Decentralization in the 2017 National Health Action Plan (PNAB): Manifestations of Brazilian Conservative Liberalism in Public Health PolicyAbstract
This article presents an analysis of the 2017 National Primary Care Policy (PNAB) as part of the broader context of the dismantling of Brazilian democracy. With the liberal paradigm of fiscal austerity at its core, the changes made to national guidelines were aimed at undermining the federal government’s authority to coordinate Primary Health Care (PHC) policies. The Ministry of Health’s (MH) reduced role in establishing national standards reflects an intentional shift towards enhancing municipal autonomy in policy implementation. By mapping the involved stakeholders and political entities, this study examines the implications of the changes introduced since the 2011 PNAB. It is argued that the 2017 PNAB promotes a more restrictive understanding of PHC by creating direct and indirect incentives for the establishment of traditional Basic Care teams, thereby diminishing the role of the Family Health Strategy (ESF) as a tool for expanding and consolidating PHC across the country. In conclusion, this paper argues that federal oversight of health policy is a crucial political and programmatic factor in advancing the authority of the Unified Health System (SUS), while a conservative liberal agenda risks undermining democratic principles.
Keywords:
Primary Health Care; Health Policy; Politics; Democracy; Unified Health System.
Resumo
O presente artigo apresenta uma análise da Política Nacional de Atenção Básica (PNAB) de 2017 como parte de um cenário mais amplo de desconstrução da democracia brasileira. Tendo como núcleo organizador o paradigma liberal da austeridade fiscal, as transformações operadas nas orientações nacionais tiveram como diretriz a desarticulação do poder federal de coordenar a política de Atenção Primária à Saúde (APS). Com a relativização do papel do Ministério da Saúde (MS) na definição de parâmetros nacionais, buscou-se ampliar a autonomia gestora dos municípios na condução dessa política. A partir de um mapeamento dos sujeitos e instâncias políticas envolvidas nesse processo, problematizamos os sentidos das mudanças efetuadas desde a versão da PNAB de 2011. Nesse percurso, apontamos que a PNAB de 2017 favoreceu uma concepção de APS seletiva ao estabelecer incentivos diretos e indiretos para a implantação das equipes de Atenção Básica tradicionais, relativizando o modelo da Estratégia de Saúde da Família (ESF) como estratégia de expansão e consolidação da APS no país. Como conclusão, discutimos que a coordenação federal é uma variável política e programática central para o avanço da autoridade sanitária do SUS. Em sentido contrário, uma agenda liberal conservadora tende a se impor aos preceitos democráticos.
Palavras-chave:
Atenção Primária à; Saúde; Política de Saúde; Teoria Política; Sistema Único de Saúde; Democracia.
Introduction
The first version of the National Primary Care Policy (PNAB) was published by Administrative Order No. 648 of 2006, setting the course for the organization of the Unified Health System (SUS) in the coming decades. According to Paiva (2021), the publication of the PNAB in 2006 reflected a long-standing process of theoretical and institutional developments present in initiatives such as the Community Health Agents Program (PACS) and the Family Health Program (PSF). According to the author, this policy embodied the expansion of a “technical and political consensus regarding the role of PHC in the organization of institutions and the reorganization of the health care model” (Paiva, 2021, p. 21). At that time, the Family Health Strategy (ESF) was chosen as the appropriate model to address the health needs of Brazilians in accordance with the principles of the SUS.
Five years later, in 2011, the Ministry of Health (MH) published the second version of the PNAB (Brazil, 2011), seeking to overcome the challenges encountered up to that point, such as the provision of physicians, the structure of health facilities, the management of walk-in care, and the creation of teams for specific populations, among others (Melo et al., 2018). By 2017, the PNAB was revised once again amid the democratic crisis triggered by the coup that removed President Dilma Rousseff from office. This article will focus on this political process and its programmatic consequences for the PNAB.
