Health – challenges of integration and convergence – Opinion



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In spite of the immense challenges, in the last decades, Brazil has constituted a reality of promotion and attention to the unique health in the world and unpublished in our History. The 1988 Constitution established the creation of the Unified Health System (SUS) and, at the same time, the private sectors, both for profit and non-profit, expanded.

The 30 years of SUS, recently completed, suggest a reflection. Obviously, there is much progress in health care, but it can be concluded that SUS has become a national asset. Citing Professor Eugenio Vilaça, "SUS is not a problem without solution, it is a solution with problems".

The SUS serves 207 million Brazilians. The services range from epidemiological, sanitary and environmental surveillance, through vaccination, transplants, high-cost pharmaceutical assistance, to programs to combat AIDS and hepatitis C, among others.

Integrated into the philanthropic system, the SUS has advanced and made history, despite all the issues we face. Whether it is a short-term journey or chronic organizational problems – especially underfunding of the Union, in addition to the inefficiencies of the fragmented structure and governance indicated in a World Bank study – the SUS has many challenges to overcome, such as excessive judicialization , which undermines budgets and disrupts planning. But I can not glimpse the future of Brazil without this health system.

I also can not see the horizon without increasing integration with the private sectors, both non-profit (philanthropic) and for-profit (hospitals, clinics, diagnostic services, doctors and other health professionals), health care (medical cooperatives such as Unimed, self-help, group medicine, insurance companies) and even companies that hire health insurance. This supplementary health system was consolidated paris passu with SUS.

As we said, the philanthropic partnership was essential to the consolidation of SUS, a connection that increased with the possibility of management contracts with social organizations (OSs), starting in 1998. In 1999 the alternative of action was created with the organizations of the society of public interest (Oscips). In 2004, public-private partnerships (PPPs) were regulated, allowing private funding to be sought for projects of public interest, including health.

By 2018, in Brazil, more than 200 municipalities and 23 states had partnerships with OSs. One of the main advantages of this system is the speed in the decision making process. The slowness and excess of bureaucracy are real agents of waste and suffering for the populations that most need public health care. In Espírito Santo, we advanced along this path, which we opened during our second term as head of the state executive.

The State of Espírito Santo adopted the management by OSs in 2009, and always with partners with wide experience to administer hospitals. Until last year there were already four units. Less bureaucratized, organizationally up to date and intensively professionalized, the management by OS allowed for the enhancement of investments. We created an exclusive structure in the Health Department to control, monitor and evaluate the execution of contracts. With the efficiency gains, it was possible, with investments equal to those before the adoption of this management model, to increase the number of services, one of the greatest needs of public health.

Another case of partnership is the Program of Support to Institutional Development of SUS (Proadi-SUS), developed next to philanthropic hospitals of recognized excellence. Following strategic guidelines of the Ministry of Health, the contemplated institutions develop projects in several fields, such as human resources, management, technologies and health research, among others.

But the public sector can also make the structuring of SUS advance in the management question. By betting on decentralization, we have set up in the Holy Spirit the Care Network. It is a network of integral care maintained by the SUS, by State and municipalities that proposes the reorganization of the public health system, from the entrance door in the basic health unit, through specialized consultations and examinations, to the hospital network.

At strategic points in the interior of the state of Espírito Santo, the units of the Care Network broaden and humanize the offer of care, with multiprofessional care, including the promotion of healthy living, able to solve up to 95% of the population's health problems in their own region, close to home.

Integration, cooperation, dialogue and exchange between the public, private and non-governmental worlds are already proven to be successful. With the focus on the citizen and the strengthening of the SUS and stimulating the integration of these universes, it is necessary to conduct discussions and actions about financing and regulation of the sector; public policy; productive development framework; management models, remuneration, organization and assistance; as well as human resources, infrastructure, equipment and technologies.

Considering the change in the epidemiological situation, with a predominance of chronic diseases, which demand permanent attention, on acute diseases, and if we want to move towards an inclusive and qualified, ethical and economically sustainable Brazilian health system, we must not deviate from this collaborative route, but rather to invest the talent and political effort to increase the exchange of experiences of excellence that Brazil has built in the last 30 years, such as the innovations in management in the non-governmental sectors and the structuring of primary care in the public system. Challenge is what is not lacking, but paths we already have. It is only to advance in the walk of cooperation.

* ECONOMIST, WAS GOVERNOR OF THE STATE ESPÍRITO SANTO (2003-2010 AND 2015-2018)

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