Health Policy and Economics (State of Health)
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Anglo-Saxon theorists made much more use of the concept of the political system; nevertheless, in the late s and early s the State was also reborn as an important conceptual element in understanding the organizing process of those societies in their domestic environment. The domestic counterpoint is necessary as this concept, understood as the national unit against other national units, always in play in the international panorama, has never been difficult to understand Easton, Referring to this discussion of establishing the State as an analytic concept and its antinomy, the political system, Schwartzman a reminds us that the preference for the concept of the political system manifests itself according to a historical-cultural specificity, that is, the almost lack of State in the USA and in England compared to continental Europe.
Actually, this comment is almost a quote the author used from J. Nettl who talked of the "[…] relative loss of interest […]" Schwartzman, a , p. Researchers in these countries much more commonly use the terms government or authority in the studies, closer to the "simple and light functional entities than to the historically weighty notion of the State" Schwartzman, a. Obviously, this historical-cultural outline neither exhausts nor circumscribes the problem as the political-philosophical tradition of the researcher affiliated with a range of concepts and notions is internal to the cultural backgrounds.
This affiliation enables us to recognize a discursive matrix in it which locates it at some point between the left and right wing of the political spectrum, both in practice and in political reflection. Let us digress briefly discussing how some of those possible positions view the problem of the State and its presence in the everyday life of individuals and societies. We will consider three positions: the Marxist left, the social democrats post Second International and the liberals.
These were, after all, the positions that informed the debate on the State and its role in Brazilian Social Sciences. For the Marxist left, the character of the State has always been a means, the existence of which was determined as part of the long term project, that of societal self-determination, although the revolutionary trajectory of diluting State power, paradoxically, strengthens its power in the dictatorship of the proletariat.
Self-determination is expressed in the councils' topics.
The extinction of the State would be the logical derivation of organizing the proletariat as the dominant class, as it would not become the dominant class in order to perpetuate its power, but rather to abolish class dominion, the practical justification for the existence of the modern State. The State is understood as organized violence on the part of one class towards another - in the capitalist system the bourgeois towards the proletariat, according to Valentino Gerratana , Italian Communist Party Militant and organizer of the celebrated edition of Antonio Gramsci's Prison Notebooks by the Editora Einaudi, in Obviously, the discussion is neither so simple nor so free of contradictions within the left wing all over the world, especially in the debate between members of the First and Second International.
This debate is expressed in Lenin's The State and the Revolution , among others, criticizing the gradualist reading of "opportunists" abolishing the State. Gradualism would be derived from an opportunist reading of the clash between Engels and the anarchists, when he affirmed, responding to them, that the State would not abolish itself, but would extinguish itself when the necessary conditions for its existence extinguished themselves. According to Lenin, this reading would have justified the way the Second International "opportunists" appropriated State machinery to perpetuate their power while waiting for what was to come Gerratana, More recently, Poulantzas Political power and social classes; State, power and socialism and; The problem of the capitalist state sought to develop - in contrast to what is usually known as the lack of Marxist theory of the State - a deeper reflection on this entity in its historical significance.
However, despite this attempt, it seems that clarity and precision in the concept of the State remains in progress.
In this respect, David Easton's critical theory appears most pertinent. This author states that the concept in extending Poulantzas' work gained various synonyms, even metonyms, such as a part taken for the whole. At some points, Easton states that the "[…] State is the ever evasive flower of Estado Poulantzas' theory" p. So…what IS the State?
It is not only political power, that is, class practices. It is not class power relationships. It is not an "intrinsic entity". It is not a Thing.
It is not a subj ect. It is not a set of functions. It is not governmental or ideological apparatus, although it manifests itself through them. Even Poulantzas, however, the theorist with the most weight who tried to advance a Marxist State theory, also professed the practical-theoretical desire to effect the Marxist teleology of the end of the State political power through abolishing the structure of class domination. The path of the concept of state as reaped by the international left does not seem to be easily transposed. In The State in Capitalist Society , Ralph Miliband also sought to demonstrate Marx's concept of the State, principally in the particular form of economic formation, showing how at that time of his life the German philosopher was reading this concept in a variety of way; however, his premise was always that the defense of property was its central fulcrum, irrespective of its form Miliband, Of the critiques of the State as absolute, in Hegel, from the bourgeois executive committee in the Communist Manifesto to the brilliant analysis of The 18 th Brumaire of Louis Bonaparte, Marx has the State as an instance of the reality with relative autonomy, the latter reading being the most mature of his work.
