Viewpoint
The right to health in Brazil: A Constitutional guarantee threatened by fiscal austerity Luis Eugenio Portela Fernandes de Souzaa,b a
Instituto de Sau´de Coletiva, Federal University of Bahia, Rua Bası´lio da Gama, s/n, Campus Universita´rio do Canela, Salvador, Bahia 40.110-040, Brazil. b
Rua Marechal Andrea, 142 ap 701 Pituba, Salvador, Bahia 41.810-105, Brazil. E-mail: [email protected]
Abstract
After 25 years of expanding coverage and improving the quality of preventive public health measures and publicly financed medical care associated with positive outcomes for the health of Brazil’s population, our country suffers from deterioration of social policies. Among the areas of policy affected by new economic austerity measures is health — with potential to damage lives. These threats stem mainly from the 2016 approval of a Constitutional amendment that limits, for the next 20 years, public investments in health, education, social assistance, and social security. This viewpoint addresses how the changes have come about and the possible consequences. Journal of Public Health Policy (2017). doi:10.1057/s41271-017-0083-y Keywords: right to health; austerity; Brazil; public health
Introduction After 25 years of expanding coverage and improving the quality of government health services associated with positive outcomes for the health of Brazil’s population, our country suffers from deterioration of social policies. Among the affected areas of policy is health services — with potential to damage lives. These threats stem mainly from approval by the National Congress, on 15 December 2016, of a constitutional amendment that limits, for the next 20 years, public spending on health, education, social assistance, and social security. I discuss when and how the change came about and its possible consequences.
2017 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy
www.palgrave.com/journals
de Souza
Post-dictatorship Constitution: A Right to Health and Progressive Social Policies In the late 1980s, the idea of health as a human right gained momentum in the midst of struggle against the military dictatorship. In the Federal Constitution of 1988, that enshrines democratic freedoms, ‘‘Health is the right of all and the duty of the State, guaranteed through social and economic policies, aimed at reducing the risk of disease and injuries, and universal and equal access to the actions and services for their promotion, protection and recovery’’. To provide universal and equal access to health services, the Constitution created the Unified Health System (SUS) that sought to overcome previous fragmentation of care between preventive and curative actions. Before the 1988 Constitution, the Ministry of Health was responsible for the prevention programs and the Ministry of Social Security for medical services, or curative care. During the 1990s, a period dominated by the ideology of neoliberalism that was unfavorable for development of social policies, SUS expanded and contributed to improving the health of the Brazilians. Under SUS, Brazil increased vaccination coverage along with prenatal, childbirth, and postpartum care; established oral rehydration therapy in all over the country; implemented the Family Health Program and programs of emergency care and AIDS control; and supplied essential drugs free of charge. Brazil also strengthened its health surveillance system. These population health and health services initiatives have been decisive for controlling diseases susceptible to prevention by vaccines, for reducing infant mortality, and for increasing the population’s life expectancy.1 These achievements derive principally from two innovations in the Constitution of 1988: decentralization of health care management and social participation. Decentralization, by making municipal governments legally responsible for the implementation of health activities, stimulated introduction of new funds into the health system — from local treasuries. Social participation has been essential for guiding use of resources in accord with plans approved by the Health Councils in each town. Health Councils, comprising equal numbers of representatives of the public administration and from civil society, monitor implementation of the plans.2
2017 Macmillan Publishers Ltd. 0197-5897
Journal of Public Health Policy
The right to health in Brazil
Even under SUS, however, old problems have persisted or even worsened, and new ones arisen. Communicable diseases such as tuberculosis and malaria continue to have high prevalence rates. Diabetes and hypertension have increased in prevalence. New problems include dengue and, more recently, chikungunya and Zika infections. Violence has grown, including aggression with firearms. Most important, social and regional inequalities in the incidence and prevalence of all these health problems persist. This demonstrates Brazil’s need to strengthen social policies and the public health system including its health care services. Between 2004 and 2010, Brazil experienced a period of economic growth and income redistribution, with a real increase in the minimum wage and expansion of coverage of income transfer programs.3,4 SUS expanded primary care and emergency services, and created new programs including care for mental and oral health needs. While strengthening Brazil’s public health system, growth of the economy and incomes also caused the private health insurance market to grow. The latter benefitted segments of the population whose incomes increased sufficiently to purchase private policies to supplement SUS and, in particular, eased their access to specialized medical services.