As articulated by Fábio Wanderley Reis (2009), the formulation of public policies takes place in arenas of power struggles and among actors with diverse ideological perspectives, and a certain degree of institutional stability is a desirable aspect of these circumstances. Through this analytical framework, the democratic environment in which the first and second versions of the PNAB were developed differs substantially from the period in which Ordinance No. 2,436/17 established its third version. Therefore, considering that the political-institutional context decisively influences policy formulation and implementation, the hypothesis that the 2017 PNAB broke with previously defined guidelines, which sought to establish PHC as the structural axis of universality, comprehensiveness, and equity that characterize the SUS, makes sense. Despite the maintenance of the constitutional legal framework, the new restructuring shifted health authority away from the Ministry of Health, deepening the autonomy of municipal entities in the conduct of health policy and paving the way for the adoption of a restrictive PHC model.
This shift in the power to direct health policy-characterized by greater autonomy for municipal administrators-does not depend exclusively on legislative or constitutional changes. The institutional trajectory of the SUS itself demonstrates that the balance of power can be altered through administrative orders and resolutions, which, although they are infra-constitutional instruments, can emphasize, alter, subvert, or undermine the spirit of the law. In the 1990s, the SUS Basic Operational Guidelines (NOB) played a central role in defining the direction of the decentralization model adopted by health policy. At that time, the issuance of ministerial ordinances promoted the municipalization of management and, through financial transfer mechanisms, expanded the federal government’s power to guide and coordinate health actions (Levcovitz; Lima and Machado, 2001). Although the changes instituted by the 2017 PNAB did not alter the constitutional powers set forth in Law No. 8,080/90, under which the federal government is responsible for defining and coordinating the National Health Policy, they shifted the federal government’s authority to guide health policy.
As part of a broader political shift, other significant infra-constitutional changes affected the SUS following the regressive move that impacted the PNAB in 2017. Examples of these changes include the expansion of the budget for parliamentary amendments; the creation of the Agency for the Development of Primary Health Care (ADAPS); changes in PHC funding through Previne Brasil; the suspension of the Mais Médicos (More Doctors) program (Giovanella, Franco, & Almeida, 2020; Morosini, Fonseca, & Baptista, 2020); and the weakening of the National Immunization Program (PNI) in the context of the COVID-19 pandemic. More than a change in procedures, these transformations should be understood as part of a liberal-conservative agenda, opposed to the public and universal conception of rights enshrined in the 1988 Constitution.
The consideration of the democratic context and its influence on the content of public policies is an important theoretical premise for this article. As Wanderley Guilherme dos Santos (2017) analyzes in his book “Democracia Impedida,” in 2016, Brazil experienced a profound disruption of democratic normality, triggered by the coup against President Dilma Rousseff. In the vacuum of governmental destabilization that came to mark the federal government, political forces at odds with the principles and values cherished by the SUS advanced the disorganization of the public health system, a process that was consolidated with Michel Temer’s rise to the presidency of the Republic in April 2016. From our analytical perspective, there is an intrinsic link between the realization of public health principles and the maintenance of the democratic order of the Brazilian state, which brings us back to Sérgio Arouca’s speech at the 8th National Health Conference, a milestone of the Brazilian Health Reform (RSB), in which he states, “Democracy is Health.”
In addition to analyzing critical junctures, this study argues that the transformations of the PNAB are best understood when viewed as part of the political and institutional shifts that affected the democratic nature of the Brazilian state at that time. In this sense, considering that the 2017 PNAB was the result of a democratic environment in disarray, the objective of this study is to identify the main changes that occurred in the conceptual, management, and healthcare fields, comparing them with the 2011 publication. At the center of this analysis is the relativization of national policy coordination. Through this analytical framework, we employ the “selective” and “comprehensive” approaches systematized by Giovanella and Mendonça (2009) to highlight distinct traditions of PHC. Our argument is that the guidelines incorporated into the 2017 PNAB represent a return to the general principles of the selective PHC approach, thereby curtailing the expanded scope pursued by the previous framework.
From a theoretical and analytical perspective, this study argues that understanding the changes made to the PNAB in 2017 requires identifying the political and institutional shifts that have affected the democratic nature of the Brazilian state. This framework allows identifying the ideas, actors, and political institutions involved in the PNAB revision process within the context of shifting governing coalitions. With this framework in mind, the development of this study involved a review of documents produced between 2012 and 2017 in the context of the debates and initiatives for the formulation and implementation of the 2017 PNAB. Priority was given to documents produced based on the debates of the National Health Conferences, the National Forum on Primary Care Management, and the Tripartite Interagency Commission (CIT). In addition to this review, the study included a systematization and comparative analysis of the 2017 PNAB (Ordinance No. 2,436) with the 2011 version of the Policy (Ordinance No. 2,488).
