Bel Levy (Saúde Amanhã)
The role of the health sector in the development of the country and the challenges posed to Brazil by the 2030 Agenda of the United Nations were on the the order of the day at Fiocruz, on September 11 and 12, during the seminar Health, Environment and Sustainable Development, promoted by the Brasil Saúde Amanhã Network. In an interview, the economist Carlos Gadelha, Coordinator of Prospecting Actions of Fiocruz, analyzes the global and national contexts and asserts: “The Unified Health System (SUS) and the Economic and Industrial Complex of Health (CEIS) are the preconditions – or the only opportunities – for Brazil to reach the Sustainable Development Goals (SDGs) until 2030. They are not problems for the country. They are an indispensable part of the solution. Without SUS, there is no sustainable development”. The investigator of Group for Innovation in Health at Fiocruz participated in the first panel discussion, Development and Sustainability.
Saúde Amanhã: The 2030 Agenda articulates several dimensions of development. What questions does it pose to health?
Carlos Gadelha: The 2030 Agenda for Sustainable Development consists of a set of aspirational principles, global values that we must pursue as humanity. It proposes a model of economically dynamic development, which is socially fair and respects environmental conditions. But the development process, as Brazilian structuralists would say, is not natural. It is not a linear process, a consequence of evolution on the planet. On the contrary, the natural consequence of evolution on the planet is inequality, imbalance and exclusion.
Accordingly, Agenda 2030, which ultimately promotes equity, opens a set of opportunities, in the academic field and in the political arena, to the resumption of a project of global, national and local development. And their SDGs will not be met if we continue to follow and reproduce the exclusionary structure of capitalism and its market logic. A dialog among society, State and market, in this order, is necessary to make the interests of society to express themselves in the State and in the market – this way, the company adjusts to both, and not the other way around.
This perspective is pivotal to health. It is present in all the legacy of Sergio Arouca and in shaping the field of collective health, which is more extensive than the tradition of public health. We understand that health cannot be seen only as a system of care and treatment of diseases, which adds some individuals and excludes others. It should be a field for the formation of national systems that guarantees equity, sustainability and democracy to the collective. All these values are at the base of the 2030 Agenda. In Brazil, we cannot raise this discussion without addressing SUS without thinking about how SUS can, at the same time, promote equity, be compatible with productive, economic and technological dynamism and generate a solidary pattern of organization of the society, that it is not divided between who can and who can not pay for the access to the health system.
Saúde Amanhã: So, sustainable development passes through health?
Carlos Gadelha: Yes. Equity is in the DNA of SUS. Without a public, universal, free and quality health system, Brazil will not reach the Sustainable Development Goals – nor in 2030 nor never. The role of the State is critical for access to health care to be universal. If, instead of adopting a model of Collective Health for all, we adopt a policy that fragments the health sector in a public system for the poor and a private one for the rich, we will be against the 2030 Agenda.
There is a tradition rooted in the field of health, that is that of its social determinants. From that perspective, we think, for example, as our principles and concerns may be present across all policies. This is crucial. This is the first step. The second one is to consider the health sector as an intrinsic part of a pattern of sustainable development, involving economic dynamism, equity and environmental sustainability. And, for that, it is imperative a national health system, with universal access, as SUS.
The areas of industrial production and innovation also show how health invades the dimension of sustainable development. Across the world, health is a strategic area for investments in research, technological development and innovation. About one-third of worldwide research and innovation are in healthcare. Therefore, there is an interdependence between the productive and technological framework to be adopted by the country and the model of society that we want to build. Depending on the productive and technological structure, we can have more or less unequal societies, more or less sustainable ones. It is, therefore, essential to promote a dialog among policies, innovation and infrastructure industrial and the health field. We cannot discuss the national policy of science, technology and innovation separately from health.
Saúde Amanhã: How do you assess the global and national trajectories since 2015 towards the SDGs?