Global Economic Crisis Affects Brazil: Social Upheaval Follows From 2011 forward, a global economic crisis strongly affected Brazil. Counter cyclical measures adopted during the Lula Presidency in 2009 and 2010 are no longer in effect and the economic policy initiatives taken by the subsequent government, led by Dilma Rousseff, have been ineffective in overcoming the crisis. The Gross Domestic Product (GDP), that grew an average of 4.5 per cent per year from 2004 through 2011, began to fall — declining by 3.8 per cent in 2015.5 In parallel, unemployment rose from 6.8 per cent in December 2014 to 11.5 per cent in December 2016.6 In 2013, mass demonstrations erupted. Even though demonstrators’ complaints were vague, their actions conveyed a general feeling of dissatisfaction. People seemed to perceive the social improvements during the period of economic growth as insufficient and expected no better in the future. Thus, popular support for the government of President Rousseff fell quickly.
2017 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy
de Souza
In response to the mass demonstrations, the government launched the ‘‘More Doctors Program,’’ staffed in part by Cuban doctors who worked with low-income inhabitants in poorly resourced peripheries of large cities or in rural regions far from urban centers. Mayors and community leaders in the areas that benefitted supported the program; but representative bodies of doctors, such as the Brazilian Medical Association and the Federal Council of Medicine, plus the urban middle class heavily criticized it. Doctors and the middle class who generally do not use the public health services accused then President Rousseff of populism.
Reduction of Federal Spending on Health in Favor of Austerity Measures Encouraged by these mobilizations, trade unions and community associations, led by the Catholic Church’s National Conference of Bishops of Brazil, collected more than two million voters’ signatures for a bill to establish a floor for federal spending on health care of 10 per cent of gross current revenue. This bill, delivered to the president of the National Congress on 5 August 2013, was opposed by the majority of Congressional representatives. Instead, the National Congress approved a Constitutional amendment on 15 March 2015 (number 86). It had the effect of reducing the level of federal funds spent on health. Two months earlier, on 19 January 2015, the National Congress had approved Law 13,097/2015 authorizing participation of foreign capital in health care. This provision favors the private health sector to the detriment of the public sector. In 2016, the combination of economic crisis and political exhaustion strengthened opposition to the government. Opposition leaders denounced President Rousseff accounting maneuvers as a sufficient basis for impeaching her, even though they knew that all previous governments had carried out these same schemes. These maneuvers were commonly tolerated in the past by both the judicial branch (the system of courts that interprets and applies the law), and the legislative branch (in charge of making laws and of overseeing the executive branch). Most of the deputies and senators who had supported the Rousseff government until December 2015, abandoned it. They removed the president from office on 12 April 2016. The vice-president, Michel Temer, assumed the presidency on this same day. He quickly
2017 Macmillan Publishers Ltd. 0197-5897
Journal of Public Health Policy
The right to health in Brazil
proposed a fiscal austerity program that was counter to the campaign promises that their political coalition — Rousseff’s Workers’ Party and Temer’s Party of the Brazilian Democratic Movement — had made before the 2014 presidential election. If the second Rousseff government (from January 2015 to April 2016) suffered from ambiguous and contradictory statements and policies, the post-impeachment Temer government is clear in its intentions and actions. The new president has made his central goal explicit: to ensure a surplus in public accounts so as not to compromise the public debt service that represented 45 per cent of the federal budget in 2016.7 To achieve this goal, the Temer government proposed — and the National Congress approved (on 15 December 2016) — a Constitutional amendment (number 95) establishing that the annual ceiling for the growth of government spending for the next 20 years will be equal to the inflation index of the previous year. That is, the government spending in 2018 will not be higher than the 2017 spending plus 4 per cent (estimated inflation index for 2017), in 2019 it will not be higher than the 2018 spending plus the inflation index for 2018, and so on. The federal Institute of Applied Economic Research (Ipea)8 estimated the impact of this amendment: in 2036, federal health spending will represent 1.2 per cent of GDP compared to 1.7 per cent in 2016 (assuming an average annual growth of 2 per cent of GDP). In per capita terms, spending will be fixed at US$ 156.00 for 20 years. Before amendment number 95, Congress had approved (8 September 2016) a bill called ‘‘Unbinding Union Revenues’’. It asserts that 30 per cent of the federal government’s revenues do not need to follow the constitutional rules that define minimal amounts to be allocated to ‘compulsory’ areas: education, health, social assistance, and social security. This same bill extended to the states and municipalities the option of disengaging part of their revenue from allocation from these mandatory destinations. Thus, the National Congress has not only reduced federal spending in social policies, but has also caused a broader effect: reduced spending by states and municipalities in these areas.
