The Political Dimension of Health Systems Resilience: Brazil’s Health Sector Reform Movement and the Unified Health System

Abstract

The scientific production on health systems resilience reveals a major debate as to the concept, its dimensions and applications, as well as criticisms of, for example, the distance separating studies of the topic from those addressing Brazil’s health reform sector movement, the Movimento da Reforma Sanitária Brasileira (MRSB). This article aims to close that gap and also to bring political analysis to bear on a study of health systems resilience. It takes a qualitative approach, first offering a brief review of the literature on resilience, exploring its dimensions as regards health systems and Brazil’s national health system, the Sistema Único de Saúde (SUS), and then identifying the critical conjunctures in which the MRSB has operated, to form a case study of this movement’s political action as a precondition for a resilient SUS. The results point to various moments at which the presence, organisation and collective action of the MRSB were crucial to increasing the SUS’s resilience: the MRSB has been fundamental as a component in the construction and maintenance of the SUS, from its very conception, in resistance to attempts at dismantling the public system, through to its ability to learn and innovate.

Key words:
Health system resilience; Unified Health System; Brazil’s Health Sector Reform Movement

Resumo

A produção científica sobre resiliência em saúde revela grande debate em torno do seu conceito, dimensões e aplicações, além de críticas, como o distanciamento de estudos que tratam desse tema daqueles que se dedicam a analisar o Movimento da Reforma Sanitária Brasileira (MRSB). O objetivo deste artigo é aproximar os estudos que tratam da resiliência de sistemas de saúde daqueles que se dedicam a analisar o MRSB, tendo em vista, ainda, incorporar a análise política em um estudo de resiliência em saúde. Adota uma perspectiva qualitativa, tratando, inicialmente, de uma breve revisão da literatura sobre resiliência, do aprofundamento das suas dimensões nos sistemas de saúde e no Sistema Único de Saúde (SUS), e, em seguida, da identificação das conjunturas críticas de atuação do MRSB, conformando um estudo de caso da ação política desse movimento como condição de resiliência do SUS. Os resultados apontam diferentes momentos nos quais a presença, a organização e a ação coletiva do MRSB foram cruciais para aumentar as capacidades de resiliência do SUS, pois esse ator conformou-se como um componente fundamental na construção e na manutenção do SUS, desde sua formulação, passando pela resistência ao seu desmonte, até sua capacidade de aprendizagem e inovação.

Palavras-chave:
Resiliência de sistemas de saúde; Sistema Único de Saúde; Movimento da Reforma Sanitária Brasileira

Resumen

La producción científica sobre resiliencia en salud revela un gran debate en torno a su concepto, dimensiones y aplicaciones, así como críticas, como el distanciamiento de los estudios que abordan este tema de los dedicados a analizar el Movimiento de Reforma Sanitaria Brasileña (MRSB). El objetivo de este artículo es reunir los estudios que abordan la resiliencia de los sistemas de salud y los que se ocupan del análisis del MRSB, con vistas a incorporar el análisis político al estudio de la resiliencia en salud. Adopta una perspectiva cualitativa, revisando inicialmente la literatura sobre resiliencia, analizando sus dimensiones en los sistemas de salud y en el Sistema Único de Salud (SUS), y luego identificando las coyunturas críticas en el trabajo del MRSB, constituyendo un estudio de caso de la acción política de este movimiento como condición para la resiliencia del SUS. Los resultados apuntan a diferentes momentos en los que la presencia, organización y acción colectiva del MRSB fueron cruciales para aumentar las capacidades de resiliencia del SUS, ya que este actor se convirtió en un componente fundamental en la construcción y mantenimiento del SUS, desde su formulación hasta la resistencia a su desmantelamiento, hasta su capacidad de aprendizaje e innovación.

Palabras clave:
Resiliencia de los sistemas de salud; Sistema Único de Salud; Movimiento Brasileño de Reforma Sanitaria

Introduction

In the past ten years, a growing number of studies^1-6 have used the concept of resilience to examine how health care systems respond to political, social, public health, economic and humanitarian crises, natural disasters and epidemics, given that these crisis harm population health and the operation of health care services^1-6.

The concept of resilience is polysemous and has originated, and is applied, in different fields of knowledge. In relation to health systems, it first meant the ability to prepare for internal and external shocks, manage them and learn from them^2,3. More recent studies^1,3-6 have sought to identify and quantify the dimensions in which health systems are resilient, as well as drawing international comparisons² and applying the concept to Brazil’s Unified Health System, the Sistema Único de Saúde (SUS)^1,3-5.

Given the complexity of health systems, other studies^2,7 have endeavoured to approximate the concept of resilience to the dynamics of institutional development, to identify processes of political change², so as to avoid treating resilience basically as resistance and adaptation. A number of authors^1,3-7 have stressed the need to address the specifics of health systems in contexts with a high degree of underfunding and deficiencies in management and resources, leading them to consider resilience as a permanent component of health systems, such as the SUS⁷.

Jatobá and Carvalho⁷ argued that resilience should be understood as a permanent strategy for coping with crises, thus refining the preventive, absorptive and adaptive dimensions by formulating compound indices to express systems’ potential for resilient behaviour in view of their structural and functional features. In the same direction, Lobato⁴ signalled the need to bring analysis of conjuncture, intersectorality, underfunding and privatisation into the examination of resilience in the SUS.