Carlos Gadelha: The geopolitical context has changed dramatically since 2015, when the 2030 Agenda was formulated: we had an impeachment in Brazil, the election of Donald Trump in the United States, facts that are not isolated and whose repercussions are not only local. Without a doubt, the current context of crisis and institutional instability in Brazil is unfavorable to the achievement of the SDGs. We live in an atmosphere of perplexity and uncertainty regarding the direction of the national standard of development, and the matter is not whether or not we will fulfill the Agenda. We should go further: the SDGs should be adopted as strategic elements for the discussion of alternatives to national development. If the principles of 2030 Agenda are not present in the struggle for a fairer and more sustainable Brazil, it will become inexorably distant from our reality. And that is what makes this referential so important as an instrument of political struggle: by the horizon of 2030, we must not lose sight of ODS.
It is not possible to think about a project of a nation without discussing the overall dynamics of capitalism, the role of States and the reconfiguration of global geopolitics. In the same way, we need to discuss the role of national States once more, especially the peripheral ones, such as Brazil, and the local dimension, where human interaction with nature takes place. In this regard, we understand SUS as a national project, essential for a pattern of development based on equity and sustainability. Therefore, to implement Agenda 2030, we must politically recognize that the goals placed for the health sector require the organization of universal systems, in which the State has a fundamental role. There is no universal health care system in the world in which the State does not fund at least 70% of the expenses.
Saúde Amanhã: Are the goals set by the 17 ODS feasible in the current global context?
Carlos Gadelha: While some critics consider the Agenda 2030 an utopian or rhetorical referential, I say its proposal is renewed and revitalized nowadays, because the SDGs are a conceptual and political room for fight, to be completed within the global review of a development project that is economically dynamic, socially fair, environmentally sustainable and which respects the global, national and local scale.
The Agenda 2030 has the merit of proposing a new development model. That merit increases in the current context of global, national and local crisis, because the systemic dimension proposed by its goals requires structural and concrete actions in all countries. However, there are some points on which this initiative could have gone further. Its proposal is equity, but the world is heterogeneous and unequal in the distribution of wealth, in the productive infrastructure, in the capacity for innovation. Therefore, if we aim for a sustainable development, we need to face global, national and local inequalities – and this could be clearer.
In my point of view, the systemic dimension of health would need to be emphasized in the Agenda. The goals and the means of implementation listed for the health area are extremely punctual, relate health to the treatment of diseases and are based on classical indicators, such as maternal and child mortality. The other goals are related to the reduction of Aids, tuberculosis, malaria, tropical diseases – which is fundamental. But the health area goes far beyond that. Now, it is our role to stress it in order to reduce structural barriers to development and to recognize social protections – health, education, social security – as systems essential to welfare. We are talking about universal systems, such as SUS.
Saúde Amanhã: Is Brazil on the road to the sustainable development proposed by Agenda 2030?
Carlos Gadelha: The basis of sustainable development is at risk in Brazil. From the perspective of the economy, the ideal of industrial and innovation policy needs to be reviewed. There is no experience, worldwide, in which social and economic development occurs without an active industrial policy, in the sense of a productive and technological diversification that enables a more egalitarian society. That bridge needs to be made. From the social point of view, we face the risk of weakening of social protection systems, including our Brazilian National Public Health System. The horizon of restriction of financing for SUS in the next 20 years is terrible, especially for a young health system like ours, in full construction. And the environmental dimension, in turn, continues to be seen as a restriction and not as an opportunity.
This model of development is typical of the 19th Century, from the early 20th Century. Today we need to think of another way. A State that prioritizes solar and wind in energy in its energy matrix, for example, has the opportunity to establish, through policies and programs that promote that guideline, the conditions required for economic and social development of new technologies and innovation. A country driven by environmental sustainability, which preserves and investigates its natural resources, may find in its biodiversity responses to scientific and technological development and innovation in health. In Brazil, unfortunately, all that potential is being wasted.