Known Effects of Austerity Measures Despite some controversy,9,10 most studies show that during economic crises, ‘austerity policies,’ such as those of the Temer government,
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generate job losses and increased unemployment11,12 that lead to impoverishment13,14 and an increase in inequalities — among others, for life expectancy, mental health, self-perceived health, and access to health care — between most and least affluent population groups.15–17 These effects of austerity compromise mental health.18–20 Studies show increased incidence of stress and alcohol abuse,21 increased rates of suicide,22–24 recrudescence of chronic diseases,25 as well as of infectious diseases in vulnerable populations,26,27 including children.28,29 The effects of the austerity policies were evident in the ‘Asian Tigers’. After a period of economic expansion there, a period of crisis followed in the 1990s. Some of these countries (including Indonesia and Thailand) adopted austerity measures with social spending cuts, especially in health. Increased child mortality and AIDS mortality followed. In Greece, too, the effects of the austerity measures were tragic: increased incidence rates of infectious diseases, such as malaria and AIDS, and increased suicide rates, among others.30 Thus, the evidence suggests that fiscal austerity, economic shock, and weak social protection interact to escalate health and social crises.31,32 In the words of Labonte´ and Stuckler,33 austerity is ‘‘an empirically and ethically unjustified policy’’ (p. 312). The World Health Organization (WHO)34 noted that ‘‘…there is widespread agreement that countercyclical public spending provides the means of reviving economies’’ and ‘‘it has positive impact on health’’ (p. 6). WHO recommends that governments adopt ‘‘pro-poor’’ and ‘‘pro-health’’ policies to deal with economic crisis.34
Health and Social Security for Lower Income Brazilians Under Attack A large part of Brazil’s population lives in a situation of social vulnerability; at least, 14 million families’ per capita incomes do not exceed US$ 57 per month. A health tragedy may occur if the government implements the newly approved austerity measures. By removing the financial support for social protection systems — even those protected by the Constitution — these measures will most likely contribute to increasing inequalities — health services accessibility, in incidence and prevalence of several diseases, and in mortality rates.
2017 Macmillan Publishers Ltd. 0197-5897
Journal of Public Health Policy
The right to health in Brazil
This change may compromise the quality of life for tens of millions of Brazilians in the population of 207 million. Talking to The Guardian (9 December 2016), the UN special rapporteur on extreme poverty and human rights, Philip Alston, decried the amendment 95 as an attack on the poor. ‘‘It is completely inappropriate to freeze only social expenditure and to tie the hands of all future governments for another two decades. If this amendment is adopted it will place Brazil in a socially retrogressive category all of its own.’’35 Not everyone may agree with my interpretation of this situation, but the facts seem to support it: the Temer administration has, from the start, disregarded Constitutional rights to health, education, social assistance, and social security. Temer maintains just one goal: leaving untouched the payment of public debt — debt that has never once been audited! Unlike other indebted countries, creditors in Brazil are not foreign banks, but native investors. In theory, local presence of the creditors could make it easier to reach a negotiated solution to pay the debt — or part of it — without harming the people. In 2014, the Presidential candidate who competed against President Dilma Rousseff had proposed just that fiscal austerity policy — and was defeated. Thus, President Temer began his term under a mantle of double illegitimacy: first based on the process of impeachment (without proof of crime of responsibility by President Rousseff), and second, by adopting an economic policy rejected by the voters. President Temer’s attack on the will of the voters (the policies favored by the voting majority in 2014) accompanies his disrespect for social rights. Approval of the Constitutional amendment (number 95) that freezes social spending now deepens the attack on democracy by violating the Constitution’s non-modifiable clauses, including the rights to health and education.36
President Temer’s ‘Double Illegitimacy’ and Threats to Democracy in Brazil How do those who currently hold the highest positions in the Republic expect to sustain their political power in light of the double illegitimacy? Will they try to block the general elections of 2018? Will Brazilians lose their political rights and democratic freedoms?
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The coalition now in power (as of this writing, June 2017) is not overcoming nor even damping the evolving political, economic, and social dimensions of the crisis. Indeed, judges have accepted allegations of corruption against coalition leaders. President Temer himself has been under police investigation, authorized by the Federal Supreme Court, since 18 May 2017, after a businessman’s confession involved him directly in acts of corruption. Signs of economic recession persist. Increases in unemployment, delay in payment of salaries for public servants in several states, emergence of yellow fever in urban populations, and strikes by many kinds of workers confirm continuation of the social crisis in Brazil today. It is not possible to predict all of the consequences.