Health systems’ responses^3-5 to the COVID-19 pandemic demonstrated that resilient health systems are essential not just to assuring the right to health, but also to maintaining social and economic activities. This underlines the importance of analysing resilience in view of the macro- and micro-political dimensions of the health sector⁵. Also, Massuda et al.⁶ stressed that theoretical models for examining health systems resilience have not addressed the political and ideological tenets of Brazil’s health sector reform (Reforma Sanitária Brasileira, RSB) as regards social determination in health, the healthcare work process and the importance of political participation by civil society as a strategy for advancing the struggle for the right to health, but rather that their application has been reduced to technical analysis, which can be considered a managerial concern, but disregards the political dimension.

Despite calls for the political dimension to be introduced into studies of health systems resilience, especially as regards the SUS, there is a distance between studies addressing this issue and those devoted to examining Brazil’s health sector reform or Health Sector Reform Movement (Movimento da Reforma Sanitária Brasileira, MRSB)^8-10.

This article seeks to understand the MRSB’s actions, from the inception of the RSB, as a fundamental component in strengthening the resilience of the SUS at critical moments in its construction and maintenance, when the MRSB supported resistance to efforts to dismantle the SUS, as well as strengthening its ability to learn and innovate and its responses to critical conjunctures⁷.

The article is organised into four sections besides this introduction. After a methodological note, the third section presents the results of the literature review, which discuss and evidence the grounds for the analysis of resilience by reference to the activities of social actors, with a view to associating the concept to the MRSB, given that the literature reviewed is directed primarily to institutional aspects. In order for the results to be more readily understood, they are presented in three subsections, the first dealing with the development, applications and limits of the concept of resilience, the second considering the relation between the MRSB and resilience in the SUS and the third examining the MRSB’s political action in strengthening the SUS’s resilience. The conclusions are given in the final remarks.

Methodological note

The qualitative approach taken in this study was based on a review of the literature featuring manifestations by the entities that represent the MRSB^8-10, the intention being to identify moments when an organised national initiative endeavoured to influence public policies by advocating for the principles guiding the SUS or for the conditions indispensable to putting those principles into practice. A conjuncture was identified as critical when the MRSB came out publicly in defence of the SUS by way of different instruments, in different political arenas and by building networks and coalitions with other political actors. The main entities representing the MRSB and voicing its positions have traditionally been the Brazilian Health Studies Centre (Centro Brasileiro de Estudos em Saúde, Cebes) and the Brazilian Collective Health Association (Associação Brasileira de Saúde Coletiva, Abrasco) and, more recently, the alliance between these entities and a broader network of other actors known as the Front for Life (Frente pela Vida, FpV).

As this is a qualitative study based on the existing literature and is restricted to the activities of the MRSB, disregarding other actors involved in the health policy arena, the findings cannot be generalised, even though they do point to the possibility of including the political dimension.

Results and discussion

Development, applications and limits of the concept of resilience

Resilience has been approached in different ways, demonstrating its polysemy and plasticity^11,12: some identify it with the notion of resistance, others with sustainability and development. The concept of resilience has been widely incorporated into the health field, given the challenges faced by health systems in the twenty-first century, including intense migratory flows, the Ebola and Zika epidemics, natural disasters and the COVID-19 pandemic, which posed the need for studies to gauge the resilience of health systems and services^13,14.

Since 2014, the international agencies have joined this debate, concentrating their proposals on specifying the dimensions of health systems resilience, with a view to drawing comparisons and making recommendations^13-18.

Studies produced since the COVID-19 pandemic have signalled the need for analysis of resilience to include characteristics of the health system’s context, the relevant power relations and networks of actors¹⁹ and also the “interdependencies among the complex and adaptive subsystems that make up the health system (ranging from community participants up to local, regional or national public health and secondary care organisations)”¹¹ (p.16). Paschoalotto et al.¹⁴ also noted the need for broader studies of health systems resilience in middle-income countries, such as Brazil, where systems are highly fragmented in both public and private sectors. Massuda et al.⁶ pointed to the need to adapt analytical models of health systems resilience to the complex context of Brazil’s health care system. It should be added that studies analysing resilience can offer important input on the ability of the SUS to respond to public health emergencies, which can also serve to improve Brazil’s health care system.

Meyer et al.¹⁸ proposed assessment of a list of specific capacities, competences and processes that health systems need in order to assure their resilience in response to infectious diseases, outbreaks and natural hazards. Witter et al.¹⁷ drew attention to a possibly mistaken use of resilience as the transfer of responsibility to other actors with less response capability, ignoring power dynamics and historical and cultural precedents underpinning the health system’s modus operandi. Lobato⁴, corroborating that line of argument - and contrary to the hegemonic, neoliberal view based on downsizing the State, restricting public funding and privatising health care - highlighted the State’s role in designing, implementing and maintaining resilient social and health policy systems. As summarised by Witter et al.¹⁷, therefore, the concept of resilience has to comprise the manner in which power shapes all health systems and seek answers to how, why, when and for whom the capacity for resilience is developed and supported.

