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OUTSOURCING IN HEALTHCARE, CHANGES IN SUS MANAGEMENT

AND WORK RELATIONS IN A NEOLIBERAL BRAZIL

Anderson Iacer Bueno Carneiro1

Caio Murilo Leite2

Rafael Santiago3

Abstract: Labor relations have been adapting to new legislation and the market prole over the ye-

ars, a way that broadens a debate in the health sector, correlating changes in the management of the

Unied Health System (SUS) and the arrival of the provision of services, by the cooperative entities,

with a contractual conguration,which reinforces the labor issue and expresses the scenario of ne-

oliberalism in Brazil. The present research aims to raise the discussions present in the cited parts,

having the versions, such as unions, associations and workers’representatives,which present a critical

position and point to the precariousness of labor relations, fearing the lack of inspection of resources

transferred in the current model, while public managers and service providers say they are able to

meet the demands and contracts signed with municipalities and states, so that health outsourcing takes

place in our country. Legislation in constant adaptation seeking to guide the quality assistance to the

health user seeking a political and social balance. For this, a bibliographic review was carried out on

the proposed themes, with the main and most recent articles found. In this way, it is considered that

in a country that descends from slavery and exploitation of cheap labor, the problem is not that social

spending ts in the public budget, but that universal rights t in the psyche of the elites, who are in-

dignant with basic rights oered the working class.

Keywords: Public Management. Health. SUS. Outsourcing. Work

1 Specialist in Health Planning and Management audit by Facuminas

2 Mechanical engineering from UTFPR

3 Nurse at the Federal University of Pará

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INTRODUCTION

Working in Brazil plays a social role and reinforces the need to achieve the dignity of human

beings, providing means of subsistence and organizing their quality of life. Throughout history, the

labor sector has experienced dierent moments, changes in employment relationships, innovation in

Brazilian legislation, permissibility of actions and policies to promote debate and market sustainability

(PIALARISSI, 2017).

In the health sector it could not be dierent with the promulgation of law 8,080 of 1990. The

achievement of the Unied Health System brings an ascendancy in the provision of services and in

this, regulated by law 8142, of December 28, 1990, it provided for community participation in the

management of the SUS, exemplifying the intergovernmental transfer of nancial resources in the

health area and fundamentally established other measures (SANTOS, 2018).

These measures were redundant for service providers and promoted debates with the

participation of entities linked to the third sector, given that municipalities and states began to

organize and decentralize health in Brazilian territory. Thus, the resources allocated to health funds

can be applied to cover the services provided, both in primary care and in specialized care and the

philanthropic sector (FISCHER; FALCONER, 1998).

These debates concern society and also professionals in the eld, as studies indicate that the

new work relationship, linked to privatization in healthcare, brings with it the social precariousness of

work and reveals the fragility of labor policy in Brazil. These attacks are not only linked to working

conditions, but also reveal a lack of investment to enhance the functionalism, which directly implies

the public service oered to the population (PIALARISSI, 2017).

LABOR RELATIONS AND MARKET INNOVATIONS

Social and cultural factors must be remembered, such as the change in work and employment

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relations, with the creation of the individual micro entrepreneur, which highlights a society that

permeates the idea not so far removed from colonial and slave-owning Brazil. Since the abolition

of slavery, Brazil has not ignored the diculty in mapping and promoting social equality, as well

as demonstrating resistance on the part of the market to improving labor relations with its people

(AZEVEDO, 2019).

The neoliberal model of privatization demarcates the interests of the dominant classes, which

involves keeping the growth and earnings of their establishments under control. According to recent

research, one of the most protable sectors in Brazil is health, which has considerable annual growth

and demonstrates an even greater potential for leverage in the coming decades (REIS, 2018).

With the possibility of nancing and costing, public managers begin to evaluate possibilities

for contracting services by third sector entities. Entities that present themselves as NGOs , foundations,

institutes and associations, oering health services or even administering and managing hospitals

and public health services in a philanthropic or contracted manner. This is seen as an advance when

thinking about outsourcing, as control is not solely in the hands of states and municipalities. Carefully,

unions and entities representing Workers fear that this will harm work and employment relationships,

making the services provided precarious (DRUCK, 2016).

On the other hand, public management states that the Third Sector organization has the

competence and legitimacy to be linked to the SUS in a contractual manner, respecting the established

contracts and legislation in force in the country. As a result, the participation of this sector becomes

more present in the reality of many municipalities (DRUCK, 2016).

In view of this, there is a concern regarding the public resources used by these entities, which

now have nancial control over the services thus supplemented. Authors reveal that there is a need for

supervision and watchful eyes from the audit courts, legislators and the Public Ministry. This form

is one of the ways to maintain transparency and fairness in the bidding and execution processes for

services. One question remains: will states and municipalities be able to maintain routine oversight of

the resources sent to these entities? (DRUCK, 2016).