Based on this framework, this article is organized into three sections, in addition to this introduction. With this in mind, the next section presents an analysis of the political factors that diminished the federal government’s coordinating role regarding the PNAB, aiming to identify the political actors involved in the 2017 policy revision. In the third section, we present a documentary analysis of the changes introduced in the 2017 PNAB and their consequences for the care model. Finally, in the final considerations, we present a summary of the political and programmatic challenges affecting federal coordination and the consolidation of comprehensive primary health care.
The conservative political coalition and its agenda for the PNAB
The first discussions aimed at reformulating the National Primary Care Policy began in 2015, at events such as the 6th and 7th National Forums on Primary Care Management (2015 and 2016), the 15th National Health Conference (2015), and meetings of the Ministry of Health’s General Coordination of Primary Care Management (CGGAB) (Almeida et al., 2018). At these meetings, the discussions echoed the political tensions of the national context, reflecting the distinct concepts and proposals that were already in contention. While the proposals from the 15th National Health Conference emphasized social control and aimed to expand service coverage based on a comprehensive PHC model, the debate in the Management Forums progressively pointed toward a return to the selective approach.
The 6th National Forum on Primary Care Management, held in October 2015, can be considered the starting point for revising the PNAB. At this forum, discussions focused on the need to increase the autonomy of municipal managers; make team composition and professionals’ work schedules more flexible; define a portfolio of PHC services; and transform the role of Community Health Agents (ACS) (Brazil, 2015a). At the 7th Forum, held the following year, proposals were on the agenda that relativized the ESF model, which later gained institutional status. At the time, the agenda also included the merger of ACS with Endemic Disease Control Agents (ACE) and changes in the calculation of federal PHC funding, which later appeared in Previne Brasil, such as funding per registered person rather than based on the total population of municipalities (Brazil, 2016).
The National Primary Care Management Forums are traditional forums organized by the Ministry of Health to discuss proposals related to primary care management. Previous forums have included the participation of health managers, health workers, researchers, and representatives of civil society. However, at the 7th National Forum on Primary Care Management, held during Michel Temer’s administration, there was no opportunity for public participation (EPSJV/Fiocruz, 2016). Clearly, the discussions took on a less democratic scope, with an overrepresentation of the managers’ perspective, thus establishing a decision-making format that would lead to the erosion of the public health agenda in the following years.
During the 15th National Health Conference, held in December 2015, the debate on the PNAB reform took a different direction from that of the 6th Forum of Health Administrators, demonstrating a divergence within the political coalition active in these two forums. The conference reaffirmed the expansion of Family Health coverage and the expansion of Family Health Support Centers (NASF) (Brazil, 2015b). The participants’ policy formulation expressed a health consciousness that called for the consolidation of an expanded PHC model and the democratization of the state through the radicalization of the constitutional precepts of the SUS.
Michel Temer’s interim government and its political coalition would ultimately rupture this participatory aspect of health policy, revealing that the political influence of social control over the revision of the PNAB would rapidly lose its ability to shape the new content finalized in 2017. In summary, between 2015 and 2017, the PNAB revision shifted from spaces more open to public debate, such as the National Health Council, to processes defined in more politically restricted arenas, such as the Tripartite Interagency Commission (CIT) (Morosini; Fonseca; Lima, 2018). In this shift, the managerial autonomy of municipalities in the delivery of PHC, strengthened under the Temer administration, contrasted with the potential for effective political engagement demanded by social control.
From a similar perspective, Almeida et al. (2018) note that aspects such as changes to the composition of Family Health Teams (eSF) and the inclusion of federal funding for Primary Care Teams (eAB) featured in the 2017 PNAB received political support from the National Council of Health Secretaries (CONASS) and the National Council of Municipal Health Secretariats (CONASEMS). In the authors’ analysis, the recommendations of these Councils for revising the PNAB outweighed the arguments of Ministry of Health (MH) technical staff, who largely advocated for the theoretical and operational continuity of the ESF as the priority model (Almeida et al., 2018).
