The Front for Life and updating the Brazilian Health Sector Reform Movement

ABSTRACT

This paper examined the Front for Life (Frente pela Vida, FpV), a movement of organised civil society in the health field, which sought to achieve political impact in response to the health crisis caused by the COVID-19 pandemic in the context of the Bolsonaro administration. Information was obtained through a document review of FpV publications, participant observation in meetings, demonstrations, livestreams and events in which the front participated or organised, as well as interviews of participants in its operating group. The analytical categories used were origin, trajectory, movements, management, the relationship between the FpV and the health sector reform movement, sustainability, challenges and the FpV’s prospects. The results showed that the FpV has led a large policy network of individual and collective subjects, scientific entities and organisations representing various segments of civil society to update the health sector movement and expand its social support base. Its trajectory has involved mainly technical, scientific and political action in multiple areas, working with the Executive, Judiciary and Legislative branches of government, as well as civil society. In conclusion, the FpV has proved to be an important social movement pressing the State to defend life and the universal right to health and to expand and strengthen Brazil’s Unified Health System, the SUS.

KEYWORDS
Politics; COVID-19; Health care reform; Unified Health System

RESUMO

Objetivou-se analisar a Frente pela Vida (FpV), um ator da sociedade civil organizado no campo da saúde, que buscou incidir politicamente diante da crise sanitária da pandemia da covid-19 no contexto do governo Bolsonaro. As informações foram obtidas por meio de revisão documental de publicações da FpV, bem como pela observação participante de reuniões, manifestações, lives e eventos nos quais participou ou organizou, além de entrevistas com participantes do seu grupo operativo. A análise considerou as categorias origem, trajetória, atores, gestão, relação entre a FpV e movimento sanitário, sustentabilidade, desafios e perspectivas da FpV. Os resultados evidenciam que a FpV capitaneou uma grande rede de políticas formada por sujeitos individuais e coletivos, entidades científicas e organizações representativas de diversos segmentos da sociedade civil, conformando uma atualização do movimento sanitário com ampliação de sua base de sustentação social. Sua trajetória contemplou, principalmente, a ação técnico-científica e política em múltiplas arenas, tendo nos Poderes Executivo, Legislativo e Judiciário, e na sociedade civil, espaços privilegiados de inserção. Conclui-se que a FpV se revelou importante ator social na conjuntura recente, tensionando o Estado na defesa da vida, do direito universal à saúde e da expansão e fortalecimento do Sistema Único de Saúde.

PALAVRAS-CHAVES
Política; Covid-19; Reforma dos serviços de saúde; Movimento sanitário; Sistema Único de Saúde

Introduction

This study addressed the Front for Life (Frente pela Vida, FpV), an actor of organised civil society in the health field, which sought political influence in response to a severe public health crisis caused by the COVID-19 pandemic in the context of the Bolsonaro government. The FpV was set up as a concerted response by various entities in the collective health field to mobilise other organisations in the struggle in defence of the right to life, democracy and Brazil’s Unified Health System (Sistema Único de Saúde, SUS).

By acting in various different political arenas, the FpV established itself as an important political actor able to influence health policies, settings for social participation in the health field and the electoral debate regarding the 2022 presidential succession. For these reasons, it is important in the present conjuncture to study the FpV as an organic manifestation of entities of the Brazilian Health Sector Reform Movement (Movimento da Reforma Sanitária Brasileira, MRSB) – also known as the health sector movement. Accordingly, this article discusses the FpV’s origins and trajectory, its composition and action strategies, its management and the characteristics of its action in updating the MRSB, as well as its sustainability, prospects and future challenges.

Material and methods

This study was anchored in a qualitative approach that considers social, historical, political and subjective processes. The techniques it used were the collection and analysis of documents, projects and motions drafted by the FpV, nine semi-structured interviews of members of the coordinating (operating) group and other entities connected with it (table 1), participant observation of events it organised, including the March for Life (Marcha pela Vida) and the National Free, Democratic, Popular Health Conference (Conferência Nacional Livre, Democrática e Popular de Saúde), as well as the discussions via the FpV WhatsApp group, lives and virtual and in-person plenaries. Data were collected from October to December 2022. The study was approved by the research ethics committee of the Universidade Federal do Delta do Parnaíba, as in ethics assessment certificate (Certificado de Apresentação de Apreciação Ética, CAAE) No. 72855723.5.0000.0192, Opinion No. 6.338.628.