For classic liberals, it is enough that the State defends property and maintains the monopoly on the use of legitimate violence, the so-called rule of liberal law, separated into three autonomous powers, as opposed to absolutism in the constant pursuit of the "eternal pursuit of possible balance. Those classical law institutions, the maximum expression of which is the liberal constitution, assume that "[…] political rights should be realized on the economic scale", as long as society is "[…] a society of autonomous citizens enjoying uniformly distributed private property" Habermas, , p.
This premise leads the author to conclude that no such society has existed at any time. This was the period in which the modern State was established in the early days of the development of capitalist society, when the idea of generalized liberties and the end of the still clinging darkness of the feudal system was the project of the newly ascendant class. However, with the development of the capitalist system of production, both State and liberal activites changed:. The entrepreneurial and state regulatory activities correspond to the logic of reproducing the system at its current stage.
The expansion of state planning activities and directly productive investment by the State meets the requirements of a new market structure and of the dominance of large oligopolistic units within. The invisible hand of the market should be able to devote some of its primacy to regulatory state action.
Until the s, state intervention in the economy was seen as a necessary measure to compensate for the market's "imperfections". From the s onwards, both liberals and social democrats have understood the need to maintain good investment conditions for private enterprise. In the s, however, an offensive was mounted by the liberals, in the guise of neoliberals, to withdraw the State from activities into which the s' crisis had pushed it. The new "minimalist State" was underway. The postrevolution social democrats, forged in the fires of constructing the European Welfare State, attempted to maintain their historical conquests of protecting employment and working families, won after much struggle within and outside of the State: regulated working day, workers' rights that were respected by employers, the prohibition of child labor, work safety conditions within the capital-labor relationships; establishing social security, public housing policies for workers, universal health and education, protecting women, children and the elderly within the public ambit of the State.
The idea of democratizing the large spheres of power, be they administered by the State, be they large private companies, entered the debate in the latter decades of the 20 th century. This was the role of the social democrats, whose greatest exponent was Norberto Bobbio. The study of the State was the greatest concern during this period, especially based on Antonio Gramsci's particular reading of the concept of civil society in works such as The concept of civil society - O conceito de sociedade civil and The future of the State - O futuro do Estado , published in Brazil in and respectively.
The State was not understood as an epiphenomenon of the economic determinants, but rather as an essential element in the organization and conformation of social reality in its entirety. In other words, an actor fully acting and interacting with the other forces competing to define the course of the future of the society in which they found themselves.
It was a disagreement between liberals and Marxists on the State's role, its ontology and its bases, referred to by the North American David Easton earlier in this reflection. The author is uncomfortable with the return of the State to the discussion of political science in the United States and defends the use of the concept of the system and more appropriate for explaining the phenomena of party competition for political power.
However, for Latin American countries, especially Brazil, this discussion has no connection with reality, given the process of the State's construction here. State presence is so marked and preponderant that the idea that the national state was born even before the nation is coherent with accepted thinking in academic political science; otherwise, see these remarks by sociologist Fernando Henrique Cardoso:.
For us, it is almost impossible to think of it, because we were born in the Portuguese Empire, subjugated by an all-powerful state. Sometimes we forget, therefore, that this is not in fact necessarily a permanent situation ….
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The independent national state in Brazil was born after the transfer of the imperial state Portuguese to this country. It was the only situation in Latin America in which the Metropolitan State and all its bureaucracy, moved with D. The inspiration of the above interpretation by Cardoso is clearly rooted in the Weberian tradition, with Raymundo Faoro the first theorist to outline it in all its sophistication in The owners of power - Os donos do poder.
In fact, this is an interpretation that deeply marked Brazilian social thinking in the first half of the 20 th century. The idea of the formation of the State, before even the birth of the nation, had profound consequences in the way the intellectual elite and national cultures view and act towards the role of civil society in Brazil. The latter, and its popular classes, came to be seen as an amorphous mass needing to be shaped, cared for and guided towards superior illuminist thinking that gave meaning to their future and to "civilized order".