Santos and Guimarães (2020) point out that, more than a mere adjustment of bureaucratic and organizational parameters, this process signaled a shift in the political coalition that, in some way, had underpinned the expansion of the SUS during its first three decades. These transformations, as we are pointing out, were in tune with the broader disorganization of the democratic conditions of the Brazilian state.
It is important to note that the PNAB reform took place over the course of a little more than a year of debates, undoing years of incremental development of one of the central pillars of the SUS. The preliminary text of the ‘New PNAB’ was presented at the CIT meeting in July 2017, and by September of that same year, the path was already clear for its institutionalization with the signature of Ricardo Barros, then Minister of Health under Michel Temer (2016-2018) (Morosini; Fonseca; Lima, 2018).
In response to the exclusion of oversight bodies and opportunities for public participation from the policy review process, the National Health Council (CNS) submitted Recommendation No. 035 of 2017 to the CIT, calling for a broader and more substantive debate (Brazil, 2017a). In light of the increasingly undemocratic stance of the then Minister of Health, in December of the same year, the CNS once again took a stand against Ordinance No. 2,436 through Recommendation No. 61, arguing that it was inconsistent with the constitutional terms established for the SUS agreement (Brazil, 2017c). As a result, a public consultation was launched, which, over a 15-day period, received approximately 8,000 contributions (Almeida et al., 2018). These efforts, however, had no effect on the entrenched circuit of political coordination and decision-making that had been gaining ground since 2016.
In line with the CNS’s arguments, several public health institutions and professional councils-including Fiocruz, the Brazilian Association of Public Health (Abrasco), the Federal Nursing Council (COFEN), the Federal Dental Council (CFO), and the Brazilian Center for Health Studies (Cebes)-spoke out against the process and the content that shaped the ‘New Version of the PNAB.’ The common understanding was that the changes underway represented a threat to the constitutional principles of universality, equity, comprehensiveness, and social participation. As discussed in this article, the regressive nature of these transformations revolved around the weakening of federal coordination and the concomitant transfer of decision-making power to local administrators.
As outlined in Wanderley Guilherme dos Santos’s book (2016), the period that began with the legal-parliamentary coup against President Dilma Rousseff (2015-2016) was marked by a political climate characterized by hasty and undemocratic decisions. Examples of this condition include the labor reforms that substantially altered the Consolidated Labor Laws (CLT) in 2017 and 2019, the pension reform, and the dismantling of the Unified Social Assistance Service (SUAS), the Constitutional Amendment of 95, the so-called state-owned enterprise law, and the unprecedented approval of the Central Bank’s operational autonomy. All these cases are, ultimately, expressions of the weakening of the public exercise of political power and, consequently, of the imposition of private and oligarchic interests on collective life.
The recovery of this political context reveals that the PNAB, as consolidated in 2017, followed a path markedly different from that taken by previous versions of the policy. A different approach to primary health care was required due to fewer democratic spaces for debate, which imposed severe limits on social participation and allowed a narrow field of political actors to dominate. More importantly, a substantial reduction in the Ministry of Health’s coordination was imposed, as we will see in the following sections, pointing toward changes in federal steering power and making the care model more flexible by expanding the prerogatives of municipal management.
Impacts of the undemocratic context on the ESF
The 2017 PNAB incorporated practices and care for population groups not addressed in previous publications. This version of the policy proposed the integration of palliative care into the set of primary health care (PHC) initiatives and provided for the establishment of teams within the prison system, thereby expanding access to health services for people deprived of their liberty, a historically vulnerable population. The 2017 version also added regionalization and prioritization as key objectives, suggesting the development of a regionalized network for service delivery.
Despite these proposals to relatively expand the scope and reach of PHC, the overall trend of the observed changes was toward reinforcing a selective approach by relativizing the Family Health Program (ESF) model. In line with this assessment, Giovanella, Franco, and Almeida (2020) found that the changes to the 2017 PNAB posed a risk to the principles of the SUS and a threat to the ESF by devaluing multidisciplinary teamwork and the collective, territorial, and longitudinal understanding of care.
