We spoke to fellow health workers in Sao Paulo about their initiative to defend public access to health services and good conditions for workers and patients. You can follow the activities of Viva SUS on Instagram: vivasus_
We are a health workers group from Sao Paulo, most of us working in mental health care. We started our group in 2022. Sao Paolo is a large city, we already had a group of health workers in the northern part of the city, which formed around a so-called ‘health reform’ introduced by the local health secretary. This legal reform for the Sao Paulo area obliged us to adhere to fixed productivity rates. The law was a kind of prototype or model that might also be applied in other regions in the future. Before the law, consultations should be no longer than 20 minutes. The reform further reduced this to 15 minutes, so four patients an hour. This means we have even less time to understand what our patient’s life is like, beyond the symptom, e.g. what their daily routine is like, what their social relationships are like, what kind of food they have access to. We organised a bigger meeting to discuss the reform and around 100 workers attended. From this initial meeting smaller local groups formed.
The public health system
There are some particularities regarding the health system of Brazil. The public health system, called SUS, was established with the national constitution of 1988, after the end of the military dictatorship. During the struggle against the dictatorship in the 1980s many independent health initiatives developed in industrial and working class areas. In 1988 these initiatives were institutionalised in the SUS. But actually, this health system was never really implemented nationally, its implementation depends on municipal or city laws. We have three governmental levels in Brazil: cities, states and federal government. In Sao Paulo, Brazil’s largest city, the SUS is actually not public, it is primarily run by so-called ‘non-profit’ or third-party organisations that get a lot of money. These third-party organisations have been set up by private corporations to get contracts from the public health system. Other organisations were initially set up by medical professional associations and the university of medicine, but they also have turned into important private players. This process of privatisation is also supported by the Lula government. Another aspect is that if you use services of the SUS with a private health insurance cover, which only richer people have, the money that is paid for the treatment by the insurance is supposed to stay within the SUS. But actually, all this money goes into the pockets of the third-party organisations. The Lula government now says that if you don’t pay the insurance money into the public system, then at least provide additional services, such as examinations or surgeries. We fear that this is an even more obvious form of privatisation than the establishment of the third-party organisations themselves.
The outsourced sector
In our area there are four or five major organisations and they employ more than 80% of all health workers. Only a few public hospitals are left that are owned by the city. These are the only workplaces where the unions are still present, but due to their minoritarian position within the wider health sector they have lost influence. They continue their symbolic protests or appeals to the law makers, but this type of struggle doesn’t work anymore. In contrast, nearly all primary health care in Sao Paulo is run through third-party organisations. We have more than 600 primary health care units in Sao Paulo alone. These organisations have become majoritarian in the health system from about 2012. From 2012 onwards vacancies for civil servants in the local public health care administration have not been filled anymore. This means that there is no municipal public body that would organise or plan local public health. All this is left to these allegedly non-profit organisations in collaboration with the governing political parties. They control the health system. This opens the door for the intensification of corruption. In terms of numbers, the largest of these organisations in Sao Paulo is paid nearly 1 billion USD every year. The disastrous state management during the COVID pandemic demonstrated to which extent public administration and the integration of health services had been undermined by this process. Health workers don’t see themselves as public sector workers anymore, but as employees of individual corporations. Or they see themselves and fight only as an individual profession, like the doctors. This makes it more difficult to create a unity, also because the labour contracts with the organizations are precarious and workers can be fired relatively easily, as they are not covered by the CLT (Consolidated Labour Laws).
The current ‘productivity reform’
The recent law concerning productivity targets created a lot of anger amongst health workers, but it was difficult to turn that anger into organised resistance. On paper the SUS gives workers and the wider population a lot of rights of participating in the decision making process, but in reality these rights don’t exist. The mayor and the owners of the organisations decide. The reform doesn’t specify any ‘positive’ parameters, for example, the reduction of child mortality or the reduction of certain illnesses in the area – they just create productivity parameters for each category of treatment. Time is allocated only for direct treatments, not, for example, for conversations within your team how to organise and improve care. The logic is not anymore one of prevention of disease, but of productivity management. There is no logic of universal free health care anymore, but a business logic. There are no parameters for the organisations or the governing bodies themselves, e.g. you have to provide x number of doctors for a population of size y. The parameters of the reform just target the workers. All governments support this attack, the right wing government in Sao Paulo city, but also the left wing government of the federal system.
The resistance
At the beginning, at the first meetings to discuss the new laws, there were many workers and patients. The majority of workers are from these multi professional teams like physiotherapist psychologists, occupational therapists, some are doctors. Initially we were very much focussed on addressing the institutions, e.g. we organised a meeting with the mayor about the new law. We wrote a lot of letters. All this was not effective and it was very frustrating for us. We referred to legal rights, but nothing happens if we don’t have political power to implement or enforce them. People who referred to their constitutional rights were actually fired. So then we started to turn around and look for another way of acting. We put the word out on social media, and we start to go to areas where there are other forms of movements, struggles or initiatives happening, mainly in the neighbourhoods. For example, we linked up with an initiative to defend access to a local accident and emergency department that was threatened with closure. We went on protest marches with them and joined meetings primarily with local women and children. We are also in touch with other independent groups that focus on workers’ struggles in other sectors, for example in public transport and education. These public services are also affected by the proliferation of these third-sector organisations, as a means of privatisation. The unions there are still stronger than in the health sector. We organised two wider assemblies for workers and the local population, where we talked about the logic of public health and the current attack on it. We explained our idea that everyone should be hired by the municipality directly. We are still at the beginning of our struggle, we haven’t built the power yet, for a strike for example.
There was a public health workers strike in Rio de Janeiro recently, but it happened because the city wasn’t paying them. It was a defensive struggle, it was not about the logic of our work. So we are getting paid. In Campinas, the mental health workers went on strike, too, after the local government wanted to shift work from a cooperative to a private business. It was a powerful movement because it wasn’t just about nonpayment of wages. It was a struggle to maintain the logic of public health. In Sao Paulo, we don’t have this kind of power and union between workers yet. We are still building that power. We are producing a magazine that promotes self-organization and self-defense. We spread them in health clinics. We propose that workers make public the situation they are facing. People are angry, but they don’t believe that they can change something. That’s why we organise assemblies. We also go to universities and speak to medical students there, mainly psychology and physiotherapy students.
Historically the best organised group of patients in terms of resistance are mental health patients. Like in many other countries they organised struggles 50 years ago against the conditions in mental asylums, which were like prisons, and for the implementation of a public health system in the community. This was similar to the anti-psychiatric movement in Italy. Another group that organised recent protests are mothers of children with autism. They advocate for specific care for their children. Then there are movements from the LGBT community for better HIV treatment and by women groups for better access to abortion services. There are many struggles on the level of neighbourhoods for better local health provisions, which question the so-called third-party organisations. One of the big issues are lack of appointments and long waiting times. This is devastating for us as workers, too. At the end of the day, you decide who will have access to healthcare today and who will not, who will have to go home without treatment and continue living a half life.
We are preparing for our third independent workers’ assembly and the launch of our magazine. We talk about taking back the SUS, but throughout our reflections we have concluded that it was never really ours. Perhaps we have to raise awareness, to equip ourselves, to collectivise, to organise in order to transform the system and propose access to healthcare that makes sense for society in general.