This way of viewing civil society was not the privilege solely of the conservative thinker. When drawing up theories, academia also centralized its analysis on the State's role and functions as the inducing agent of society movement as a whole. The discovery of civil society was one of the tasks to which the new generation of intellectuals dedicated themselves, academically maturing in the forges of resistance through the urban social movements of the s. However, the State did not lose its effectiveness, neither in life nor in future academic reflections.
We must not throw out the baby with the bathwater. Given the theft to which work in Brazil is still subject, the State is the institution to which the entire trade union movement refers in its clashes with capital. Brazil recovers its public sense of democracy in the decade in which the world saw the collapse of the social alternatives real socialism to the exploitation of labor as the modus operandi of the material production system.
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In the same period, the modern Western version of the State is questioned in the center of the goods producing world, the one in which that same State was born as necessary for organizing large scale production and social control of public life inherent to the capitalist system of production.
In this sense, the reflections by the Brazilian historical and intellectual tradition are closer to Boaventura de Sousa Santos, in Reinvent democracy - Reinventar a democracia Santos, than to those of the English intellectuals, concerning the daily life of workers as a way of distancing themselves from State preeminence, as the analytical focus of the human phenomena of the struggle for power.
The Brazilian State, from the narrowest perspective, concurrently with the creation of society itself, presents itself to the citizens as a Siamese twin to its existence.
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The social movements that occurred in Brazil in the s were directed at the State viewing it not as an enemy but rather as legitimizing their needs and demands, as Silva and Ribeiro show. The contradictory vision which pits civil society against the State does not seem to resonate in the lives of the majority of the population not served by the collective consumption goods ordinary to modern urban life. To some intellectuals this sounded like limiting in choice; to the population that uses municipal health care services, however, it was presented as a document of their "existence" for the State.
Recognizing citizenship. Nor is it strange for the trade union movement to seek State justice when it clashes with capital over defending workers' rights, or for urban social movements who appeal to the same actor to satisfy collective consumption needs. In other words, in Brazil, neither the popular classes nor the trade-union-organized working classes view the State as a mere bourgeois "executive committee" or a a mere entity that regulates contracts.
With the exception of the anarchist movements of the s and s, organized by new Italian leaders who began to work directly in the middle of urban industry and for whom the State was society's policeman, the struggle of the Brazilian trade union movement was limited to the factory environment, outside of the public regulation space in the early days of organization. Being a tributary of an enslaved society, Vargas' state was a counterpoint to the savagery of the working conditions imposed by the old agrarian exporter order and by the devaluation of work as an established activity of civilized life, according to the standards of the capitalist mode of production.
In truth, Brazil, as with the majority of Latin American countries, only saw political democracy re-established on more consolidated bases, due to the processes of urbanization and the increasing complexity of societies, in the late s and early s. Coincidentally, it was in this period that the "Washington Consensus" Batista, ; Portela Filho, came into force changing the State in the region, weakening its capacity to arbitrate at the very moment when the chance for power to alternate between various groups and factions of social classes became more real.
However, despite the countless privatizations of economic activities and the State's withdrawal from a variety of fields in which it used to have the monopoly social security, safety, oil extraction , a great part of its creative force remained. In Brazil, In Brazil, the cases of several citizens' councils working in state administration and the experiences of participatory budgeting even considering their limitations are emblematic of the possibilities.
From the perspective pointed out by Santos , therefore, first of democratically rediscovering work, looking at the State as a brand new social movement then becomes more socially attractive and more concrete for Brazilian society. It is not unusual for us, in our day-to-day practices, political struggle and demands, to turn to the State and understand it as the legitimate agent to settle disputes and meet collective demands for goods, especially in these times of possibilities to dispute a variety of electoral projects, something that has only occasionally occurred in our history.
In other words, the democratic discovery of the State and the chance to experience alternative governance projects. Rethinking the role of the State in Brazil based on public and social policies. Brazilian Social policies should be understood with reference to the State. The discussion of the nature of public policies is tributary to Social Science reflections on state development and planning in its dynamic.