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Workers reveal that the salaries and benets oered by these sectors are most of the time

lower and dierent from those that would be available to public servants, further instigating the debate

on precarious work relations. Unions linked to the working class express diculties in collective

negotiations with employers and the impact of this debate appears to be long and persistent. Thus, it

demonstrates the need to know the worker’s prole and the working conditions to which he or she is

being exposed (PIALARISSI 2017).

According to Franco and Druck (2009), it is highlighted that there are six types of

precariousness in Brazil:

1. Vulnerability of forms of integration and social inequalities;

2. Intensication of work and outsourcing;

3. Insecurity and health at work;

4.Loss of individual and collective identities;

5.Weakening of workers’ organization;

6. Condemnation and dismissal of Labor Law.

In health, other factors must be exposed, such as the loss of quality of services oered to the

population and the deciency of human resources management, which causes dissatisfaction on the

part of professionals and patients (PIALARISSI, 2017).

Solutions should be debated by public administrators, managers and representatives of the

working class, in order to guide the problems and organize strategies and suggestions for improvements

(PIALARISSI, 2017).

GUARANTEE OF HEALTH CARE FOR THE POPULATION

Over the years there have been important changes in policies and guidelines related to the

management model applied to the SUS, including nancing congurations and resource reallocation.

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Therefore, planning is essential for professionals to have working conditions and income, users

to achieve the quality of care oered and service providers to achieve this balance (MENEZES,

MORETTI, REIS 2019).

Emphasize that public health services are permeated by the responsibility of the state, using

what is described in the Federal Constitution of 1988, in its “Art. 196 -Health is the right of everyone

and the duty of the State, guaranteed through social and economic policies that aim to reduce the risk

of disease and other health problems and universal and equal access to actions and services for their

promotion, protection and recovery” ( MENEZES, MORETTI, REIS 2019).

The social credibility of the social work carried out by social entities were foundations that

contributed to the growth of the third sector, which reinforces the traditional values of Brazilian

culture and thus there was improvement and strengthening of these which became part of the health

promotion, protection and recovery services , as provided for in legislation and public health policies

(MENEZES; MORETTI; REIS, 2019).

ESTABLISHMENT AND ORGANIZATION OF CONTRACTS

According to the terms of art. 198 of the Federal Constitution and art. 4th of Law No. 8,080,

of 1990, the SUS is made up of health actions and services , provided by federal, district, state and

municipal public bodies and entities, with the participation of the private sector in a complementary

manner, through partnerships. or the purchase of services (SALGADO, 2017).

Concrete and emerging situations in the country in the eld of health due to growing and

more complex demands required legal-administrative alternatives for the provision of services to

the population and complementing the direct action of the Public Power. Public-private cooperation

requires the use of management methods and instruments, which requires exceeding previously

established goals, highlighting the importance of ensuring adequate technical guidance and

instrumentation for professionals, civil servants and public managers who conducted the planning

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and negotiation processes. , implementation, monitoring, evaluation, supervision and control of the

results of these contracts (SALGADO, 2017).

There are several models of contractualization and institutional performance in the SUS.

The gure below seeks to investigate and exemplify two of these models through a owchart, how it

happens and how it proves to be functionally important.

Figure 1. SALGADA, Valeria. Contracting in the SUS. Contracting models. Available in: https://

www.contratualizacaonosus.com/documentos-1. 2017.

The Flowchart presented straties internal and external contractualization and presents in an

explanatory manner the dierences between them, with: 1) internal contractualization being the model

that takes place through a management contract or similar intermediary within the administration,

between the SUS manager and entities linked to the Health Secretaries, with the purpose of meeting

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previously established performance goals. It is important to highlight its administrative coordination

and supervision functions provided for in item I of the sole paragraph of art. 87 of the Federal

Constitution and Articles 19 to 28 of Decree-Law No. 200 of February 25, 1967. Its purpose is to

encourage the contracted body or entity to adopt the results-based management model; and expand the

government’s internal capacity to implement public health policies in a coordinated and synergistic

manner; 2) external contractualization that occurs between the SUS manager and private entities,

preferably non-prot ones also with a public contract model directly with the following: Ministry of

Health, State or Municipal Health Secretariats and their linked entities, providing compliance with

the contractual object , including pacts and agreements between the parties. This is provided for in

the National Program for Improving Access and Quality in Primary Care, and in the contracts signed

with SUS managers (SALGADO, 2017).

OUTSOURCING REINFORCES EXISTING NEOLIBERALISM

To understand and distinguish liberalism and neoliberalism, it is important to note that

classical liberalism advocates that the government does not intervene in the economy, respecting the

functioning of the market in a free and unregulated manner (REIS, 2018). In neoliberalism, there is

an inversion of this principle, in which the market becomes the standard for regulating government

practices, limiting state intervention (REIS, 2018).

