A relação entre o público e o privado no sistema de saúde brasileiro: repensando o papel do Estado.

Abstract

This study analyses the role of the State in the context of the Brazilian health system, with regard to the public/private relationship, making a comparison with international experiences, in particular the reforms carried out in the centric countries. It is based on an analysis of the Keynesian theory to identify not only the role to be played by the State besides the counter-cyclic function, but also to situate historically the birth of the universalist systems of social protection in Europe. The changes undergone by the capitalist system in the 70s led to a reversal of politico-ideological orientation which brought proposals of the introduction of market mechanisms into social protection systems and a drawing back of the State. To understand the picture of the State that emerges from this, it is presented and analyzed the fundamental concepts of the regulation and its application in the context of the specificity of the health service market. The presentation of international experience, particularly the explanation of the motivation of the reforms carried out and the results achieved, is given here with the aim of comparing later with what is specific in Brazil in the relationship between public and private. The reflection on the development of the health system in Brazil dwells on its evolution during the period between the creation of pension funds (CAP) and the 1988 Federal Constitution in order to gather particularities in the relationship between the State and the Market, and at the same time to show the moment of the break with the model of protection based on social insurance, which the country followed at this time. The difficulties in putting into practice the concept of universality as defined in the Constitution are analysed from the point of view of the untimeliness of the change of model and the bias towards privatism which the health system in Brazil follows. The contradictions generated by the public/private interfaces in health are explored, focusing on the lack of demarcation of room for action by them, but mainly focusing on their financing. The main conclusion drawn is the believe on that the permissivenes of the State in allowing the private sector to encroach on and appropriate public resources and spaces, and even in increasing the commercialisation of health, makes it difficult for the concept of universality in health attendance to become reality. Finally, the study describes the conflict of interests of the actors involved in the system, which makes it difficult for the Brazilian State to exercise its capacity of governance, and points to the necessity to review the basis of the relationship State versus Market and the redefinition by society as to how much involvement it wishes to give to private enterprise in the area of health.