That said, in this section we will analyze the main aspects that allow us to conclude that the “New PNAB” reflected a regressive policy orientation, consistent with the context in which it was developed. Essentially, the change in the care model relates to the redesign of federal funding, team composition, and the duties and workloads of professionals. Table 1 presents a summary of these aspects.
It is essential to this understanding to recognize that the changes implemented in 2017 shifted the political orientation of federal funding, weakening it as a mechanism for steering the healthcare model and reducing the Ministry of Health’s coordinating role. As analyzed by Morosini, Fonseca, and Lima (2018), steering the establishment of federal parameters through funding was essential to the expansion of the ESF in the country. In turn, the relaxation of requirements for municipal managers regarding the transfer of federal funds meant, in practice, a de-emphasis of the ESF as the priority model promoted by the federal government. In effect, various municipalities could define, with greater discretion, central aspects of team composition, the scope of services, and the possibility of funding through arrangements other than the ESF.
Another set of flexibility measures introduced by the 2017 PNAB that had implications for the care model were the changes regarding the role of Community Health Agents (ACS). The 2017 document led to a reduction in the role of this category by failing to establish a minimum number of ACS per team. In the previous 2011 version, it was mandatory that 100% of the population served by the ESF be covered by the work of the ACS, with a minimum of four and a maximum of twelve (12) of these professionals per team. In the new version, 100% population coverage by ACS was suggested only for populations at risk and in vulnerable conditions (Brazil, 2017b).
Along with these changes, the 2017 PNAB proposed expanding the responsibilities of the ACS and the possibility of merging them with the ACE, encouraging structural reforms in their scope of practice. Initially, the work of the ACS was focused almost exclusively on community-based activities, including home visits and health education, with the potential to foster dialogue and encourage community participation (Morosini; Fonseca, 2018). However, arguments put forward by managers, including in forums such as the National Primary Care Management Forums, denied the importance of community-based work and proposed a more technically oriented approach that risked undermining the work developed since the creation of the PACS. Against a backdrop of severe public spending cuts and the erosion of labor rights, the proposal to reduce the number of these workers gained momentum and was included in the 2017 PNAB (Brazil, 2017b). The study by Freire et al. (2021) found a significant reduction in the number of ACS per ESF in Brazilian municipalities since the establishment of the PNAB in 2017, particularly in the Southeast, South, and Central-West regions. Thus, we understand that the third version of the Policy follows a path opposite to the movement toward consolidating the comprehensive approach, pointing toward a traditional and restricted model of health care.
Another significant change was the establishment of two service standards-“essential” and “expanded”-which were presented as options to be implemented according to local circumstances. The 2017 PNAB did not specify the activities and procedures envisaged for each of these classifications, limiting itself to noting that ‘essential’ would encompass minimum services to be provided to the entire population. When considering its political implications, by authorizing each municipality to have the autonomy to define a minimum or expanded service offering, the 2017 PNAB takes steps away from the principle of equity. More precisely, services would not be available to the entire population on equal terms according to need but would be contingent on the preferences of the municipal administrator (Brazil, 2017b). At the same time, this change is consistent with a concept of complementarity between the public and private sectors, given that by establishing minimum services, access to other services becomes contingent on individuals’ purchasing power to access services offered by the market.
Although the document stated that the ESF would be the priority model for reorganizing, expanding, improving, and consolidating PHC, what actually took shape were conditions conducive to reversing its development as a historical trend within the SUS. Evidence of this was the inclusion of federal funding for traditional Primary Care (eAB) teams in the third version of the PNAB. The changes to the parameters of physicians’ work hours favored, for example, the expansion of traditional primary care units at the expense of eSFs. Consequently, the 2017 PNAB eliminated the possibility of organizing transitional eSFs, which could have had physicians with a 20-hour workweek. The criteria established for access to this funding proved to be less stringent than those instituted for eSFs, a fact that can be interpreted as an incentive to reverse progress in the care model.