Table 1
List of interviewees and their respective functions and entities

N	Name*	Function, Entity (Period of office)
1	Guinar Azevedo e Silva	President, Abrasco (2018-2021)
2	Túlio Batista Franco	Coordinator, Rede unida (2018-2022)
3	Fernando Zasso Pigatto	Chair, CNS (2018-2021 and 2021-2024)
4	Rosana Teresa Onocko Campos	President, Abrasco (2021-2024)
5	Lúcia Regina Florentino Souto	President, Cebes (2018-2022)
6	Luciana üdovic e Meire Rastelli	Coordinators, Cry of the Excluded
7	Soraya Soubhi Smaili	Member of the board, Andifes/Coordinator, Centro de Estudos Sou Ciência
8	Dirceu Bartolomeu Greco	President, SBB (2019-2021)
9	Elda Coelho de Azevedo Bussinguer	President, SBB (2021-2023)

• Source: prepared by the authors.
• ^*
  All had access to the manuscript and authorised publication of their names.

First, the FpV¹ website was searched to identify the key political events and documents that record its political activities. From that material, three analysis matrices were constructed using Microsoft Excel®, viz.:

• a. systematic survey of news items published by the FpV, using the categories ‘publication date, ‘type of occurrence, ‘actors’, ‘objective’, ‘publication abstract and link’;

• b. systematic survey of the main actions taken by the FpV by month and year; and

• c. matrix with the distribution of FpV actions by year, type and issue.

Participant observation was used as a complementary strategy at in-person and on-line meetings, demonstrations, lives and events that the FpV took part in or organised, as well as nine interviews of participants from its operating group and other related entities. The inclusion criterion admitted all actors who formed part of the FpV operating group and accepted the invitation, as well as other actors mentioned in the operating group interviews.

Data analysis was systematised by way of the categories ‘origin’, ‘trajectory’, ‘actors’, ‘management’, ‘relation between the FpV and the MRSB’, ‘sustainability’, ‘challenges’ and ‘prospects of the FpV’, considering the health policy process, the subjects and the political conjuncture in which the FpV emerged and acted.

Results and discussion

With a view to making them better understood, the results are presented in four sections that reflect the categories identified for analysis of the FpV in this study, viz.: a) Trajectory of political action; b) Management; c) Relation of the FpV with the MRSB; and d) Sustainability, prospects and challenges.

Trajectory of the FpV’s political action

Organisation of the FpV began with alliance building and the publication of two critical documents regarding the Bolsonaro government and the COVID-19 pandemic. The first was a note on the importance of social distancing, in light of scientific recommendations by the Brazilian Society for the Progress of Science (Sociedade Brasileira para o Progresso da Ciência, SBPC); the second was the ‘Open letter in defence of life, democracy and the SUS’, which was published by Brazil’s National Health Council (Conselho Nacional de Saúde, CNS).

The FpV emerged, on the initiative of the board of the Brazilian Collective Health Association (Associação Brasileira de Saúde Coletiva, Abrasco), from a group set up comprising representatives of Abrasco, the Brazilian Center for Health Studies (Centro Brasileiro de Estudos de Saúde, Cebes), the Brazilian United Network Association (Associação Brasileira da Rede Unida, Rede Unida) and the Brazilian Bioethics Society (Sociedade Brasileira de Bioética, SBB), which were all active on the CNS, in its sector of National Entities of Health Professionals/Scientific Community in the Health Field. Since 2018, these four entities had formed a collegiate body for the purpose of sharing ideas and positions on issues discussed on the CNS. These entities later mobilised other national bodies for a meeting at which strategies were discussed for joint action in response to the pandemic. Participating in that meeting (as recalled by Lúcia Souto) were the SBPC, the National Conference of Bishops of Brazil (Conferência Nacional de Bispos do Brasil, CNBB), the National Association of Heads of Federal Higher Education Institutions (Associação Nacional de Dirigentes das Instituições Federais do Ensino Superior, Andifes), plus the Brazilian Press Association (Associação Brasileira de Imprensa, ABI) (mentioned by Túlio Franco) and the Brazilian