In Brazil, the study of resilience in health care is still in its early days⁴ and resilience as regards the SUS has been little examined¹⁹, although some studies should be mentioned. Massuda et al.⁶, drawing on analytical categories proposed by the World Health Organisation (WHO), examined the SUS’s resilience in response to COVID-19. They pointed to austerity policies as factors that weakened the health system’s response to the pandemic, adding to the chronic problems of the SUS and the conjuncture marred by the disastrous role of the government and its Ministry of Health. Bigoni et al.²⁰ discussed the functionality and resilience of the SUS to the pandemic’s impact on provision of non-COVID-19 health care. That study pointed to continued underfunding and the discontinuance of collaborative management of the SUS as causing the breakdown in the system’s functionality and weakening its historical resilience in responding to new pandemics.

Paschoalotto et al.¹, exploring components of a resilience-related research agenda for the SUS, proposed a model for analysing resilience adapted to the characteristics of the Brazilian health system. Lobato⁴, meanwhile, warned that it is important to understand the theoretical conceptions guiding approaches to analysis of systems resilience in order to permit advances in the dimensions mentioned above and incorporate other indicators beyond those already developed hegemonically by the international agencies. She also stressed that analysis of resilient health systems should consider the importance of the State’s role, the conception of health policy and funding for the health field, because proposals for resilient health systems in Latin America and Brazil should proceed in the opposite direction to the neoliberal approach based on restricting public funding and privatising health care⁴.

A more recent study by Paschoalotto et al.¹⁴, drawing on a comprehensive literature review combined with expert interviews, surveyed current knowledge on the concept, the phases in its different uses, its analytical framing and mechanisms for implementing resilience in health systems after the initial impact of the COVID-19 pandemic, to propose a new framework for analysing the dimensions of health systems resilience. They presented a systems-based approach in which technology and information systems connect decision makers with all dimensions of a health systems resilience (governance, leadership and regulation; funding; human resources; physical resources; medicines; and service provision). In that model, regulation gains greater emphasis in governance, while leadership, communication and social participation figure on a fourth level, connecting all the other dimensions with the context.

The concept of health system resilience can thus be seen to have evolved, from what was proposed initially, towards analysis of a system’s capacity to absorb shocks and maintain its functions and identity. The process of analysis of resilience should thus contemplate management, planning, evaluation and learning, and include analysis of the role of the actors, the population and institutions that act in health systems. Accordingly, it has to understand the agents internal and external to the system, considering crisis management as a set of measures that entail absorbing shocks, adapting and transforming health systems and population health, in the context of the realities framing them and the different types of shock, such as epidemics, pandemics, natural disasters and so on¹⁴.

Jatobá and Carvalho³ note also that the concept of resilience in health, when applied to the collective health field, yields a broader theoretical perspective on the understanding of political, social and cultural factors that strengthen institutional relations in public health systems. Resilience, in that form, is a field of studies and interventions to be understood in systemic and plastic terms. Moreover, health systems can be analysed in objective and subjective terms, to consider political, social, historical, cultural and psychosocial dynamics¹⁷.

The concept of health system resilience thus faces an important challenge: to develop broad strategies for organising health systems and services that dialogue with the social sciences, the health sciences, technology development and innovation, spanning production in the field of science and the social practices of movements and actors operating in the health field¹⁷.

In view of the revelations of this brief literature review, the health systems resilience debate can be seen to be growing strongly, stimulated - among other things - by the new issues raised by the COVID-19 pandemic and by new studies being conducted around the world. There is still a long way to go, considering the insufficiency of research on the subject in middle- and low-income countries, for instance those in Latin America, whose specific characteristics must be examined given their impacts on resilience in health care. The resilience of the SUS has to be examined in that context, whose specific characteristics challenge the proposed theoretical models described above.

When examining the relationship between the MRSB and the resilience of the SUS, the first thing one notices is that many of the authors who propose a broader range of dimensions to be considered by analysis of health systems resilience ultimately emphasise the importance of studying that relationship, in that they highlight the importance of the actions of the leading political actors, the ideology and the set of values that structure health system guidelines and operationalisation, as well as the economic interests involved in the dynamics behind the structuring of health services.

What is striking, however, is that these important recommendations have not given rise to a consistent set of studies advancing analysis of these dimensions of resilience as applied to the SUS, focusing especially on the issue of power as a determinant variable in health systems resilience. In that respect, resilience results both from institutional capabilities, which take material form in the correlation of specific forces²¹, and from the practices and devices activated by agents in producing the web of power relations²².

The MRSB and the resilience of the SUS

The lack of studies of resilience as applied to social movements like the MRSB finds a possible response in the study by Olsson et al.²³, which asks why the concept of resilience is not widely used in the social sciences, as it is in other fields of knowledge. The explanation given is that the concept entails a notion of systems equilibrium and stability giving the ability to absorb, persist and maintain their parameters in response to stress or an external shock. That conception of closed systems that self-regulate in order to maintain the stable functioning of their internal components draws on the sociology of Parsons, which has been superseded in the social sciences because of its ideological content that regards deviations as dysfunctions to be corrected in order to restore stability and normality. Meanwhile, the theory of complex adaptive systems advanced by Luhman assumes that systems renew and reorganise by way of memory, creativity and innovation, as explained by Vidal²⁴. Accordingly, bridging the gap between the resilience approach and studies of complex systems must begin with the conception of an open system, whose recovery from a shock or stress entails multiple interactions among its components operating on different scales and in key subsystems.