Consequently, to access federal funding for eSFs, all professionals were required to work forty (40) hours per week, whereas for Primary Care (eAB) teams, the minimum required weekly workload was ten (10) hours, which was closer to an on-call work schedule. Given the historical challenges municipalities have faced in hiring and retaining 40-hour-per-week physicians, the relaxation of the minimum workweek requirement for eAB funding and the tightening of this requirement for ESF served as an incentive to expand the former.
In addition to the structural aspects already listed, another regressive aspect of the changes proposed in the 2017 PNAB focused on the operating parameters of complementary teams, such as the Family Health Support Center (NASF), Oral Health Teams (eSB), and riverside and riverine teams. In general, the changes implemented also tended to weaken the incentives for creating these services through federal financial incentives for municipal managers. Regarding the NASF, the 2017 PNAB essentially altered the program’s structure by reducing the emphasis on matrix support, one of its main pillars (Melo et al., 2018). Programs such as Health in Schools (PSE), the Health Academy, and the Home Care Program were not even mentioned. This omission called into question the guarantee of continuity for these programs, which have become dependent on supplementary funding to remain operational.
Regarding the care provided by riverside and river-based teams, the main change in the proposed model was the removal of the ACS requirement and the possible replacement of ACSs with ACEs. The dismantling of territorialized care, in which ACS play a central role, is particularly acute in the Legal Amazon and the Southern Mato Grosso Pantanal regions, where the work process is marked by barriers to access and accessibility that must be overcome on a daily basis so that services can reach people by air, water, or land (Lima et al., 2021). All things considered, it should be noted that there was no mention of funding for microscopists, professionals specifically assigned to riverside eSFs in regions where malaria is endemic.
As for oral health teams, it was stipulated that they would consist solely of dental surgeons and dental hygienists, excluding dental assistants. In addition to the reduction in team composition, it is crucial to note that the implementation of these teams and the consequent provision of these services remained optional, limiting the democratization of oral health care. Access to this service is a marker of social class inequalities across the entire country. Confirming the trend of regression toward a selective approach to PHC, data from the study conducted by Lucena et al. (2020) indicate that, between 2017 and 2019, there was a reduction of nearly 9% in the total number of Oral Health teams within the ESF. The greatest losses occurred in the South and Northeast regions, concentrated in municipalities with more than 100,000 (one hundred thousand) inhabitants and with greater social inequality. This scenario contrasts with the investment trends observed between 2002 and 2016, when the number of Oral Health teams grew by over 470% (Pucca Júnior et al., 2020), a result of incentives introduced with the creation of “Smiling Brazil”-the National Oral Health Policy (PNSB), published in 2004.
It is worth noting that part of this framework changed in the years following the publication of the 2017 PNAB, under the Bolsonaro administration. For example, Administrative Order No. 2,539 of September 26, 2019, increased the minimum workload for AB teams from ten (10) to twenty (20) hours; changed the nomenclature from “AB teams (eAB)” to “Primary Care teams (eAP)”; and prohibited the replacement of existing eSFs with eAPs. These changes were in response to resistance from civil society and public health institutions (Brazil, 2019). Nevertheless, incentives continued to favor the implementation and maintenance of traditional AB teams, posing a risk to universal access, comprehensiveness, coordination, and the quality of health care provided to individuals and communities.
Final Considerations
After 2016, key aspects that ensured a minimal institutional balance in Brazilian democracy were undermined. Among the power structures that shifted was a growing trend toward the relativization of federal coordination powers in the health sector, accompanied by a strengthening of local authorities’ autonomy. The expansion of the National Congress’s prerogatives over the federal budget is perhaps the most evident expression of this relationship between the dispersion of power and the Brazilian conservative agenda. If the institutionalization of political conflict is a premise of contemporary democracies, upon which the quality of public policies depends, substantial changes in social policies have taken place within the Brazilian context of this environment’s erosion. It is from this theoretical framework that we analyze in this article the political and programmatic meanings established in the PNAB in 2017.
In the case of the PNAB reformation, the political and institutional context played a decisive role in its formulation and implementation. The erosion of the Ministry of Health’s authority in favor of greater municipal political and administrative autonomy led to a relative weakening of the federal government’s power to coordinate and set policy, thereby undermining principles that had previously been central to the Family Health Strategy’s care model.