Association of Sciences (Associação Brasileira de Ciências, ABC) and the Arns Commission (Comissão Arns) (as recalled by Gulnar Azevedo e Silva). In the words of the then president of Abrasco, in an interview for this study, the respective presidents decided to engage in “joint action to generate a broader movement”, which they named the FpV.

The FpV was officially launched on 29 May 2020, in a virtual political act attended by leaders of the founding entities, members of parliament and representatives of various organisations and social movements. The act invited organised sectors of society to join the FpV. By dialoguing with a diversity of social actors, the FpV leveraged and strengthened a network of social movements in the health sector.

The FpV’s action strategy was rooted in three dimensions: technical and scientific; political; and civil society mobilisation. The FpV produced a number of documents (plans, manifestos, notes, letters and reports) reflecting its positions and proposals anchored in technical and scientific knowledge, which – among other things – fostered relations with scientific entities in various different fields. The FpV also called on the Executive (at the federal, state and municipal levels), the Legislature (federal House and Senate) and lastly the Judiciary, to fulfil their duties effectively. It also acted to mobilise the widest possible diversity of civil society actors, with a view to forming a public health awareness.

By and large, around the core group that formed the FpV’s coordinating body (the self-styled ‘operating group’ of Abrasco, Cebes, CNS, Rede Unida and SBB) was a set of individual and collective actors who frequently joined in FpV actions and, accordingly, constituted that network. In the words of Fernando Pigatto (chair of the CNS in the 2021-2024 administration) at interview, over the whole course of its trajectory, the FpV played a leading role in diverse, reactive and propositional actions carried out both in isolation and jointly with other entities: “from its creation until this year [2022], the Front has acted to resist, confront and propose in response to COVID-19 and in defence of the SUS and Democracy”. The reactive actions involved primarily criticism of the State’s action or omission in conducting health policy with regard to COVID-19. As regards its proposals, the FpV prepared a National Plan in Response to the COVID-19 Pandemic and manifestos of proposals for combating the pandemic appropriately and strengthening the SUS.

During the time that social distancing measures were in place in the COVID-19 pandemic, the FpV turned clearly to new information and communication technologies and tools and intensified its use of digital media (sites, blogs, WhatsApp, YouTube etc.). From analysis of the information collected regarding the FpV, it was possible to consider its trajectory systematically in terms of three phases that mark out the formation of this collective subject: Phase 1 – organising the FpV in response to COVID-19; Phase 2 – establishing the FpV as a political actor in the health sector; and Phase 3 – the FpV in rebuilding Brazil. The FpV’s main strategies and actions in each of these three phases, as well as the actors involved, are described below.

PHASE 1 – ORGANISING THE FPV IN RESPONSE COVID-19

The first phase of the FpV’s trajectory, including its process of organising and then mounting its first activities in response to the federal government’s actions and omissions in combating the pandemic, corresponds to 2020. In that complex scenario, framed in the vacuum left by the State response to the pandemic, the FpV called the first Virtual March for Life, on 9 June 2020, with the support of more than 560 scientific entities, organisations, social movements and activists from diverse sectors of civil society.

The following month, the Front launched the National Plan to Combat the COVID-19 Pandemic², an extensive document underpinned by the technical and scientific knowledge of various different areas of the collective health field. That plan set out pathways for tackling the pandemic, besides emphasising the centrality of the State and the Ministry of Health in coordinating these actions and in formulating and directing related public policies³. The FpV worked to amplify the document’s political influence and it was presented to members of the national congress, the foreign affairs committee of the lower house, and formally delivered to the Ministry of Health. Note that the CNBB did not join in the process of developing this plan, because, as of the document’s second version (issued on 3 July 2020), when examining women’s health in the context of the COVID-19 pandemic, it included contributions in the field of gender and health, in the form of thinking about sexual and reproductive rights (legal abortion)².