Olsson et al.²³ noted that the concept of resilience has been thought of, more recently, as including a dimension of ambiguity, encompassing both change and resistance to change, and discussed the strong normative content which sees resilience as positive, especially as the ability to resist change.

Neo-institutionalist analysis of attempts to reverse the Welfare State has often applied a political approach to resilience, deploying the concepts of path dependence and critical conjuncture²⁵. While path dependence highlights the factors that assure institutional stability, critical conjuncture entails widening the range of possibilities for change and increasing the autonomy of the actors involved. Critical conjunctures result from political and economic crises that alter the correlation of forces, allowing new actors to emerge or even expanding the autonomy of established actors, enabling them to formulate new political and institutional alternatives as the constraints imposed by the institutional trajectory are relaxed.

Sjöstedt² argued that an institutional trajectory does not describe a stable system, but rather a process in which each step taken in a given direction increases the cost of turning back. He concludes by asserting that neo-institutional theory has a great deal to contribute to expanding the concept of resilience, providing that the dynamics of institutional change are taken seriously and any assumptions about institutions as static and linear are put aside, in order to understand institutional arrangements as mechanisms for self-reinforcement that shape institutional and social constraints. Attention should thus be given to the external shocks embedded in the concepts of both resilience and critical conjunctures and to the endogenous mechanisms that are also sources of change.

In order to understand the MRSB’s political action in relation to resilience in the SUS, it has to be borne in mind that, unlike other reforms that led to the creation of national health systems originating in projects nurtured by national and international bureaucracies, the SUS was constructed by the social forces that fought for democracy, which set in motion various processes of change in the legal, political, institutional, organisational and operational dimensions of the health system. The MRSB was thus one of the leading social actors in the process of mobilisation that resulted in the recognition, in the 1988 Federal Constitution, of health as a citizen’s right and the State’s duty and in the creation of the SUS, which was institutionalised with the passing of Laws No. 8,080/1990 and 8,142/1990.

The MRSB proposals that guided the creation of the SUS were grounded in an expanded conception of health as, more than the “absence of disease”, the “physical, mental and social wellbeing” that stems from healthy conditions of life, that is, proper access to food, housing, education, transport, leisure, security and health services, as well as the work, employment and income compatible with meeting those needs. Given that these conditions cannot be fulfilled by individual efforts alone, the MRSB argued that health is the inalienable right of all and any citizen and should be guaranteed by the State by means of economic and social policies to improve the quality of life of individuals and groups, which should include a health policy that guarantees universal, equitable access to measures and services to prevent diseases and promote and restore health.

The end-purpose principles of the SUS, those that express the very nature of the system, are universality, equality and comprehensiveness in health care. Meanwhile, organisationally, the SUS was conceived on the basis of the dimensions of participation and decentralisation, leading to the creation of an institutional architecture with various different arenas: bi- and tripartite commissions for negotiation and concertation among units of the federation health councils and health conferences and for participation and formation of political will^26,27.

In that light, construction of the SUS is understood here to seek to alter the correlation of forces by introducing political actors representing subnational levels and civil society into its decision-making and social oversight processes, with a view to maximising the necessary conditions sustaining the SUS proposal, as well as the system’s ability to withstand and innovate in critical situations.

The critical conjuncture in which the SUS was instituted and developed featured permanent issues of two orders that threatened the project and its implementation: 1) the proposal for a universal system in which the right to health for all citizens and residents was to be assured by the State, giving material form to the constitutional principle of equality, was to be confronted by one of the most unequal countries in the world; and 2) the introduction of a universal health system in an economic conjuncture dominated by austerity policies, with restrictions on public spending, would entail the problem of underfunding permanently threatening institutionalisation and endeavours to expand State capabilities in the health sector.

Although alternating between periods of greater or lesser social mobilisation, the MRSB has always presented specific proposals regarding the various problems identified in components of the SUS, with a view to influencing public health policy²⁸. Among the various issues, the MRSB has often positioned itself in favour of the following: the expansion of public health spending, to guarantee more funds and stable funding flows; improvement and institutionalisation of management, with responsibility shared among the three levels of management and bottom-up, participatory planning, to make regional, comprehensive health care systems politically and technically possible; expansion of infrastructure in the physical, personnel and material network, with appropriate installations, careers of State for health care professionals and establishment of the Health Economic and Industrial Complex; organisation of regionalised comprehensive care networks with service provision coordinated by a universal, quality, Primary Health Care function; stronger direct social participation by civil society entities and movements; and restoration of the awareness of citizens’ social rights^28-36.

Political action by the MRSB in strengthening the resilience of the SUS

The promulgation of the Federal Constitution stands as a critical conjuncture represented by the transition to democracy, in which the correlation of forces shifted in favour of opposition groups and the set of democratic movements. However, the SUS entered the Constitution as a result of a process of organisation by the MRSB which managed to define a common project and organise support for it in the National Constituent Assembly. The fact that the system itself was written into the Constitution increased its ability to withstand efforts for it to be replaced by the focalised programmes advocated by international agencies in the 1990s, given the high political costs of changing the Constitution.

Nonetheless, the fact remains that the health sector is framed by two organic laws - No. 8,080/1990 and No. 8,142/1990 - as a result of President Collor’s vetoes of the articles providing for participation and decentralisation, which were not restored until after his impeachment. The MRSB raised the rallying cry of “Dare to Obey the Law” in defence of the decentralised, participatory system stipulated in the Constitution.