About the Author Luis Eugenio Portela Fernandes de Souza, Ph.D. is a Professor of the Federal University of Bahia (Brazil) and member of the World Federation of Public Health Associations’ (WFPHA) Policy Committee.
References 1. Victora, C.G., Barreto, M.L., Leal, M.C., Monteiro, C.A., Schmidt, M.I., Paim, J., Bastos, F.I., Almeida, C., Bahia, L., Travassos, C., Reichenheim, M. and Barros, F.C. (2011) Health conditions and health-policy innovations in Brazil: The way forward. The Lancet, 377(9782), 2042–2053. Available in http://www.thelancet.com/journals/lancet/issue/vol377no9782/ PIIS0140-6736(11)X6024-5. 2. Paim, J., Travassos, C., Almeida, C., Bahia, L. and Macinko, J. (2011) The Brazilian health system: History, advances, and challenges. The Lancet, 377(9779): 1778–1797. Available in http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60054-8/fulltext. 3. Barrientos, A., Debowicz, D. and Woolard, I. (2015) Antipoverty Transfers and Inclusive Growth in Brazil (July 2014). IRIBA Working Paper: 04. Available in https://ssrn.com/ abstract=2496845 or http://dx.doi.org/10.2139/ssrn.2496845. 4. Ferreira, F., Firpo, S. and Messina, J. (2015) Explaining the decline in earnings inequality in Brazil: 1995–2012. Policy in focus: A publication of The International Policy Centre for Inclusive Growth United Nations Development Programme. Volume 12, Issue No. 3, 2015, pp. 40–43. Available in http://www.ipc-undp.org/pub/eng/PIF33_Is_there_a_Brazilian_model_ of_development.pdf. 5. World Bank. Data. Available in http://data.worldbank.org/indicator/NY.GDP.MKTP.KD. ZG?locations=BR. 6. World Bank. Data. Available in http://data.worldbank.org/indicator/SL.UEM.TOTL.ZS? locations=BR.
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7. Anderson, P. (2016) Crisis in Brazil. London Review of Book, 38(8). Available in http://www. lrb.co.uk/v38/n08/perry-anderson/crisis-in-brazil. 8. Vieira, F.S. (2016) Crise econoˆmica, austeridade fiscal e sau´de: que lic¸o˜es podem ser aprendidas? Brası´lia: Ipea (nota te´cnica no 26), agosto de 2016. http://www.ipea.gov.br/portal/ index.php?option=com_content&view=article&id=28422:nota-tecnica-2016-agosto-numero26-disoc-previdencia-rural-crise-economica-austeridade-fiscal-e-saude-que-licoes-podem-seraprendidas-&catid=192:disoc&directory=1. 9. Granados, J.A.T. (2014) La crisis y la salud en Espan˜a y en Europa: >Esta´ aumentando la mortalidad? Salud Colectiva, Buenos Aires, 10(1): 81–91, enero – abril. 10. Granados, J.A.T. and Rodriguez, J.M. (2015) Health, economic crisis, and austerity: A comparison of Greece, Finland and Iceland. Health Policy, 119(7), 941–953. 11. Stuckler, D., Basu, S., Suhrcke, M., Coutts, A. and McKee, M. (2009) The public health effect of economic crises and alternative policy responses in Europe: An empirical analysis. Lancet, 374, 315–323.. 12. Haw, C., Hawton, K., Gunnell, D. and Platt, S. (2015) Economic recession and suicidal behaviour: Possible mechanisms and ameliorating factors. International Journal of Social Psychiatry, 61(1), 73–81. 13. Ifanti, A.A., Argyriou, A.A., Kalofonou, F.H. and Kalofonos, H.P. (2013) Financial crises and austerity measures in Greece: Their impact on health promotion policies and public health care. Health Policy, 113, 8–12. 14. Mosquera, I., Gonzalez-Rabago, Y., Bacigalupe, A. and Suhrcke, M. (2016) The impact of fiscal policies on the socioeconomic determinants of health: A structured review. International Journal of Health Services, 1–18. doi:10.1177/0020731416681230. 15. Bacigalupe, A. and Escolar-Pujolar, A. (2014) The impact of economic crises on social inequalities in health: What do we know so far? Int J Equity Health, 13(52). 16. Maynou, L. and Saez, M. (2016) Economic crisis and health inequalities: Evidence from the European Union. International Journal for Equity in Health, 15:135. doi:10.1186/s12939016-0425-6, 2016. 