In all its actions, the FpV made a priority of defending the SUS, to the point of holding the national campaign ‘Brazil needs the SUS’, which was launched in December 2020 with a view to “mobilising society to the importance of defending the SUS and the risks it faces”⁴. Some months later, the FpV joined with various education entities to launch the manifesto ‘Occupy schools, protect people, recreate education’⁵, expressing a position contrary to proposals to relax health restrictions in the school system of Brazil’s states. A new, revised and expanded version of this manifesto was later issued with the title ‘Occupy schools, protect people, value education’⁶.

In view of the foregoing, the work of the FpV in this first phase of its trajectory can be characterised as forming the network and prioritising technical, scientific and political contributions in proposing pathways to meet the main challenges posed during the COVID-19 pandemic. It is important to draw attention to the evidence regarding the ability of the FpV, of more than 560 entities, to mobilise and to extend participation beyond the health sector. This was true of both the March for Life, with its wide diversity of participants, and the coalition formed with entities in the education field.

PHASE 2 – ESTABLISHING THE FPV AS A POLITICAL ACTOR IN THE HEALTH FIELD

The second phase of the FpV’s trajectory took place over the course of 2021. It became better established by extending the array of its alliances and by political action focused on addressing the pandemic and defending the SUS, in addition to holding the Bolsonaro government accountable for the grave public health crisis. In that period, as its health care system collapsed, Brazil suffered record numbers of cases and deaths.

Given the severity of the public health situation, the FpV arranged a number of proposals, which were submitted to the Legislature and Judiciary, for the implementation of measures to address the pandemic that were both appropriate and designed to meet the health needs of Brazil’s population. In addition to these actions, the Front worked to support the Parliamentary Commission of Inquiry into the Pandemic (the Pandemic CPI), which was convened in the national congress to ascertain responsibilities in the avoidable cases and deaths that occurred in Brazil during the pandemic.

In the ambit of the Judiciary, in addition to its manifestos, the FpV co-authored Claim of Non-compliance with a Fundamental Precept (Arguição de Descumprimento de Preceito Fundamental, ADPF) No. 822⁷, also known as the ‘Lockdown ADPF’, requiring that the Federal Supreme Court instruct the entities of the federation, especially the federal government, to apply strict measures to control circulation of people, so as to save lives in the rampant COVID-19 pandemic in Brazil and with a view to safeguarding the SUS.

The FpV denounced the calamity in Brazil not only to Brazilian national bodies but to international organisations – the Pan-American Health Organisation, the World Health Organisation and the United Nations. In that context, the Front also addressed a ‘Letter to humankind: life above all’ to the STF, stressing the importance of a nationwide lockdown, and called the second March for

Life. From May 2021 on, social movements resumed street protests with the participation of the FpV. The rallying cry of these acts was ‘Vaccine for all, 600 reals’ emergency aid, in defence of the SUS and out with Bolsonaro’⁸.

In the technical and scientific dimension, in this phase, working with diverse education and social service entities, the FpV produced the manifesto ‘Health, education and social assistance in defence of life and democracy’⁹, which analysed the pandemic’s unequal impact on education and, with the participation of 50 organisations, proposed principles and guidelines to ensure comprehensive care for children and adolescents. In view of the attacks on health, education, science and technology, the FpV positioned itself against the proposal to decouple mandatory budget funding for health and education and against the proposal to dismantle the Anísio Teixeira National Education Studies and Research Institute (Instituto Nacional de Estudos e Pesquisas Educacionais Anísio Teixeira, Inep).

The second phase of the FpV’s trajectory made a priority of influencing the State politically by intensifying its denunciations of federal government omissions and antiscientific, negationist actions, as well as working more closely with the Legislature and Judiciary, with a view to advocating for universal vaccination and implementation of appropriate public health measures to contain the pandemic and assure basic income to people in situations of greater social vulnerability.

