authorized studies of future private partnership initiatives for base units of Brazil’s National Health Service (SUS), free for all residents in Brazil, lived for only one day. Since it was published in the Federal Gazette, the decree sparked vast criticism. The reactions came from politicians and the health sector. On Wednesday, October 28th, President Bolsonaro revoked what he had signed on Tuesday, October 27th.

The decree signed by President Jair Bolsonaro and Minister of Economy Paulo Guedes included local primary care and healthcare centers in the President’s investment partnership program for the development of studies of possible partnerships with the private sector for the building, modernization, and operation of local Basic Health Units (UBS) in the states, Federal District and municipalities.

By decree, states and municipalities could join the program. And the private sector could administer the service, such as staff management, equipment, and building maintenance.

However, the Decree sparked huge amounts of criticism immediately after it was published in the Federal Gazette. The reactions came from politicians and the healthcare sector, and provoked an explanatory note from the Ministry of Economy justifying the measure.

The note said that the decision to include the UBS in the program was taken after a request from the Ministry of Health, which currently has over 4,000 unfinished local centers and has already consumed R$1.7 billion (US$303 million) in SUS resources, according to the Ministry of Health.

The Ministry of Economy also reported that “the joint assessment is that the private initiative’s participation in the system must be encouraged in order to raise the quality of service provided to citizens, rationalize costs, introduce compensation mechanisms for performance, new scale criteria and integrated healthcare networks in a new service model.”

The president of the National Health Council, Fernando Pigatto, said the concept had not even been discussed with society in general.

“This debate came at the wrong time and in the wrong way. We cannot allow this, amid a pandemic, when extra resources were allocated to health as happened this year, and the SUS coped. We need the federal government to make the investment that needs to be made to provide people with dignity so that people can be served with quality,” he said.

In Congress, the vice-president of the Citizenship committee, federal deputy Rubens Bueno, submitted a legislative bill to revoke the presidential decree.

After the criticism, on social media, President Jair Bolsonaro announced on Wednesday that he had revoked the decree. He said: “The SUS and its false privatization. The purpose of Decree 10,530, now revoked, was to complete these [construction] works, as well as to allow users to seek private health care with these expenses paid by the federal government. The mere reading of the decree at no time signaled the privatization of the SUS. If there is a future understanding of the benefits proposed by the decree, it could be reissued.”

‘Obscure’, ‘hasty’, and ‘unconstitutional’

Experts heard by the G1 were concerned about the text published on Tuesday. “Obscure”, “hasty”, and “unconstitutional” were among the adjectives used to classify the decree. In a memo by the Ministry of Economy and the Presidency, the federal government stressed that “the measure does not represent any prior decision.” The Ministry of Health did not comment on the issue.

Below – in 5 questions and answers – is a review by experts on the issue:

1. What does the Decree say?

Decree No. 10,530/2020 refers to “the qualification of the promotion policy for the primary healthcare sector within the scope of the Presidency of the Republic’s Investment Partnership Program (PPI), for the purpose of preparing studies on alternative partnerships with the private sector.”

Within the scope of the Investment Partnership Program (PPI), the text provides for the “development of studies on alternative partnerships with the private sector” to build, modernize and operate healthcare facilities in the country (known within the SUS as Basic Health Units, the UBS).

The document is signed by President Jair Bolsonaro and Minister of Economy Paulo Guedes. There is no signature by the Minister of Health.

In a note, the General Secretariat of the Presidency of the Republic said that the studies should identify “the feasibility (or otherwise) of specific implementation” of the alternatives suggested by the studies.

2. What does this mean, in practice?

Daniel Dourado, a researcher in health and law from the University of São Paulo (USP), says the government text is obscure. “It is a very strange decree, very obscure, the wording is very poor. It is very difficult because you can’t understand what it is talking about,” says Dourado, while reminding that the government’s PPI program “is basically about concessions and privatizations.”

For Dourado, “THE issue is that there are already public-private partnership models in health; that is not what this is about. What we assume is that they are trying to find another model. What I find worrying about this decree is that it won’t address something that already exists. If it were, there wouldn’t be any need to issue a decree saying that they will study new business models.”

Public health specialist Lígia Bahia, from the Federal University of Rio de Janeiro (UFRJ), considered the decree “hasty” and the fact that the health area has not been heard was “strange”. “This reversal, this incursion of the Ministry of Economy into health is an extremely worrying event, it is a disaster. Minister Paulo Guedes understands nothing about health,” said Bahia.