17. Karanilolos, M. and Kentikelenis, A. (2016) Health inequalities after austerity in Greece. International Journal of Equity in Health, 15(83), 1–3. 18. Zivin, K., Paczkowski, M. and Galea, S. (2011) Economic downturns and population mental health: Research findings, gaps, challenges and priorities. Psychological Medicine, 41(7), 1343–1348. 19. Van-Hal, G. (2015) The true cost of the economic crisis on psychological well-being: A review. Psychology Research and Behavior Management, 8, 17–25. 20. Fiori, F., Rinesi, F., Spizzichino, D. and Di Giorgio, G. (2016) Employment insecurity and mental health during economic recession: An analysis of the young adult labor force in Italy. Social Science and Medicine, 153, 90–98. 21. Goeij, M.C., Suhrcke, M., Toffolutti, V., Van De Mheen, D., Schoenmakers, T.M. and Kunst, A.E. (2015) How economic crises affect alcohol consumption and alcohol-related health problems: A realist systematic review. Social Science and Medicine, 131, 131–146. 22. Uutela, A. (2010) Economic crisis and mental health. Current Opinion in Psychiatry, 23(2), 12730. 23. Simou, E. and Koutsogeorgou, E. (2014) Effects of the economic crisis on health and healthcare in Greece in the literature from 2009 to 2013: A systematic review. Health Policy, 115(2–3), 111–119. 24. Rachiotis, G., Stuckler, D., McKee, M. and Hadjichristodoulou, C. (2015) What has happened to suicides during the Greek economic crisis? Findings from an ecological study of suicides and their determinants (2003–2012). British Medical Journal Open, 5, e007295. doi:10.1136/bmjopen-2014-007295.
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25. Glonti, K., Gordeev, V.S., Goryakin, Y., Reeves, A., Stuckler, D., McKee, M., et al (2015) A systematic review on health resilience to economic crises. PLoS ONE, 10(4), e0123117. 26. Suhrcke, M., Stuckler, D., Suk, J.E., Desai, M., Senek, M., McKe, M., et al (2011) The impact of economic crises on communicable disease transmission and control: A systematic review of the evidence. PLoS ONE, 6(6), e20724. 27. O’Riordan, M. and Fitzpatrick, F. (2015) The impact of economic recession on infection prevention and control. Journal of Hospital Infection, 89, 340–345. 28. Christian, P. (2010) Impact of the economic crisis and increase in food prices on child mortality: Exploring nutritional pathways. Journal of Nutrition, 140(1), 177S–181S. 29. Rajmil, L., Siddiqi, A., Taylor-Robinson, D. and Spencer, N. (2015) Understanding the impact of the economic crisis on child health: The case of Spain. International Journal for Equity in Health, 14, 95. doi:10.1186/s12939-015-0236-1. 30. Stuckler, D. and Basu, S. (2014) A economia desumana. Porque mata a austeridade. Lisboa: Editorial Bizaˆncio. 31. Karanicolos, M., Mladovsky, P., Cylus, J., Thomson, S., Basu, S., Stuckler, D., et al (2013) Financial crisis, austerity, and health in Europe. Lancet, 381, 1323–1331. doi:10.1016/S01406736(13)60102-6. 32. Lopez-Valcarcel, B.G. and Barber, P. (2017) Economic crisis, austerity policies, health and fairness: Lessons learned in Spain. Applied Health Economics and Health Policy, 15, 13. doi:10.1007/s40258-016-0263-0. 33. Labonte´, R. and Stuckler, D. (2015) The rise of neoliberalism: How bad economics imperils health and what to do about it. Journal of Epidemiology and Community Health, 1–7. 34. World Health Organization (2009) The financial crisis and global health. Report of a highlevel consultation. Geneva, Switzerland — 19 January 2009. Available in http://www.who.int/ topics/financial_crisis/financialcrisis_report_200902.pdf. 35. The Guardian, 09 December 2016. Available in https://www.theguardian.com/world/2016/ dec/09/brazil-austerity-cuts-un-official. 36. Comparato, F.K, Torres, H.T., Pinto, E´.G. and Sarlet, I.W. (2016) Financiamento dos direitos a` sau´de e a` educac¸a˜o: mı´nimos inegocia´veis. Revista Consultor Jurı´dico, 27 de julho. Available in http://www.conjur.com.br/2016-jul-27/financiamento-direitos-saude-educacao-minimosinegociaveis.
