Protagonism and challenges of Nursing in the construction and consolidation of the Brazilian health systemThe Brazilian Unified Health System (Sistema Único de Saúde - SUS), in its little more than three decades of existence, has accumulated important advances despite never aligning itself with the different governments that assumed the management of the Brazilian state, and facing very adverse circumstances, which contributed to make the full implementation of the constitutional SUS unfeasible and cause important institutional, regulatory, and budgetary setbacks.
But what do we mean when we invoke a constitutional Unified Health System? We are talking about the Brazilian Health System thought, debated and built throughout the 1970s and 1980s, a period in which health workers and students, entities representing professional categories such as the Brazilian Nursing Association (Associação Brasileira de Enfermagem - Aben), Brazilian Association of Collective Health (Associação Brasileira de Saúde Coletiva - Abrasco), Brazilian Center for Health Studies (Centro Brasileiro de Estudos de Saúde - Cebes), progressive political parties, social unions and movements, composed what we call the Health Reform Movement (Movimento da Reforma Sanitária - MRS). This movement was organized to fight collectively for democracy and garantee, through the Federal Constitution of 1988(1), not only health as a right for all and as a duty of the state but also the principles and guidelines of the new national health system that should be universal, integral and egalitarian. Thus, it was from the performance of the MRS that SUS was created, and it is from its permanent surveillance that SUS resists.
The legal framework that guaranteed health as a social right and the tripartite management of the system1 was decisive for SUS to advance in several areas, ensuring access to health actions and services of different levels of complexity for the entire population. In all professional areas and at all levels of care, nursing has been a protagonist, whether in the direct care of citizens, in the coordination, planning or management of services, programs and policies, in all Brazilian municipalities.
The existence of SUS is linked to the significant participation of nursing workers, who make up more than half of all health professionals-a contingent of more than two million professionals working in health services in Brazil, approximately 60% of these in public institutions. It should be remembered that Brazilian nursing is composed of three professional categories, being 77% technicians and assistants and 23% nurses, despite 1/3 of the technicians and assistants having a graduate degree. However, the concentration of professionals in large urban centers and in the Southeast region is still a challenge to ensure universal access to health care2.
Recently, even in a scenario of fake news and scientific denial, the Covid-19 pandemic has given relevance and social recognition to SUS as a fundamental system for coping with health emergencies and to nursing as a protagonist in the care process. Such recognition was fundamental for the category to achieve, by law3, the National Floor Wage, an important achievement that has been fought for for more than three decades.
The pandemic has highlighted the value of the nursing workforce. However, precarious working conditions and low investments in training remain and contribute to the worldwide problems of shortage of nursing professionals and the migration of the skilled workers to Central capitalist countries, resulting in the phenomenon known as “brain drain” of countries whose health systems lack these workers. In addition, although the recognition of the profession has increased in the post-pandemic period, the health and safety of nursing workers remains at risk, with exhausting work hours and multiple professional ties, most of which are unprotected and unstable4.
In Brazil, investing in training new professionals and in absorting and fixating of these is urgent for the consolidation of SUS, as well as the creation of new jobs with protected work-related links in regions of care gaps. The challenge is also to promote qualified training focused on the needs of the SUS and the epidemiological profile of a population in the process of aging and chronicity, in a context in which approximately 57% of nurses and 72% of technicians are trained in private institutions2 and with the looming threat of distance education.
Still in relation to training, it remains the challenge of the necessity for articulation of the contents focused on technical skills-highly valued in the curricula of the courses-with ethical values and knowledge from the field of Humanities and collective health, which help to understand the relationship of social conditions with the process of illness and the causes that affect thousands of human beings in situations of vulnerability and material and “spiritual” misery, victims of an exclusionary system and unable to guarantee a dignified life, work and health to the majority of humanity, which suffers more deeply the consequences of pandemics, climate change, climate change extreme heat and forced migration.
It is important to reiterate that care, since modernity, has been subjected to the laws of capitalism and to the organization and control of wage labor, becoming a service, a commodity. And, as for all wage labor, also for care transformed into service, in capitalism, time is the measure that determines care, rather than the quality and humanization of the act. New technologies are increasingly present in health and nursing work to reduce the time spent on technical procedures, which are already being performed by machines and artificial intelligence programs.