Institutionalisation of the SUS through a process of decentralisation altered the composition of the MRSB, whose base ceased to be predominantly intellectuals and professional people connected with academia, to find its anchor in the growing political role of managers in defence of the SUS, with municipal managers represented politically by the national council of municipal health secretaries (Conselho Nacional de Secretarias Municipais de Saúde, Conasems) and state managers, by the national council of health secretaries (Conselho Nacional de Secretários de Saúde, Conass), especially in periods when social movements fell to their lowest ebb^8,9. There was also an intense process of migration of academic personnel to the national, state and municipal managerial functions and, from these, to academia.

From the outset, the MRSB opted for a combined strategy of occupying spaces in the State apparatus and strengthening representative civil society organisations^8,9. On the one hand, this strategy imposed constraints on those who occupied positions in government, but, on the other, increasing the capabilities and resources that could come to strengthen civil society organisations. One of the main characteristics of the MRSB is that it has maintained this dual political approach, with institutional constraints on the one hand and civil society organisation on the other, which did not assure autonomy, but did afford greater complexity and the possibility of creating alternatives.

The MRSB’s contribution to the resilience of the SUS in each of these conjunctures will be evidenced below and systematised into five major periods¹⁰: 1) institution and implementation of the SUS under neoliberal hegemony (1989-2002 - the governments of Fernando Collor, Itamar Franco and Fernando Henrique Cardoso I and II); 2) continuing macroeconomic adjustment policies and strengthening of the rationalisation project (2003-2010 - Lula I and II governments); 3) Dilma government, political crisis and impeachment of the president (2011-2016); 4) health sector counter-reform and dismantling of social and health policies by the Michel Temer government and extended after the election of Jair Bolsonaro (2016-2019); and lastly 5) the COVID-19 pandemic and reconstruction of Brazil (2020-2023).

The period from 1989 to 2002 corresponds to the governments of Collor, Itamar and FHC, made up of actors connected with the political forces and parties opposed to the RSB project. Ironically then, the SUS was instituted and implemented by political groups opposed to it⁸. The political action taken to maintain the Organic Health Sector Law intact has already been mentioned above; however, it is worth noting that the movement was also strong enough to thwart the focalisation project promoted by the international agencies during the FHC government, which was designed to substitute PHC for the proposed universal health system. On the contrary, PHC was to become an important component of focalisation, but now as part of the SUS (Chart 1).

Chart 1
Examples of political action by the MRSB in the period from 1989 to 2023^{8,9,26,27,32,33,35}.

1. 1989 to 2002 ► Participation by leaders and subjects that formed the base of the movement, in political and institutional processes to reform the public health system (management of programmes, projects and services considered consistent with the principles and guidelines of the RSB, as well as the loci of social oversight of the SUS); ► Documents produced: ● For the 4th Brazilian Collective Health Congress, analysed social issues and public policies, the Health Sector Reform and the SUS, underfunding for health care and criticised pay-for-performance, non-decentralisation and the “parallel healthcare system”; - Presented 10 proposals, most prominently in defence of generic drugs and the adoption of a National Human Resources Policy; ● For the 10th National Health Conference (Conferência Nacional de Saúde, CNS), with positions and proposals or advancing the Health Sector Reform project and implementation of the SUS, as well as criticisms of the macro economic adjustment policies and downsizing of the State; ● For the 11th CNS, pointing out the need to renew and update commitments to the Health Sector Reform with a view to universalisation and equity; ● For the 2002 presidential elections: the document updated the proposals of the previous document and endeavoured to identify difficulties in operationalising the guidelines of the SUS and returning to the principles of the Health Sector Reform.

2. 2003 to 2010 ► Occupation of spaces in government institutions by political and social forces aligned with the public health movement; ► Documents produced: ● Document with 20 items reiterating the one issued in 2002, advocating the “radical implementation of the Health Sector Reform, with a view to real and substantial improvement in the conditions of health of Brazil’s population”. ● Letter of Brasília, produced at the 8th Symposium on National Health Policy: - Criticised the low levels of health and social and regional inequalities, mounting commitment of the public budget to debt service payments, underfunding of the SUS, concentration of wealth and the “poor SUS for the poor”; - Advocated a policy of “socioeconomic development”, regulation of constitutional amendment No. EC-29 and a review of the subsidies and tax exemptions given to (private) supplementary health care; ● Contributed to the discussions of the 2006 elections: seeking commitments from candidates for president, state governors, senators and congressmen to the principles and proposals of the RSB and the SUS; ► Plenaries and discussions on the directions of the Health Sector Reform.

3. 2011 to 2016 ► Public hearings to discuss health funding; ► Manifesto published in favour of the Universal Right to Health; ► Questions to Congress in favour of Complementary Bill No. 123/2013 and immediate approval for allocation to the SUS of 10% of the Union’s current gross revenues; ► Position on the federal government’s exemptions policy (uncoupling of revenues of states and the Union) and its impacts on social security, health care and social assistance.