2017 Macmillan Publishers Ltd. 0197-5897
Journal of Public Health Policy
The right to health in Brazil: A Constitutional guarantee threatened by fiscal austerity Luis Eugenio Portela Fernandes de Souzaa,b a
Instituto de Sau´de Coletiva, Federal University of Bahia, Rua Bası´lio da Gama, s/n, Campus Universita´rio do Canela, Salvador, Bahia 40.110-040, Brazil. b
Rua Marechal Andrea, 142 ap 701 Pituba, Salvador, Bahia 41.810-105, Brazil. E-mail: [email protected]
Abstract
After 25 years of expanding coverage and improving the quality of preventive public health measures and publicly financed medical care associated with positive outcomes for the health of Brazil’s population, our country suffers from deterioration of social policies. Among the areas of policy affected by new economic austerity measures is health — with potential to damage lives. These threats stem mainly from the 2016 approval of a Constitutional amendment that limits, for the next 20 years, public investments in health, education, social assistance, and social security. This viewpoint addresses how the changes have come about and the possible consequences. Journal of Public Health Policy (2017). doi:10.1057/s41271-017-0083-y Keywords: right to health; austerity; Brazil; public health
Introduction After 25 years of expanding coverage and improving the quality of government health services associated with positive outcomes for the health of Brazil’s population, our country suffers from deterioration of social policies. Among the affected areas of policy is health services — with potential to damage lives. These threats stem mainly from approval by the National Congress, on 15 December 2016, of a constitutional amendment that limits, for the next 20 years, public spending on health, education, social assistance, and social security. I discuss when and how the change came about and its possible consequences.
2017 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy
www.palgrave.com/journals
de Souza
Post-dictatorship Constitution: A Right to Health and Progressive Social Policies In the late 1980s, the idea of health as a human right gained momentum in the midst of struggle against the military dictatorship. In the Federal Constitution of 1988, that enshrines democratic freedoms, ‘‘Health is the right of all and the duty of the State, guaranteed through social and economic policies, aimed at reducing the risk of disease and injuries, and universal and equal access to the actions and services for their promotion, protection and recovery’’. To provide universal and equal access to health services, the Constitution created the Unified Health System (SUS) that sought to overcome previous fragmentation of care between preventive and curative actions. Before the 1988 Constitution, the Ministry of Health was responsible for the prevention programs and the Ministry of Social Security for medical services, or curative care. During the 1990s, a period dominated by the ideology of neoliberalism that was unfavorable for development of social policies, SUS expanded and contributed to improving the health of the Brazilians. Under SUS, Brazil increased vaccination coverage along with prenatal, childbirth, and postpartum care; established oral rehydration therapy in all over the country; implemented the Family Health Program and programs of emergency care and AIDS control; and supplied essential drugs free of charge. Brazil also strengthened its health surveillance system. These population health and health services initiatives have been decisive for controlling diseases susceptible to prevention by vaccines, for reducing infant mortality, and for increasing the population’s life expectancy.1 These achievements derive principally from two innovations in the Constitution of 1988: decentralization of health care management and social participation. Decentralization, by making municipal governments legally responsible for the implementation of health activities, stimulated introduction of new funds into the health system — from local treasuries. Social participation has been essential for guiding use of resources in accord with plans approved by the Health Councils in each town. Health Councils, comprising equal numbers of representatives of the public administration and from civil society, monitor implementation of the plans.2
2017 Macmillan Publishers Ltd. 0197-5897
Journal of Public Health Policy
The right to health in Brazil
Even under SUS, however, old problems have persisted or even worsened, and new ones arisen. Communicable diseases such as tuberculosis and malaria continue to have high prevalence rates. Diabetes and hypertension have increased in prevalence. New problems include dengue and, more recently, chikungunya and Zika infections. Violence has grown, including aggression with firearms. Most important, social and regional inequalities in the incidence and prevalence of all these health problems persist. This demonstrates Brazil’s need to strengthen social policies and the public health system including its health care services. Between 2004 and 2010, Brazil experienced a period of economic growth and income redistribution, with a real increase in the minimum wage and expansion of coverage of income transfer programs.3,4 SUS expanded primary care and emergency services, and created new programs including care for mental and oral health needs. While strengthening Brazil’s public health system, growth of the economy and incomes also caused the private health insurance market to grow. The latter benefitted segments of the population whose incomes increased sufficiently to purchase private policies to supplement SUS and, in particular, eased their access to specialized medical services.
