Those who fight for a Unified Health System (SUS) that reduces inequalities rather than deepening them have long warned about ongoing pressures to privatize the healthcare system in Brazil. But it is also necessary to think about ways to de-privatize it: that is, strategies to bring back under public control the components that have been handed over to corporations and that, as a result, fragment the system and harm the population.

This is a warning coming from Leonardo Mattos, coordinator of the Observatory for the De-privatization of Health and the Group for Research and Documentation of the Commercialization of Health, associated with the researcher Ligia Bahia. Mattos was a featured interviewee in Outra Saúde’s “SUS: 35 years” series.

“In order to have a truly universal SUS in Brazil, we will need to de-privatize it,” he argues. “One thing is not possible without the other. We need to take this conclusion to its ultimate consequences in terms of projects, proposals, and policymaking.”

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To do so, it is first necessary to understand how the private sector penetrates the public health system. Mattos, who is also a professor at the Institute of Collective Health Studies at the Federal University of Rio de Janeiro, identifies four main ways this happens. The first form of privatization occurs in the area of health financing and resource allocation. Today, total health spending in Brazil amounts to 9.7% of GDP, but public investment accounts for only about 40% of that total – roughly 4% of GDP. “In other universal health systems, this figure reaches 80% or more,” he explains.

“This composition of spending is a structural problem that has persisted over time. When we look at health expenditures, it becomes clear that the system’s financing is very unbalanced,” the researcher warns. The remaining 5.7% of spending comes from private sources, largely from families through out-of-pocket expenses for medicines and private health insurance. This leads to the second form of privatization within the system: supplementary health care.

Historically, the private medical services sector serves about 25% of Brazil’s population, primarily through health insurance companies. This clientele is made up largely of the upper classes and workers in the formal labor market. “It is important to remember that these health plans benefit from numerous incentives, mainly through tax exemptions for both individuals and legal entities. In other words, there is public financing of the private sector,” Mattos warns.

This distorted financing structure is, in his view, “a source of countless inequalities.” A health insurance market of this size also contributes to the fragmentation of the health system, he says. “There is reason to believe that this market has grown too large, generating significant disorganization and inefficiency, as well as medical practices that are poorly suited to our reality,” Mattos adds.

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The third way private interests penetrate the SUS is through the provision of services. Brazil has a large network of private providers operating at all levels of care and degrees of complexity, Mattos explains, and the public system relies heavily on them to serve the population. One example is the Ministry of Health’s Agora Tem Especialistas (“Now There Are Specialists”) program, which seeks to expand access to consultations, diagnostic tests, and surgeries by making extensive use of private providers – effectively displacing these services within the SUS to a secondary role.

This happens even when companies are not directly involved in managing the health system itself, as is the case in primary health care through so-called social healthcare organizations, the OSS. These entities are contracted primarily by municipal governments to administer care to the population. Operating with public funding and guided by a neoliberal logic, they impose targets that are disconnected from the real needs of local territories and frequently lead to precarious working conditions for their employees.

Together, these dynamics contribute to at least three major problems, according to Mattos. First, they generate a fragmented and segmented health system. Second, they prevent Brazil from developing a system oriented toward health needs and grounded in territorial and regional planning. Third, they contribute to the historical and chronic underfunding of the SUS, weakening the provision of services to the population.

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Yet the privatization of health care in Brazil did not begin with the SUS, Mattos explains. Rather, its creation merely reorganized privatization on new foundations. “The Brazilian health system has a historical tendency toward privatization that intensified dramatically during the military dictatorship and continues to this day,” he says – a process that was not interrupted by the health reform. At the same time, he points out, the SUS has made it possible to de-privatize key areas of care, including the national immunization program, the nationwide expansion of primary health care, and the national transplant system, which operates with a unified waiting list for all patients.

But how, and where, should the process of reversing the forms of privatization outlined above begin? Mattos argues that this effort should start by examining experiences in the Global South, in order to think through alternatives developed from the South for the South. He emphasizes the importance of looking not only to Latin America, but also to countries in Africa and Asia. “None of these experiences will tell us exactly what to do in Brazil, but they will show us that it is possible to put de-privatization on the agenda, and that doing so can lead to real victories,” he says.

The objective, he insists, is not merely to expand the public sector, but also to reduce the role of the private sector. Both Brazil’s own history and the experiences of other countries demonstrate that this is possible, though it will not happen “by magic,” Mattos says.

To move forward, he argues, it is necessary to look at the health system as a whole and seriously consider the available paths for change. This process, however, cannot be realized without popular mobilization. “We need to build a broad and complex agenda, one that will require a very strong and honest debate among ourselves and with society as a whole,” he says.

One of the central challenges at present, according to Mattos, is convincing as many people as possible of the importance of de-privatization. “I don’t believe we will achieve profound changes in the health system – or in society in general – unless we build political forces capable of mobilizing people around a better project for society, based on social justice, sovereignty, and the universal right to health,” he concludes.

The interview with Leonardo Mattos was conducted by Gabriela Leite and published in Portuguese on Outra Saúde.

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