According to Augusto , p. Whereas planning, especially in the s and s, can be seen as state action par excellence with a more ambitious horizon for structural change in society, public policies do not have this objective, with lower capacity for transformation. Public policy refers to state action in the "[…] different dimensions of social life […]" and the function of which is to impose "[…] a specific rationality on the various orders of State action, rearranging things, sectors and situations" Augusto, , p. The same reasoning is applied to political sciences.
Since the s, when the notion of planning gave way to discussions on public and social policy, the driving force of the evaluation of these forms of state intervention was economic efficiency as a unit of measure. This debate continued into the s, profoundly marking social policies as either redistributive or merely compensatory.
The poor cousin of the redistribution versus compensation equation, equity, as a rule, was impaired in the name of efficiency. It does not, however, invalidate the elevation of the political social idea as an action that is not subservient to economic policies but rather with relative autonomy of objectives. This process took place in the s Augusto, Two topics, the foci of State action, were included in the concerns of the military government as essential to achieving the planned development of the time: health and education.
Two topics that strongly mobilized discussion of the State's role in maintaining the workforce through indirect salary, thus easing the payment costs for capital. In the health care sector, associated with this discussion on maintaining the workforce using public funds, the issue of the "health industry" also emerged, the whole population benefitting from the expansion of individual medical care, not just INSS Social Security contributants and their dependents.
This was an extensive discussion in the s and s and there is a vast amount of literature on the topic, as public health has always been the object of political dispute between social actors Giblin, Public health is, therefore, a fertile field for investigating power relationships and the way in which the State is constituted, through the policies established and practiced. With the establishment of the Brazilian Unified Health Care System, after the Constitution, which proposed to universalize services, from public health activities to high complexity care in hospitals, the discussion took on new shape.
Brazilian public health has thrown light on the difficulty of articulating the different spheres of power - municipal, state and federal - the fruit of a lack of effective federal agreement in the Brazilian republic, since its genesis. At certain periods of the history of public health in this county, a process can be observed of concentration into the central sphere, state institutions present and controlling the territory from the center.
At other times, the authority of State governments and initiatives at a local level to meet the population's health needs can be seen more clearly. To exemplify, the health policies in the First Republic played an important role in creating and increasing the Brazilian State's capacity to intervene in national territory. Since , with the establishment of health legislation, the Brazilian public authorities began to provide legal and institutional apparatus and human resources to control the health conditions of urban housing and the production and sale of foodstuffs.
The following were the responsibility of the central federal government: health services at the ports, supervision of medical, pharmaceutical and laboratory activities including the control of vaccines and serum , organizing demographic and health statistics and imposing compulsory notification for various diseases typhoid, cholera, yellow fever, plague, smallpox, diphtheria, typhoid, tuberculosis and leprosy. Little by little, national health policy constituted itself into a network of public institutions that shared a general concept of health and disease, transforming communicable diseases into a political problem.
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The Spanish flu epidemic that engulfed the country in , which also affected the elite, lead to a minimal consensus concerning the urgent need for change in public health. Under the impact of this epidemic, the federal public authority has made progress in its ability to act coercively towards society during the s Hochman, In the early 20 th century, no one knew better than sanitation doctors how to exploit this situation politically. With the success of public health in controlling the principal epidemics by the early 20 th century there was a progressive decline in the model of the organization of services such as the power of the police, which lacked meaning.
The field of public health experienced a period in which its course was redefined and priorities were changed according to the agent defined by the health movement, with emphasis on health education and combating rural endemic disease. Resulting from this new organizational model were the health centers, which held educational lectures, created posters and leaflets and organized exhibitions with projections of slides and films. Thus, they diffused education with the goal of creating a health awareness, introducing a new character to public health services: the health educator.
Priorities were caring for sexually transmitted diseases, leprosy and tuberculosis Ribeiro, A series of centralizing measures from the "revolutionaries" affected sanitation services in and health center activities were reduced and they were transformed into dispensaries subordinate to the Hygiene, and Infant Care Inspectorate, annulling their preventative actions in favor of curative medicine.
In the same year, the Ministry of Health and Education was also created, the National Department of Health and Medical-Social Care of which coordinated special services to prevent and treat tuberculosis and leprosy, hospitals, laboratories and health centers in the bigger cities and health centers in the rural areas. Governing is different. Republicans are struggling to define the role of the state in health care.
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