4. 2016 to 2019 ► Critique of the then Minister of Health’s position in opposition to the SUS, also noting that “Ricardo Barros is a menace to the right to health and to the SUS” and once again calling for “a different President of the Republic, by direct elections, and for a different policy for Brazil”; ► Positions contrary to: ● Reformulation of the National Primary Health Care Policy; ● The labour reform; ● Reform of Regulatory Workplace Safety Standards; ► Positions in favour of: ● The Psychiatric Reform and a decent, contemporary, mental health policy; ● Democracy and Health, the SUS and suspension of Decree No. 9,759/2019, which extinguished numerous collegiate bodies of the federal public administration; ● A stronger National Tobacco Control Policy and against reduction of taxes on tobacco products; ● Primary Health Care and the universal right to health; ● Repeal of Ministry of Health Order No. 2,979/19, which instituted the Previne Brasil programme and altered expense funding for PHC in Brazil; ► Legal action by supporting direct unconstitutionality proceedings filed against Constitutional Amendment No. 95/2016 and advocating for the decriminalisation of abortion up to the 12th week and against tax exemption for agricultural herbicides and pesticides.

5. 2020 to 2023 ► Position in favour of universal vaccination, implementation of appropriate public health measures to contain the pandemic and basic income for the most socially vulnerable population groups; ► Organised the Free, Democratic and Popular National Health Conference, designed to contribute to constructing an agenda of health policy guidelines for Brazil; ► Expressed support for the Lula-Alckmin platform, which was associated with the defence of democracy and maintenance of social protection and social wellbeing policies and, following their victory, participated in the Presidential Transitional Staff.

• Source: Authors.

The second period began when Lula assumed the federal Executive, in 2003, dividing impressions in the public health movement. Despite some health policy gains, including the expansion of primary care through the Family Health Programme and the Family Health Strategy, implementation of pre-hospital care, intervention in critical areas of care (mental health, oral health, drug care) and in social participation²⁶, the macroeconomic adjustment policies continued along the same lines as in the FHC governments³⁰, limiting the health policies inspired in the RSB project (Chart 1).

Between 2005 and 2008, the public health movement, now organised as the Brazilian public health reform forum (Fórum da Reforma Sanitária Brasileira, FRSB), took a position critical of the government, acting autonomously and organically in the civil society sphere, without abdicating from the necessary interrelationships with loci of State power⁷. That autonomy, in many cases, was also encouraged by members of the MRSB who occupied functions in the government and saw the actions of civil society as a means of strengthening their own positions. In December 2010, the forum presented a Strategic Agenda for Health in Brazil (Agenda Estratégica para a Saúde no Brazil)³², proposing health policy guidelines for the period from 2011 to 2014, which was delivered to the then president-elect, Dilma Rousseff. That document specified priority dimensions for intervention and indicated strategies for action by the Executive, so as to mark out health policy programmes, objectives and targets, and also signalling the difficulties facing the functioning and organisation of the SUS. Importantly, the second Lula government (2007-2010) faced the world crisis of 2008 and its consequences, such as the emphasis on neoliberal policies and financialisation of the economy, together with amplification of criticisms and actions against universal policies and the Welfare State³¹ (Chart 1).

The third period, from 2011 to 2016, saw the MRSB’s activities intensify in various different arenas to favour the SUS and the constitutional right to health in the deteriorating correlation of political forces and worsening attacks on the system, as described below. The movement positioned itself in several documents criticising the Federal government’s inadequate response to the wave of demonstrations in June 2013 and questioned the allocation of public funds to public debt service payments and non-structural compensatory policies, as well as the regressive system of taxation that overburdened the poorest in favour of discounts afforded by tax waivers in healthcare, education and incentives for purchases of automotive vehicles and household appliances³². The public health movement’s agenda also called for adequate and stable funding for health care, including various measures (Chart 1). Attuned to campaign discussions leading up to the 2014 elections for the Presidency of the Republic and the National Congress in, the MRSB issued the “Brazilian Health Studies Centre Manifesto in defence of the Universal Right to Health - Health is a right, not a business”³³, criticising the WHO’s Universal Health Coverage proposal and the private market’s disputing health care with the SUS. That document provided data illustrating the various manners in which components of Brazil’s private sector benefited from the SUS, as well as analysing the chronic underfunding of the SUS and its main determinants. These culminated in the systematic formulation of an “agenda of struggles in defence of the universal rights to health and against the transformation of population health into no more than a profitable business for the private sector”³³ (p.24).

The entities of the FRSB also denounced the fact that the successive shocks the SUS was suffering included the “reiteration and constitutionalisation of underfunding for it, as in constitutional amendment EC 86, of 2015” and Law No. 13,019/2014, which opened up health care to foreign capital. As noted by the MRSB, these measures showed “that an attempt was underway to subvert the constitutional project for health care”³² (p.1). The public health movement also “vehemently repudiated the parliamentary coup that raised Vice President Michel Temer to the presidency”³² (Chart 1).

From 2016 2019, a period comprising the Temer government and the first year of Bolsonaro as president, was characterised by a conjuncture marred by increasingly severe fiscal austerity measures, counter-reforms and political crisis. In that scenario, the public health movement positioned itself on a variety of issues. In response to the mounting reversals of social rights, as evidenced by the measures cited above, the entities of the MRSB continued active in response to a number of events in the conjuncture of 2019 (Chart 1).