Saúde Amanhã: What are the actions currently needed for the country to approach the scenario proposed by the UN for 2030?
Carlos Gadelha: The first question is to define, through public policies, how to subordinate the market to society – not the opposite. The social area has to break into the economic area, because the policies of innovation and industrial development do not belong only to the universe of economy, they are impregnated by social and environmental issues. However, national productive and technological system is locked in the past. It was not structured for a more inclusive and sustainable society. Agenda 2030 may be the key for society to open that lock through politics. This lock is not neutral, it has losers and winners. And it is not just a cognitive or technique lock, but of political and economic interests that do not allow our productive, technological and innovation matrix to prioritize social objectives.
The fact is that universal systems of social protection are under attack, in Brazil and in the world. In our country, and in the case of health, in the long term it will mean intensifying inequalities and inequities, with the segmentation of society among those who can and those who can not pay for the access to social protection systems. We have a health system in which the majority will live less, with worse quality of life and will die sooner, and few will live longer, better and die later. The road to sustainable development is another one. Therefore, we have to discuss again the role of the State and reorient the project of national development towards 2030 Agenda. It is not utopian. Utopia is to assume that the market, without any interference of the society and the State, will create the conditions for a sustainable development.
Saúde Amanhã: What is the role of SUS and of the Health Economic-Industrial Complex in this context?
Carlos Gadelha: If we understand the 2030 Agenda by an equity perspective, it is clear that without SUS there is no sustainable development in Brazil. And, without a strong economic, autonomous and sovereign industrial complex, it will not be possible to maintain a public, universal, free and quality health care system. SUS is not, and should not become a fragmented clinical set aimed for the treatment of diseases. SUS is a national system which operates from the premise that all citizens are equal and that everyone has the right to health. So, we cannot have a health system for the rich and another one for the poor. And with a productive and technological base that requires an unequal country, we will not have a universal health care system. Therefore, the health economic-industrial complex should be part of the effort of the State in promoting a universal health system.
Subordinate the market to the solidarity and environmental logic proposed by 2030 Agenda means that we should not think how to produce more, but how to organize the national productive structure in order to subsidize universal systems and the sustainable development. It is the inverse of the short-sighted way as economy has been traditionally dealing with the productive field of health. Through the production of drugs, vaccines and diagnostic kits, Fiocruz shows us that this way it is possible, that it is feasible to combine industrial production and innovation for meeting social demands. SUS and the health-economic-industrial complex are the preconditions – or the only opportunities – for Brazil to reach the SDGs until 2030. They are not problems for the country. They are an indispensable part of the solution.
Saúde Amanhã: What are the effects of 2030 Agenda to Fiocruz?
Carlos Gadelha: As a strategic State institution, Fiocruz is involved with the social and economic development of the country through research, technological development and innovation and, also, the articulation between health and sustainable development. Accordingly, the question that we have put in our political and academic forums is how to turn the vision of future proposed by 2030 Agenda in public policies in the health area and in institutional policies at Fiocruz.
We believe that the forces of mobilization of society and of its representation in the State need to be revived with future projects. This is the challenge that Fiocruz intends to respond with its Coordination of Prospecting Actions and initiatives such as Brasil Saúde Amanhã network, that, with the seminar Health, Environment and Sustainable Development (Saúde, Ambiente e Desenvolvimento Sustentável) takes an important step in the deepening of this discussion in the health area. There is a convergence of values: Agenda 2030 is the right place for us to discuss, in a global and national context, the issues of sustainable development. And it necessarily involves the discussion of the role of society and the State in shaping the strategy to be adopted.
In this perspective, Agenda 2030 has the potential to be a mobilizing and catalyzing movement for society to change the institutional, economic and social patterns inherited from the past, which block the Goals of Sustainable Development. Or that global commitment will become an agent of transformation, changes, or become a rhetorical instrument. It is up to us - health organizations, intellectuals, society – to make all these terms, sometimes dry, compatible to the understanding of all.