The president of the National Health Council (CNS), Fernando Pigatto, considered the decree as a means to strip the population of its rights. “We need to strengthen the SUS against any kind of privatization and removal of rights,” said the president of the CNS.

Pigatto said the decree would have to be assessed by the CNS Basic Care Technical Council (CTAB), which must issue a formal opinion on the text and take appropriate legal action.

3. Can the private sector partner with the SUS?

Yes, the private sector can have partnerships with the SUS. There are three possible types, explains researcher Ana Maria Malik, coordinator of FGV Saúde, of the Getúlio Vargas Foundation in São Paulo, specialized in public-private partnerships (PPPs) in health:

Those undertaken within the Institutional Development Support Program of the Brazilian Unified Health System (PROADI), in which five leading Brazilian hospitals provide services to the SUS – ranging from education projects to highly complex health care, such as transplants (although, according to Malik, these are less frequent). In exchange, hospitals are granted tax exemptions.

Those made under public private partnerships (PPPs), such as the Subúrbio Hospital in Salvador. Specifically in the case of Bahia, the company involved is in charge of equipping, furnishing and running the hospital – its participation includes providing medical services. The costs are paid by the state of Bahia, and assistance to people is free.

Those with Social Health Organizations (OSS), civil non-profit philanthropic institutions that are in charge of managing SUS services throughout the country, working in partnership with governments. Most health posts in São Paulo, for instance, are managed by an OSS.

In the case of the OSS, the legislation enabling these partnerships dates back to 1998. The issue was judged by the Federal Supreme Court (STF) in 2015, which authorized private institutions registered as social organizations to provide public services in the areas of education, scientific research, technological development, environment, culture and health.

4. Can the SUS be privatized?

According to USP’s Daniel Dourado, only if a new Constitution is drawn up. The right to health is guaranteed by the 1988 Constitution. In his opinion, it is an entrenched clause (“cláusula pétrea”) that, under Article 60 of the 1988 Constitution, cannot be changed through a constitutional amendment.

Dourado explains that, although the Constitution provides for private companies to be granted concessions of public services and profit from them – as is the case of road concessions, for instance – this cannot be done in health.

“When they refer to a business model and privatization and concession, one thing must remain very clear: the logic of the private sector within the SUS is not possible, it is unconstitutional,” he says.

“Health is a social right. The SUS is there – the right to health is directly linked to the SUS by the Constitution itself. If you tamper with the SUS to introduce a private logic, there is a good chance that this may fall into something unconstitutional,” he explains.

“If it [the decree] deprives part of the population of its access to health – who knows how, because they do not make it clear – it can not be done. The Constitution does not allow this and it can not be amended this way. Any shift along that path could result in an entrenchment clause. The Constitution cannot be amended to deprive or reduce rights and guarantees,” clarifies the researcher.

5. Why are the UBS important?

They are the preferred gateway to the SUS services, where primary or basic healthcare is provided.

According to the Ministry of Health, the goal of the centers is “to attend up to 80 percent of the population’s health problems, without the need for referral to other services, such as emergency rooms and hospitals.”

FGV researcher Ana Maria Malik recalls that the basic network has a fundamental role in organizing assistance. “It needs to take great care to prevent this [the partnership with the private sector] from serving different interests, which are not exactly to organize the healthcare system,” says Malik.

The three basic care principles for UBS centers are the same as those of the SUS: universality, equity, and integrality. This means that:

• access to these services must be universal;
• the care offered must not be based on the differences between people, nor exclude anyone on the grounds of age, gender, race, socioeconomic status, schooling, and other conditions;
• the services must meet the needs of the population in the areas of care, promotion and maintenance of health, disease prevention, treatment, rehabilitation, injury mitigation, and palliative care.

What does the government say?

On Tuesday, the Ministry of Economy stated that “the studies will be intended to structure pilot projects”. According to the portfolio, the development of “business models” will not prevent the Ministry of Health from “conducting public policy”.

In a note released on Wednesday afternoon, October 29th, the Ministry of Economy said that “currently, there are over four thousand UBS with unfinished building works that, according to the Ministry of Health, have already used R$1.7 billion of resources from the Unified Health System (SUS)”.

Martha Seillier, the Ministry of Economy’s special secretary for PPIs, says the “UBS structure” is lacking in several Brazilian municipalities.

“Unfortunately, of the works contracted in the past, many were not completed. That’s why we believe that the PPP model could greatly contribute to this UBS system in Brazil, so that we can, through partnerships with private companies, finalize these projects, build new UBSs and equip them. And have a top-quality service to the population,” said Martha Seillier.

Source: G1, IstoÉ