Brazil should use its G20 leadership to support public health systems and promote decolonisation of global health

Abstract

Deisy Ventura and colleagues argue that Brazil’s presidency could be used to encourage countries to move away from a market driven approach and create true universal health provision

The G20 is a political forum of both developed and emerging economies that together account for up to 85% of global gross domestic product, 75% of international trade, and two thirds of the world’s population.¹ Initially an informal gathering focused on international financial governance to address successive economic crises, the G20 has gradually acquired a more robust structure and widened its scope to incorporate new topics, one of which is global health.²

In December 2023 Brazil took on presidency of the G20 for the first time. The role gives Brazil important responsibilities in organising G20 meetings, which will culminate in a main gathering in Rio de Janeiro in November 2024, as well as the capacity to influence the agenda.^{3 4} Furthermore, the country can draw global attention to its public healthcare system, which is perhaps the most ambitious in the world and aims to ensure universal and free access to healthcare for over 200 million Brazilians. This experience puts Brazil in a good position to advocate for universal access to health and public health systems to be included in the G20 agenda, countering the privatisation discourses and fiscal austerity policies encouraged by wealthy countries, international financial institutions, and major global health funders.

Brazil should also use its influence to argue for approaching the global health agenda of the G20 from the perspective of decolonisation, which has garnered substantial debate in recent years.⁵ The theoretical underpinnings of decolonisation of global health are still being consolidated, but for the purposes of this article we define it as a political movement characterised by three key attributes: the condemnation of persisting colonial ideas and practices within the realm of health, particularly “the cultural and social effects of colonial era violence, racism, misogyny, and Eurocentrism”⁶; a call for justice and equity, furthering the demand for redistribution of the power and resources currently concentrated in the global north, and aimed at “remov[ing] all forms of supremacy within all spaces of global health practice, within countries, between countries, and at the global level”⁷; and a shift of focus from the centre to the periphery, questioning models from the global north and replacing them with “models of self-determination that centre the global south in the primary role.”⁸

In this context, we consider that the Brazilian healthcare system, Sistema Único de Saúde, (SUS), must be regarded as a decolonial project. Despite its limits and shortcomings, the SUS stands as a reference in the pursuit of equity and justice in health.

Comprehensive state funded primary healthcare system

The SUS is a decentralised health system that provides a broad range of services, including primary care, hospitals, specialised care, pharmaceutical care, and public health services, funded by tax revenues and contributions from federal, state, and municipal governments.⁹ It is free of charge to all residents and visitors, including undocumented people.¹⁰

SUS management is highly complex, comprising more than 5500 municipalities. It also has to cope with the heterogeneity of health, social, and economic factors and clashes between political interests at each government level.¹¹ The system displays principles such as social control and participatory management through deliberative bodies made up of government officials, service providers, health professionals, and users, as well as promoting open dialogues with social movements. Despite the constraints of this experience, it can be considered an example of decolonial governance.

Among SUS’s strengths is the primary healthcare model, known as the family health strategy. It is the largest community based public healthcare programme in the world, providing primary care to around 60% of the Brazilian population.¹² The core of this strategy is the formation of multidisciplinary teams comprising health professionals and community health agents, who provide emergency care, health promotion, prevention, chronic disease management, and maternal and child services.^{13 14} In December 2023, there were 50 804 family health teams across 99% of Brazilian municipalities, mobilising 278 209 community health agents.¹⁵

The model contrasts radically with hegemonic notions that frame healthcare from a market perspective, combining fiscal austerity and the privatisation of care, as countries in the global north often prescribe to the global south.^{16 17 18} The SUS also departs from concepts of universal health coverage sometimes put forward by international financial institutions, which limit coverage for disadvantaged groups to a small set of treatments, instead of recognising the universal right to health.¹⁹

SUS: a product of democracy

By invoking decolonialism, we also refer to the history of Brazil and the legacy of deep inequalities left by Portuguese colonisation. Like several other former colonies around the world, Brazil still grapples with the structural inequity generated by slavery, indigenous genocide, predatory extraction of natural resources, and the spread of different forms of authoritarianism. Within the colonial and racist logic, low income people living on the outskirts of cities were marginalised and criminalised as focuses of disease.²⁰ Before SUS was established, state funded healthcare (which was rather insufficient) was available only to formal workers, with religious philanthropic institutions providing low income groups with some health services.²¹

After the end of the last military dictatorship (1964-85), the new Federal Constitution (1988) established the SUS, unprecedentedly declaring the principle of health as a citizenship right and a state duty. Therefore, this turning point of Brazilian public health came about at the same time as democratisation and was spearheaded by health professionals and individuals in civil society movements and organisations.²² From the start, however, SUS had to cope with a combination of economic recession, political crisis, ill conceived austerity policies, and political decisions aimed at reversing the right to health.²³