The MRSB’s activities during the period from 2020 to 2023 included a number of measures taken both in isolation by its constituent entities and jointly with the other collective subjects working together in the Front for Life (FpV) - an alliance of the widest possible diversity of individual and collective political subjects in the health field and in the broadest possible social space, all led by collective health organisations - in response to the federal government’s negationism and omission in addressing the pandemic^28,29,34,35 (Chart 1).

In 2020, the FpV made a priority of contributing technically, scientifically and politically to proposing avenues to meeting the major challenges in the health policy field in Brazil, in the context of the COVID-19 pandemic. Prominent among the documents produced in this period³⁴, the Plan to Combat COVID-19²⁹, acknowledged to be the most complete document published recently by the entities of the MRSB, was motivated by the Federal government’s omissions in conducting the response to the pandemic²⁸. That plan set out a broad range of proposals for Brazil and its health system, distributed over more than 100 pages, including analyses and proposals relating to all the dimensions of resilience identified above by Paschoalotto et al.¹⁴ and, from a broader perspective, to the construction of a future with sustainability and social justice.

Over the year of 2021, the FpV intensified its denunciations of the federal Executive’s omissions and negationist and anti-scientific actions, as well as working more closely in coordination with the Legislative and Judiciary (Chart 1). From 2022 onwards, the FpV made a priority of broadening social participation in, and political influence on, the electoral process (Chart 1).

Conclusions

Faced with the obstacles and challenges to the endeavour to establish the SUS described here, the MRSB has continued active since its inception through to the most recent challenge, the COVID-19 pandemic health crisis, in which the SUS was decisive in saving the lives of thousands of Brazilians³⁶. The MRSB can thus be considered to have acted, and to continue to act, along the path considered fundamental to establishing the SUS (and thus its resilience), which is wide-ranging grassroots mobilisation, involving the widest diversity of civil society sectors working in favour of citizens’ rights and opposing the commodification of health²⁶. Nonetheless, one has to bear in mind the limits of the effect of the MRSB, given that the issue of private sector participation in healthcare, involving the internationalisation of supplementary healthcare and private sector participation in health service provision and management, is not a consensual political position and thus able to influence health policy.

The activities of the MRSB can serve as a prime case-example illustrating the possibilities for incorporating the political dimension into the present framework of analysis and discussions of the concept of resilience.