The findings of this study are consistent with analyses such as that of Morosini, Fonseca, and Lima (2018, p. 14), who point out that the changes introduced in the 2017 PNAB “undermine the policy’s catalytic and proactive nature and reflect the erosion of a commitment to expanding family health care and the public health system.”
It is interesting to note that the expansion of municipalities’ authority to define the terms and operational model of primary health care services, coupled with the relaxation of federal parameters, was not intended to increase sensitivity to the specific needs of local communities. Rather than addressing the population’s direct demands, the municipal autonomy pursued aimed to expand the power of local administrators, which cannot be equated with the public interest in combating inequalities. As we noted in the first section of this article, profound political and programmatic divergences could be identified between the expectations articulated at the 15th National Health Conference and the guidelines presented at the Managers’ Forums. In this context, the relaxation of federal parameters and the reevaluation of the ESF as a model for PHC in Brazil responded to a demand from state and municipal managers, which gained momentum at the 6th National Forum on Primary Care Management. With the 2017 PNAB, these guidelines became a historical reality. The creation of diverse service packages, changes to work schedules, and adjustments to team composition rules aligned with the expectation of reducing municipal health expenditures.
From this perspective, the 2017 reform of the PNAB represents a development that challenged the tradition of the health reform movement, which is guided by the principle of providing comprehensive, equitable, universal, and locally rooted care. Instead, it imposed a path toward selective PHC that understands care as residual, provided through minimal services for those most in need.
While it is true that many of the changes set in motion after 2016 had already found a place within the democratic dynamics of the preceding period, it must be noted, however, that the central tenets of this reactionary agenda had not, until then, been constitutionalized. The 2016 coup transformed the regressive agenda that had been contesting national political life into a formal structure of the Brazilian state.
Understanding the transformations that occurred in 2017, particularly regarding the reframing of the federal government within Brazilian democracy, allows us to contextualize the evolution of political ideas and institutions, including the changes made to the expanded scope of PHC. More than a contingent event, occurring within the fragmented dynamics of the selection of influential groups and individuals in positions of power, we are facing a political movement that sought to redefine the nature of public health policy within the Brazilian state.
In the field of health, the interpretation of the meaning of decentralization in the management of the SUS remains a subject of significant controversy. A historical review of debates on the management of health services shows that the principle of decentralization was not necessarily interpreted as synonymous with the municipalization of power (Arretche, 1997; Paim, 1992). On the other hand, analyses indicate that the process of municipalizing the SUS contributed to expanding health service coverage. From this interpretive perspective, decentralization to the local level is seen as a prerequisite for a system that is more responsive to local needs and, consequently, more democratic.
However, we also have evidence that the radicalization of municipal autonomy contributes to the fragmentation of services and the deepening of inequalities in access, limiting their integrated and hierarchical organization (Machado & Guim, 2017) in a country marked by regional disparities. As part of this problem, the decentralization of power remains a premise of the liberal paradigm of the New Public Management, which is supported by organizations such as the World Bank that have expanded contracts that have undermined public administration at the subnational level (Rizzotto and Campos, 2016). In the case of this article, as we seek to demonstrate, the conservative coalition that took power in 2016 has precisely deepened this regressive condition of local power in Brazil, which hinders, for example, the overcoming of the severe regional imbalance that manifests itself in the institutional, political, and technical capacity of SUS management.
Among the article’s conclusions is a discussion of the challenges involved in reversing these regressive changes that have become institutionalized within the SUS. If we correctly understand the direction of the SUS in relation to the broader political dynamics that define democracy in Brazil, one of the major risks that can be foreseen concerns the acceptance or only partial reversal of the changes implemented since 2017. Given this possibility, the most important thing is that the very political identity of those fighting for Health Reform does not permanently incorporate principles that were once programmatically foreign to them.
Data Availability Statement:
The data supporting the findings of this study are available in the article itself. The documentary sources used are publicly available and are properly cited throughout the manuscript.
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Edited by
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Editors:
Carinne Magnago, Marilia Cristina Prado Louvison