Despite chronic underfunding and the undermining by market forces, it stands not only as the most relevant outcome of democratisation but also, through its impact, the most relevant initiative for material democracy in Brazilian history. Hence the legacy of the SUS regarding advances in the health surveillance system, sanitary control, pharmaceutical assistance, transplants, the emergency ambulance service (SAMU), smoking control, HIV/AIDS, and blood quality. The national immunisation programme is the largest of its kind, and the country is self-sufficient in terms of immunobiological medicines.²⁴ The SUS has enabled Brazil to achieve large improvements in access to water and sanitation, immunisation coverage, and life expectancy at birth, unlike neighbouring countries in Latin America and other middle income countries.²³

Acknowledging the importance and potential of the SUS as an instrument of democracy does not mean turning a blind eye to its flaws and limitations. Chronic underfunding burdens the system, and islands of excellence coexist with areas where assistance is insufficient or fails to reach those in need. The expansion of private healthcare companies and health insurance plans, which receive substantial tax exemptions, is part of a scenario where the boundaries between public, philanthropic, and private sectors are blurred, hindering the full implementation of universal policies.²⁵ These challenges were exacerbated during President Bolsonaro’s administration (2019-22), which departed from previously established federal health and assistance policies. In addition to adopting ideological approaches to areas such as mental health, HIV/AIDS, and maternal health, the former Brazilian government drastically reduced public investment in important health programmes.^{26 27}

Decolonial health includes food security

Decolonisation of global health cannot be considered without acknowledging the problem of chronic hunger and malnutrition. President Luiz Inácio Lula da Silva championed the struggle against hunger in his first terms in office (2003-10). Thanks to social programmes developed from 2003 onwards, in 2014 Brazil for the first time left the list of countries whose populations faced chronic food shortages, as judged by the Food and Agriculture Organization.²⁸

The right to health and to nutrition are intertwined, which accounts for the emergence of important Brazilian nutrition policies within the Ministry of Health, such as the Brazilian dietary guidelines adopted in 2014. Endorsed by SUS nationwide, they highlight the consumption of ultraprocessed foods as a major risk to public health and promote typical ingredients of the Brazilian diet, such as rice and beans, as healthy and nutritious.²⁹ However, setbacks in social policies introduced by conservative governments from 2016, compounded by the covid-19 pandemic, caused 15.5% of the population to be affected by hunger and 58.7% by some level of food insecurity in 2022.³⁰

Faced with the recent experience of the covid-19 pandemic, which worsened hunger worldwide,³¹ international forums such as the G20 should consider food security as a central element of the response to international health emergencies. Although President Lula has proposed that the G20 launch a global alliance against hunger and poverty during its main meeting in Rio in November 2024,³² hunger is not yet on the G20 health working group’s agenda.³³ Brazil should use its tradition of including nutrition in public health to argue that hunger be considered under the topic of response to pandemics, as the population’s adherence to measures to control disease spread is crippled without adequate nutrition.

The role of SUS in the pandemic response went well beyond healthcare. Recent research on the peripheral responses to covid-19 shows how nutrition was a crucial aspect for the organisation of low income communities to tackle the pandemic, where people set up support networks and shared resistance strategies around food.³⁴ As the? SUS is localised, particularly through community health agents, who were familiar with or belonged to the area and were connected with local leadership, healthcare facilities had a central role in identifying and guiding people coping with food insecurity and hunger.²⁹ In 2022, building on this experience, the Ministry of Health issued guidelines to tackle food insecurity through primary healthcare, providing SUS managers with tools to identify households at risk and measures to be taken accordingly.³⁵

Despite the Bolsonaro administration preventing the SUS and other initiatives from formulating a national and systematic response to food insecurity, the system’s decentralised nature and the focus on primary care enhances another decolonial aspect of the SUS. This may evolve into a fundamental mechanism for tackling food insecurity in disenfranchised communities, particularly in a crisis context.

Decolonisation and democracy must go hand in hand

As the president of G20 in 2024, Brazil has an opportunity to contribute to expanding the agenda of decolonisation of global health by daring to stand for the SUS as a universal healthcare model to be followed and perfected in the global south. The country should also expose how prevailing ideas from high income countries account for much of the hardship the SUS must cope with, mainly through economic austerity measures and the perception of health as an exploitable market. There are precedents: when it established its HIV/AIDS programme to give universal access to treatment, Brazil challenged the recommendations of international organisations and wealthy countries, ultimately proving that equity was also a condition for efficiency in tackling the disease.³⁶

The movement for decolonisation of global health must go well beyond criticising international dynamics in research and education, or calls for limited initiatives to promote diversity. It should point to the need for structural reforms to tackle health inequities, which have been sidelined in recent decades by the dominance of neoliberal dogmas.^{37 38} In this sense, decolonisation and the struggle for real democracy, which we understand as the guarantee of the universal right to health, as showcased by the SUS, must go hand in hand.

Key messages.

• As the 2024 president of the G20, Brazil should include advocacy for universal access to health and public health systems in the agenda

• Brazil’s health system (SUS) was formed during the country’s redemocratisation and has guaranteed universal healthcare for over 30 years

• SUS has been a beacon of democratic resistance during a far-right government and shown the benefit of localised organisation in responding to covid-19 and hunger

• The success of the system argues against the prevailing messages of market forces and austerity put forward by high income countries

• The SUS, despite its limits and shortcomings, is a model to be considered elsewhere