References

• ¹ Paschoalotto MAC, Lazzari EA, Castro MC, Rocha R, Massuda A. A resiliência de sistemas de saúde: apontamentos para uma agenda de pesquisa para o SUS. Saude Debate 2022; 46(n. esp. 8):156-170.
• ² Sjöstedt M. Resilience revisited: taking institutional theory seriously. Ecol Soc 2015; 20(4):23.
• ³ Jatobá A, Carvalho PVR. Resiliência em saúde pública: preceitos, conceitos, desafios e perspectivas. Saude Debate 2022; 46(8):130-139.
• ⁴ Lobato LVC. Resiliência de Sistemas de Saúde. Cad Saude Publica 2022; 38(10):e00176622.
• ⁵ Massuda A, Malik AM, Vecina Neto G, Tasca R, Ferreira Junior WC. A resiliência do Sistema Único de Saúde frente à COVID-19. Cad EBAPEBR 2021; 19(n. esp.):735-744.
• ⁶ Massuda A, Bigoni A, Paschoalotto MA, Tasca R. Rumos para um sistema de saúde resiliente. GV Exec 2022; 21(n. esp. 2):22-29.
• ⁷ Jatobá A, Carvalho PVR. Resiliência do Sistema Único de Saúde não está (somente) nas respostas dos desastres. Rev Saude Publica 2024; 58:22.
• ⁸ Paim JS. Reforma Sanitária Brasileira: contribuição para a compreensão e crítica. Salvador, Rio de Janeiro: EDUFBA/FIOCRUZ; 2008.
• ⁹ Fleury S, organizadora. Teoria da reforma sanitária: diálogos críticos. Rio de Janeiro: Editora Fiocruz; 2018.
• ¹⁰ Santos JS. Movimento da Reforma Sanitária Brasileira na conjuntura 2013-2020: resistência e revitalização [tese]. Salvador: Instituto de Saúde Coletiva, Universidade Federal da Bahia; 2023.
• ¹¹ Copeland S, Hinrichs-Krapels S, Fecondo F, Santizo ER, Bal R, Comes T. A resilience view on health system resilience: a scoping review of empirical studies and reviews. BMC Health Serv Res 2023; 23(1):1297.
• ¹² Brand FS, Jax K. Focusing the meaning(s) of resilience: resilience as a descriptive concept and a boundary object. Ecol Soc 2007; 12(1):23.
• ¹³ Fitzgerald J. Recomendaciones para el desarrolho de sistema de salud resilientes en las Americas. Rev Pan Salud Publica 2023; 47:e101.
• ¹⁴ Paschoalotto MAC, Lazzari EA, Rocha R, Massuda A, Castro MC. Health systems resilience: is it time to revisit resilience after COVID-19? Soc Sci Med 2023; 320:115716.
• ¹⁵ Barker KM, Ling EJ, Fallah M, Vandeboget B, Kodl Y, Macauley RJ, Viswanath K, Kruk ME. Community engagement for health system resilience: evidence from Liberia's Ebola epidemic. Health Policy Plan 2020; 35(4):416-423.
• ¹⁶ Fleury S, Faria M, Durán J, Sandoval H, Yanes P, Penchaszadeh V, Abramovich V. Right to health in Latin America: beyond universalization. Santiago: United Nations; 2013.
• ¹⁷ Witter S, Thomas S, Topp SM, Barasa E, Chopra M, Cobos D, Blanchet K, Teddy G, Atun R, Ager A. Health system resilience: a critical review and reconceptualisation. Lancet Glob Health 2023; 11(9):e1454-e1458.
• ¹⁸ Meyer D, Bishai D, Ravi SJ, Rashid H, Mahmood SS, Toner E, Nuzzo JB. A checklist to improve health system resilience to infectious disease outbreaks and natural hazards. BMJ Glob Health 2020; 5(8):e002429.
• ¹⁹ Bispo Júnior, JP. Resiliência do Sistema Único de Saúde no contexto da pandemia de COVID-19: como se fortalecer? Cad Saude Publica 2022; 38(10):e00097522.
• ²⁰ Bigoni A, Malik AM, Tasca R, Carrera MBM, Schiesari LMC, Gambardella DD, Massuda A. Brazil's health system functionality amidst of the COVID-19 pandemic: An analysis of resilience. Lancet Reg Health Am 2022; 10:100222.
• ²¹ Poulantzas N. O Estado, o poder, o socialismo. Rio de Janeiro: Editora Graal; 1980.
• ²² Foucault M. Microfísica do poder. Rio de Janeiro: Editora Graal; 1979.
• ²³ Olsson L, Jerneck A, Thoren H, Persson J, O'Byrne D. Why resilience is unappealing to social science: Theoretical and empirical investigations of the scientific use of resilience. Sci Adv 2015; 1(4):e1400217.
• ²⁴ Vidal JP. Social movements and resilience: complementary or asymmetryc notions. G&DR 2018; 14(3):124-146.
• ²⁵ Pierson P. The New Politics of the Welfare State. Oxford: Oxford University Press; 2009.
• ²⁶ Teixeira CF, Santos JS, Souza LEPF, Paim JS. Sistema Único de Saúde (SUS): a difícil construção de um sistema universal na sociedade brasileira. In: Paim JS, Almeida-Filho N, organizadores. Saúde Coletiva: teoria e prática. 2ª ed. Rio de Janeiro: Medbook; 2023. p. 124-142.
• ²⁷ Fleury S. Brazil's health-care reform: social movements and civil society. Lancet 2011; 377(97779):1724-1725.
• ²⁸ Santos JS, Teixeira CF. Análise política da ação do Movimento da Reforma Sanitária Brasileira na pandemia da COVID-19: 2020-2021. Cien Saude Colet 2023; 28(5):1287-1296.
• ²⁹ Frente pela Vida. Plano Nacional de enfrentamento à pandemia da Covid-19 - Versão 3 [Internet]. 2020 [acessado 2021 jun 21]. Disponível em: https://frentepelavida.org.br/uploads/documentos/PEP-COVID-19_v3_01_12_20.pdf
  » https://frentepelavida.org.br/uploads/documentos/PEP-COVID-19_v3_01_12_20.pdf
• ³⁰ Mendes Á, Marques RM. O financiamento do SUS sob os "ventos" da financeirização. Cien Saude Colet 2009; 14(3):841-850.
• ³¹ Teixeira CFS, Paim JS. A crise mundial de 2008 e o golpe do capital na política de saúde no Brasil. Saude Debate 2018; 42(n. esp. 2):11-21.
• ³² Associação brasileira de Saúde Coletiva (Abrasco). Posicionamentos oficiais [Internet]; 2021 [acessado 2021 jan 23]. Disponível em: https://abrasco.org.br/posicionamentos-oficiais/.
  » https://abrasco.org.br/posicionamentos-oficiais
• ³³ Centro Brasileiro de Estudos de Saúde (Cebes). Posicionamentos políticos do Cebes [Internet]. 2021 [acessado 2021 jun. 21]. Disponível em: https://cebes.org.br/noticias/posicionamentos-politicos-do-cebes/.
  » https://cebes.org.br/noticias/posicionamentos-politicos-do-cebes
• ³⁴ Fleury S, Santos JS, Moreira AEMM, Araújo TMB. Frente Pela Vida: a sociedade em movimento em defesa da democracia, da saúde e do SUS. In: Ouverney AM, Fleury S. Novo Federalismo no Brasil: tensões e inovações em tempos de Pandemia de COVID-19. Brasília: Editora do autor; 2023. p. 433-491.
• ³⁵ Frente pela Vida. Marcha pela Vida. Notícias [Internet]. 2021 [acessado 2021 jun 21]. Disponível em: https://frentepelavida.org.br/marcha/.
  » https://frentepelavida.org.br/marcha
• ³⁶ Rizzotto MLF, Costa AM, Lobato LVC. A esperança impulsiona, alimenta, move e fortalece a utopia. Saude Debate 2020; 44(127):937-946.

• Chief editors:
  Maria Cecília de Souza Minayo, Romeu Gomes, Antônio Augusto Moura da Silva

Publication Dates

• Publication in this collection
  20 June 2025
• Date of issue
  June 2025

History

• Received
  02 Apr 2024
• Accepted
  25 Feb 2025
• Published
  27 Feb 2025