However, the hegemonic discourse of nursing continues to affirm that care, as the essence of the profession, cannot be separated from the caregiver, and consequently, nurses would be in a kind of recondite of the workfield, where unemployment would not reach them. It must be remembered that employment, in the capitalist system, is not linked to the need or importance of the work to be provided, and that there are recent data that indicate between 10% and 24,5%2) unemployment in nursing. In addition, nursing is among the five undergraduate courses with the most recent graduates who do not exercise remunerated activity5.
Inserted in the capitalist mode of production, new technologies that could make work less arduous and guarantee more free time to the worker have condemned millions to unemployment, or underemployment, such as payment for tasks, creating new forms of illness of the working class, including nursing. It is in this context that new challenges meet with old problems that have not yet been solved, such as infectious diseases, hunger and malnutrition, violence, among others.
Although it is noted in the scientific literature6 that part of Nursing community has allowed itself to be carried away by the ideological decoy of the myth of entrepreneurship, a strategy that seeks to “soften and humanize” the destructive logic of capital, since the pandemic context, this category shows more keenly that it (re)discovered its power in the collective organization and in taking to the streets to give visibility to its struggle for better working conditions and wages. Like the law that guaranteed the wage floor, the nursing community will still occupy the streets to claim 30-hour work journey, justified by excessive wear and tear in long and multiple hours. Still, amid the strengthening of feminist movements, nursing, a workforce composed 85% of women in the category, has demonstrated, in practice, that the naturalization of precarious and violent working conditions is not compatible with the defense of Health and care of such a valuable profession.
Nursing, constitutive of the MRS and a fundamental actor in health, is called upon to defend democracy as a requirement to have health, to defend health as a human right, to the SUS as the most important social policy implemented in the entire history of the country and to the rights of users as an intrinsic part of their act of care.
References
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1. Presidência da República (BR). Constituição da República Federativa do Brasil de 1988 [Internet]. 2016[cited 2025 Mar 2]. Available from: http://www.planalto.gov.br/ccivil_03/constituicao/constituicao.htm
» http://www.planalto.gov.br/ccivil_03/constituicao/constituicao.htm -
2. Silva MCN, Machado MH. Sistema de Saúde e Trabalho: desafios para a Enfermagem no Brasil. Ciênc Saúde Coletiva. 2020;25(1):07-13. https://doi.org/10.1590/1413-81232020251.27572019
» https://doi.org/10.1590/1413-81232020251.27572019 -
3. Presidência da República (BR). Lei 14.434. Altera a Lei nº 7.498, de 25 de junho de 1986, para instituir o piso salarial nacional do Enfermeiro, do Técnico de Enfermagem, do Auxiliar de Enfermagem e da Parteira [Internet]. 1986[cited 2025 Mar 2]. Available from: https://www.planalto.gov.br/ccivil_03/_ato2019-2022/2022/lei/l14434.htm
» https://www.planalto.gov.br/ccivil_03/_ato2019-2022/2022/lei/l14434.htm -
4. Conselho Federal de Enfermagem (COFEN). 90% dos Conselhos de Enfermagem do mundo veem risco de aumento no abandono da profissão [Internet]. 2021[cited 2025 Mar 2]. Available from: https://www.cofen.gov.br/90-dos-conselhos-de-enfermagem-do-mundo-veem-risco-de-aumento-no-abandono-da-profissao/
» https://www.cofen.gov.br/90-dos-conselhos-de-enfermagem-do-mundo-veem-risco-de-aumento-no-abandono-da-profissao/ -
5. Conselho Federal de Enfermagem (COFEN). Enfermagem: realidade de superexploração [Internet]. 2024[cited 2025 Mar 2]. Available from: https://www.cofen.gov.br/enfermagem-realidade-de-superexploracao/
» https://www.cofen.gov.br/enfermagem-realidade-de-superexploracao/ -
6. Pereira PN, Martins CM. Ideologia em produções científicas sobre empreendedorismo em enfermagem no Brasil. Saude Soc [Internet]. 2023[cited 2025 Mar 2];32(1):e220270pt. Available from: https://www.scielo.br/j/sausoc/a/PWjQtKgVm76xcqyWb7wb7TB/
» https://www.scielo.br/j/sausoc/a/PWjQtKgVm76xcqyWb7wb7TB/