Global Economic Crisis Affects Brazil: Social Upheaval Follows From 2011 forward, a global economic crisis strongly affected Brazil. Counter cyclical measures adopted during the Lula Presidency in 2009 and 2010 are no longer in effect and the economic policy initiatives taken by the subsequent government, led by Dilma Rousseff, have been ineffective in overcoming the crisis. The Gross Domestic Product (GDP), that grew an average of 4.5 per cent per year from 2004 through 2011, began to fall — declining by 3.8 per cent in 2015.5 In parallel, unemployment rose from 6.8 per cent in December 2014 to 11.5 per cent in December 2016.6 In 2013, mass demonstrations erupted. Even though demonstrators’ complaints were vague, their actions conveyed a general feeling of dissatisfaction. People seemed to perceive the social improvements during the period of economic growth as insufficient and expected no better in the future. Thus, popular support for the government of President Rousseff fell quickly.
2017 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy
de Souza
In response to the mass demonstrations, the government launched the ‘‘More Doctors Program,’’ staffed in part by Cuban doctors who worked with low-income inhabitants in poorly resourced peripheries of large cities or in rural regions far from urban centers. Mayors and community leaders in the areas that benefitted supported the program; but representative bodies of doctors, such as the Brazilian Medical Association and the Federal Council of Medicine, plus the urban middle class heavily criticized it. Doctors and the middle class who generally do not use the public health services accused then President Rousseff of populism.
Reduction of Federal Spending on Health in Favor of Austerity Measures Encouraged by these mobilizations, trade unions and community associations, led by the Catholic Church’s National Conference of Bishops of Brazil, collected more than two million voters’ signatures for a bill to establish a floor for federal spending on health care of 10 per cent of gross current revenue. This bill, delivered to the president of the National Congress on 5 August 2013, was opposed by the majority of Congressional representatives. Instead, the National Congress approved a Constitutional amendment on 15 March 2015 (number 86). It had the effect of reducing the level of federal funds spent on health. Two months earlier, on 19 January 2015, the National Congress had approved Law 13,097/2015 authorizing participation of foreign capital in health care. This provision favors the private health sector to the detriment of the public sector. In 2016, the combination of economic crisis and political exhaustion strengthened opposition to the government. Opposition leaders denounced President Rousseff accounting maneuvers as a sufficient basis for impeaching her, even though they knew that all previous governments had carried out these same schemes. These maneuvers were commonly tolerated in the past by both the judicial branch (the system of courts that interprets and applies the law), and the legislative branch (in charge of making laws and of overseeing the executive branch). Most of the deputies and senators who had supported the Rousseff government until December 2015, abandoned it. They removed the president from office on 12 April 2016. The vice-president, Michel Temer, assumed the presidency on this same day. He quickly
2017 Macmillan Publishers Ltd. 0197-5897
Journal of Public Health Policy
The right to health in Brazil
proposed a fiscal austerity program that was counter to the campaign promises that their political coalition — Rousseff’s Workers’ Party and Temer’s Party of the Brazilian Democratic Movement — had made before the 2014 presidential election. If the second Rousseff government (from January 2015 to April 2016) suffered from ambiguous and contradictory statements and policies, the post-impeachment Temer government is clear in its intentions and actions. The new president has made his central goal explicit: to ensure a surplus in public accounts so as not to compromise the public debt service that represented 45 per cent of the federal budget in 2016.7 To achieve this goal, the Temer government proposed — and the National Congress approved (on 15 December 2016) — a Constitutional amendment (number 95) establishing that the annual ceiling for the growth of government spending for the next 20 years will be equal to the inflation index of the previous year. That is, the government spending in 2018 will not be higher than the 2017 spending plus 4 per cent (estimated inflation index for 2017), in 2019 it will not be higher than the 2018 spending plus the inflation index for 2018, and so on. The federal Institute of Applied Economic Research (Ipea)8 estimated the impact of this amendment: in 2036, federal health spending will represent 1.2 per cent of GDP compared to 1.7 per cent in 2016 (assuming an average annual growth of 2 per cent of GDP). In per capita terms, spending will be fixed at US$ 156.00 for 20 years. Before amendment number 95, Congress had approved (8 September 2016) a bill called ‘‘Unbinding Union Revenues’’. It asserts that 30 per cent of the federal government’s revenues do not need to follow the constitutional rules that define minimal amounts to be allocated to ‘compulsory’ areas: education, health, social assistance, and social security. This same bill extended to the states and municipalities the option of disengaging part of their revenue from allocation from these mandatory destinations. Thus, the National Congress has not only reduced federal spending in social policies, but has also caused a broader effect: reduced spending by states and municipalities in these areas.
