Brazilian public health experts see de-privatization, regional collaboration as keys to strengthen health system

On Wednesday, July 22, public health experts Ligia Bahia and Gonzalo Vecina met at the São Paulo School of Sociology and Politics Foundation (FESPSP) to discuss ways to strengthen Brazil’s Unified Health System (SUS) amid the challenges posed by the 2026 elections. The discussion was moderated by Aparecida Pimenta, current coordinator of FESPSP’s Walter Leser Institute.

The panel was part of the seminar series Challenges for Another Brazil, organized by FESPSP and Outras Palavras. The six previous sessions addressed other strategic issues for the country’s structural transformations, such as the public budget, Social Security, labor, public safety, energy sovereignty, and industrialization. All recordings are available online.

Ligia Bahia, a professor at the Federal University of Rio de Janeiro (UFRJ) and coordinator of the Group for Research and Documentation of the Commercialization of Health (GPEDS), dedicated her remarks to calling for a sober assessment of the current state of the SUS, which is increasingly overtaken by public-private relationships. In this context, she argued it is time to adopt a strategy of “de-privatization” of the healthcare system. “If we don’t move toward this, there will be no more SUS,” she emphasized.

For his part, Gonzalo Vecina, professor emeritus at the School of Public Health of the University of São Paulo and founder of Anvisa, highlighted five key areas where efforts must be focused to strengthen the SUS – including the Health Economic-Industrial Complex, funding, and the establishment of new regional management structures.

“We must not confuse incremental changes with reforms”

Ligia Bahia opened her remarks by noting that four decades have passed since the SUS was established by the 1988 Federal Constitution and called for a thorough reassessment. She argued that despite the health movement’s courage and the importance of public healthcare, gains have been modest: “We have a social protection system in Brazil that is incomplete, very fragile, and full of holes. It is totally privatized, more so in health than in education.”

Read more: 8th National Health Conference in Brazil: two opposing projects, 40 years later

Bahia added: “Inequality must be the starting point for any discussion on health. This also connects us to other sectors. Today, we are isolated: we have little dialogue with Science and Technology, Transportation, or Housing. Thus, the concept of social determinants of health is neglected – while it is precisely through this lens that we see inequality as what kills.” 

“We must ask: have the SUS and public health policies reduced inequality? The answer may well be no, just as economic inequalities have worsened. This contrasts with the apologetic view of the SUS as the largest and best system, but as scholars, we must clearly state that public policies must be geared towards reducing inequalities.”

Her assessment also highlighted that the SUS has effectively become a public-private system. “It is private in its financing, private in its workforce, and private in the provision of medical procedures. In a country with such inequality, we have a fully privatized health system that is inadequate and turns its back on the population’s health needs,” she explained.

In her view, funding is one of the most critical aspects of this process. “We have to fund the SUS, but how? What’s happening in practice is that private funding is increasing while public funding is decreasing. The alligator’s mouth is wide open.” For Bahia, even congressional appropriations are less significant than tax subsidies for private healthcare.

Read more: SUS: de-privatization is possible – and necessary

If the growing dominance of private interests over the SUS lies at the heart of its difficulties in adequately serving the population, Bahia pointed out, this contradiction must be the focus of the political struggle in defense of the right to health. This is where the cause of de-privatizing the health system comes in. The Observatory for the De-privatization of Health, coordinated by Bahia’s research group, states that the concept refers to “processes and movements aimed at expanding or reclaiming public and democratic control over essential services and common goods in order to meet social demands and collective needs.”

“In the elections, we’ll need to have a very consistent health policy agenda,” Bahia concluded.

Five points for revitalizing the SUS

In a concise speech, Gonzalo Vecina outlined five key issues to address within the SUS during the next political cycle.

Echoing Bahia’s concerns, his first point was healthcare financing. Beyond rejecting funding cuts, Vecina advocated ending tax exemptions for private healthcare and revising monetary policy. “We have to rethink this economic equation that only serves to tax people to pay interest to capitalists. We must stop this voracious drain on funds that creates enormous inefficiency,” he criticized.

Second was healthcare system management. Vecina argued that regional consortia – formed between municipalities or between states and municipalities – can help resolve current bottlenecks, particularly in supply procurement, staffing, and waiting list management.

Third, closely related to management, was primary care. Vecina is critical of the Agora Tem Especialistas (“Now There Are Specialists”) program, which has been positioned as the flagship initiative of Health Minister Alexandre Padilha.

“This program won’t solve any problems; it won’t increase the supply of care in the long term. It will provide some temporary relief here and there, but it isn’t the solution. Primary care may not treat cancer, but it can diagnose it if properly trained. The problem is that people need to be referred somewhere – and that somewhere doesn’t exist yet. We need to create specialized care networks that are accessible through primary care, that’s how we’ll be able to solve the problem that the Agora Tem Especialistas program seeks to address,” he argued. In his view, regional consortia are the tool that can make this expansion of the SUS feasible.

Read more: Jaime Breilh: Health is incompatible with capital

Fourth, Vecina highlighted the Health Economic-Industrial Complex, advocating for a focus on manufacturing “essential” products. “We need to produce vaccines, because we are a country that consumes 200 million doses when needed. I believe the experience with the Partnerships for Productive Development (PDPs) has been positive and is yielding results. With the strides that Fiocruz, the Butantan Institute, and Lafepe are making, they will be able to achieve even more. The other laboratories still need to make further progress,” he said.

Finally, Vecina stressed the need to strengthen social oversight within the SUS. “It’s difficult – very difficult – but it’s a tool that transformed the quality of what we were able to achieve in government. We have to strengthen it,” he concluded.

The report was written by Guilherme Arruda and published in Portuguese on Outra Saúde. It was lightly edited for length.

People’s Health Dispatch is a fortnightly bulletin published by the People’s Health Movement and Peoples Dispatch. For more articles and to subscribe to People’s Health Dispatch, click here.