At the beginning of Fernando Henrique Cardoso’s (FHC) government in 1995, the country

faced a general oil strike that had a signicant impact . This movement left a lasting mark on FHC’s

government program and revealed the political interests that dominated the Executive. Neoliberalism,

which began discreetly with Fernando Collor de Mello, manifested itself more harshly during FHC’s

government, resulting in the defeat of the workers’ union movement and highlighting the presence of

neoliberalism in Brazil (REIS, 2018).

FHC came to be seen as an enemy of workers, which contributed to the election and victory

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of Luiz Inácio Lula da Silva as president in 2002.

Lula took oce for the rst time in 2003 with the expectation of bringing remarkable social

changes to Brazil. However, even with the victory of the Workers’ Party, it was not possible to prevent

the State’s privatization policy and the reforms imposed by the IMF. The health sector was also

aected by these reforms (REIS, 2018).

During the second decade of the 21st century, from 2016 to 2022, neoliberalism in the health

area manifested itself intensely, highlighting the State’s actions in favor of the market. An example of

this was the adoption, during the Temer government, of an economic policy based on austerity, to the

detriment of social policies. Furthermore, the implementation of a scal adjustment policy stands out,

which froze public expenditure for up to 20 years. This scenario was established by the New Fiscal

Regime (NRF), established by Constitutional Amendment (EC) 95, revealing the elements of new

neoliberal project in Brazilian health (MENEZES,MORETTI, REIS, 2019).

Since Temer’s administration, the Unied Health System (SUS) has been the target of

proposals for structural changes, with the spending cap being used as a way to control and publicly

expose expenses. visible, establishing a connection between austerity and collective interest. EC 95

created a sensitivity towards the expansion of expenses, making social policies merely an object of

control (MENEZES, MORETTI, REIS,2019).

The health budget at the federal level was frozen for 20 years, being readjusted only based

on ination measured by the Broad National Consumer Price Index (IPCA). EC 95 disregarded the

health needs of the population, population growth, demographic transition, the necessary expansion

of the health network and the incorporation of technology in the health area (MENEZES, MORETTI,

REIS, 2019).

Changes in the care prole, with the increase in the prevalence of communicable and non-

communicable diseases and external causes, together with ination in the health sector, higher than in

other sectors of the economy, led to a decoupling of social spending in relation to revenue growth in

the next 20 years. Even with an increase in federal revenue, there would be no additional resources for

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investments in social policies. The basic principle of EC 95 was to prevent real gains from economic

growth from being automatically directed to primary expenses (MENEZES,MORETTI, REIS,2019).

If this situation persists, with underfunding actions, it is possible that the SUS will become

increasingly smaller and more precarious than what is currently available to the Brazilian population.

These premises point to a possible return to an exclusionary health system, beneting only a few. Even

with outsourcing projects in the neoliberal model, it is not possible to predict the criteria that would

be proposed for population stratication, nor the scope and quality of care that would be provided

(MENEZES, MORETTI, REIS, 2019).

FINAL CONSIDERATIONS

The concepts presented so far refer to a past in which social policy did not aim to guarantee

rights, but rather to maintain an individual logic based on dependence on social charity, mediated by

the purchasing power of the bourgeoisie. It can be argued that, for a country with a history of slavery

and exploitation of cheap labor, the challenge is not to make social spending t into the public budget,

but rather to make universal rights are internalized by the elite, who are indignant at the basic rights

oered to the working class.

In this context, the images conveyed by advertisements emerge, which only perpetuate the

ght against racism and other social issues from the old world, disguised as something new. In it, the

public budget is disconnected from social obligations and commitments, serving only to naturalize

the exclusion of workers and serve the interests of the market.

The market, in turn, observes the ineectiveness and insuciency of public authorities in

providing health services and starts to use laws as guides to improve daily, oering opportunities for

negotiation and outsourcing in the health area.

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References

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REIS, Ana Terra. NEOLIBERAL DESERTIFICATION IN BRAZIL (COLLOR, FHC AND LULA).

PEGADA-A Revista da Geograa do Trabalho, v. 19, no. 1, 2018.

AZEVEDO, Braynna Barbosa. Outsourcing in Brazil: an analysis of the changes brought by Law

n.13.439/2017.

DRUCK, Graça. Outsourcing in public health: dierent forms of precarious work. Work, education

and health, v. 14, p. 15-43, 2016.

ORGANIZATIONAL, Dutra Gestão. Challenges of government and third sector partnerships.

Administration magazine, v. 33, no. 1, p. 12-19,1998.

SANTOS, Nelson Rodrigues dos. SUS 30 years: the beginning, the journey and the direction. Science

& Public Health, v. 23, p. 1729-1736,2018.

MENEZES, Ana Paula do Rego; MORETTI, Bruno; REIS, Ademar Arthur Chioro dos. The future

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debate, v. 43, p. 58-70, 2020.

SALGADA, Valeria. Contractualization in the SUS. Contractualization models.Available at: https://