Known Effects of Austerity Measures Despite some controversy,9,10 most studies show that during economic crises, ‘austerity policies,’ such as those of the Temer government,
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generate job losses and increased unemployment11,12 that lead to impoverishment13,14 and an increase in inequalities — among others, for life expectancy, mental health, self-perceived health, and access to health care — between most and least affluent population groups.15–17 These effects of austerity compromise mental health.18–20 Studies show increased incidence of stress and alcohol abuse,21 increased rates of suicide,22–24 recrudescence of chronic diseases,25 as well as of infectious diseases in vulnerable populations,26,27 including children.28,29 The effects of the austerity policies were evident in the ‘Asian Tigers’. After a period of economic expansion there, a period of crisis followed in the 1990s. Some of these countries (including Indonesia and Thailand) adopted austerity measures with social spending cuts, especially in health. Increased child mortality and AIDS mortality followed. In Greece, too, the effects of the austerity measures were tragic: increased incidence rates of infectious diseases, such as malaria and AIDS, and increased suicide rates, among others.30 Thus, the evidence suggests that fiscal austerity, economic shock, and weak social protection interact to escalate health and social crises.31,32 In the words of Labonte´ and Stuckler,33 austerity is ‘‘an empirically and ethically unjustified policy’’ (p. 312). The World Health Organization (WHO)34 noted that ‘‘…there is widespread agreement that countercyclical public spending provides the means of reviving economies’’ and ‘‘it has positive impact on health’’ (p. 6). WHO recommends that governments adopt ‘‘pro-poor’’ and ‘‘pro-health’’ policies to deal with economic crisis.34
Health and Social Security for Lower Income Brazilians Under Attack A large part of Brazil’s population lives in a situation of social vulnerability; at least, 14 million families’ per capita incomes do not exceed US$ 57 per month. A health tragedy may occur if the government implements the newly approved austerity measures. By removing the financial support for social protection systems — even those protected by the Constitution — these measures will most likely contribute to increasing inequalities — health services accessibility, in incidence and prevalence of several diseases, and in mortality rates.
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The right to health in Brazil
This change may compromise the quality of life for tens of millions of Brazilians in the population of 207 million. Talking to The Guardian (9 December 2016), the UN special rapporteur on extreme poverty and human rights, Philip Alston, decried the amendment 95 as an attack on the poor. ‘‘It is completely inappropriate to freeze only social expenditure and to tie the hands of all future governments for another two decades. If this amendment is adopted it will place Brazil in a socially retrogressive category all of its own.’’35 Not everyone may agree with my interpretation of this situation, but the facts seem to support it: the Temer administration has, from the start, disregarded Constitutional rights to health, education, social assistance, and social security. Temer maintains just one goal: leaving untouched the payment of public debt — debt that has never once been audited! Unlike other indebted countries, creditors in Brazil are not foreign banks, but native investors. In theory, local presence of the creditors could make it easier to reach a negotiated solution to pay the debt — or part of it — without harming the people. In 2014, the Presidential candidate who competed against President Dilma Rousseff had proposed just that fiscal austerity policy — and was defeated. Thus, President Temer began his term under a mantle of double illegitimacy: first based on the process of impeachment (without proof of crime of responsibility by President Rousseff), and second, by adopting an economic policy rejected by the voters. President Temer’s attack on the will of the voters (the policies favored by the voting majority in 2014) accompanies his disrespect for social rights. Approval of the Constitutional amendment (number 95) that freezes social spending now deepens the attack on democracy by violating the Constitution’s non-modifiable clauses, including the rights to health and education.36
President Temer’s ‘Double Illegitimacy’ and Threats to Democracy in Brazil How do those who currently hold the highest positions in the Republic expect to sustain their political power in light of the double illegitimacy? Will they try to block the general elections of 2018? Will Brazilians lose their political rights and democratic freedoms?
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The coalition now in power (as of this writing, June 2017) is not overcoming nor even damping the evolving political, economic, and social dimensions of the crisis. Indeed, judges have accepted allegations of corruption against coalition leaders. President Temer himself has been under police investigation, authorized by the Federal Supreme Court, since 18 May 2017, after a businessman’s confession involved him directly in acts of corruption. Signs of economic recession persist. Increases in unemployment, delay in payment of salaries for public servants in several states, emergence of yellow fever in urban populations, and strikes by many kinds of workers confirm continuation of the social crisis in Brazil today. It is not possible to predict all of the consequences.
About the Author Luis Eugenio Portela Fernandes de Souza, Ph.D. is a Professor of the Federal University of Bahia (Brazil) and member of the World Federation of Public Health Associations’ (WFPHA) Policy Committee.
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