Actors’ influence in a political arena depends on their ability to use their resources in a strategy that increases their visibility, recognition for their legitimacy and their ability to dialogue in different arenas, thus assuring that their project gains in spread, voice, reach and support. In this phase, the FpV extended its visibility and actions in the Judiciary and in international organisations, as well as strengthening its presence in the Legislature at various different times, which included its being invited to address the Parliamentary Commission of Inquiry into the Pandemic.

PHASE 3 – THE FPV IN REBUILDING BRAZIL

The third phase in the FpV’s trajectory took place in 2022 in an epidemiological scenario notable for the advance of vaccination against COVID-19 and the resulting decrease in the numbers of cases and deaths from Sars-CoV-2. In this phase, the FpV centred its actions on proposing a health project for Brazil in view of the upcoming 2022 presidential elections. In that context, the Front’s strategic agenda for 2022 led to the National Free, Democratic and Popular Health Conference (Conferência Nacional Livre, Democrática e Popular de Saúde, CNLDPS), with broad grassroots participation in an agenda of health policy guidelines for Brazil.

The national stage of the CNLDPS took place in August 2022, with in-person participation by health managers and professionals, social movements, researchers, public health experts and academics from various parts of the county. The conference proved to be an important political event, in that the then presidential candidate, Luiz Inácio Lula da Silva, signed a commitment to the FpV agenda, which brought together health policy guidelines for the years to come.

The document contemplated the following guiding principles:

• a. the SUS to be 100% public;

• b. SUS employment to be a ‘career of State’;

• c. healthcare systems to be strengthened;

• d. the economic and industrial health complex to be recognised as important to national sovereignty and health security;

• e. Democracy to be defended radically;

• f. Constitutional Amendment No. 95/2016 to be revoked, so as to expand funding; and

• g. health policies to be formulated and guided by a gender, race/ethnicity, class and territory perspective and considering the social determinants of health.

Subsequently, given the intense polarisation observed with the approach of the elections, the FpV positioned itself publicly in support of the Lula-Alckmin platform, reasoning that it represented a project for Brazil grounded in the ‘defence of democracy, associated with social protection and social wellbeing policies’, to the detriment of the opposing project, represented by the possible re-election of Bolsonaro, which ‘meant worsening authoritarianism and fascism associated with policies that are neoliberal and regressive as regards human and social rights’¹⁰.

After the Lula-Alckmin platform won the elections, the FpV began a dialogue with the federal government transition team, to demarcate its contribution to setting new health policy directions. In the early days of the transition team’s work, the FpV met with members of the Lula government’s transitional cabinet to stress the importance of strengthening the dialogue and raise a number of points for consideration by the new government. Later, members of the FpV joined the health team of the transitional presidential cabinet.

Amid speculation as to the composition of the incoming government, the Front decided not to exert any political influence on appointments or endorse a name for the position of Minister of Health, but rather proposed criteria which should be met by whoever occupied the position, such as a having a background in the health profession and political activity committed to the SUS, as well as having no conflicts of interest as regards the SUS. This process strengthened the work of the FpV in a context of rising authoritarianism, ultra-liberalism and neo-conservatism.

In this phase, the FpV strengthened relations between civil society and politicians in general in the struggle for the right to health. That political participation acknowledged the importance of aggregating new political actors and action strategies to be guided by a national health project constructed collectively in diverse arenas of debate and with ample political autonomy from parties and governments. Evidence of the Front’s capacity for mobilisation and organisation is given by the more than 120 local pre-conferences that preceded the national stage of the CNLDPS, which were organised autonomously, but in coordination, by the various different actors led by the FpV In this way, each participating organisation was able to imprint a specific agenda on the overall collective discussion, as was the case with the conferences organised by the Cry of the Excluded. The process represented an innovation that strongly influenced subsequent participatory arrangements and became a model for galvanising National Health Conferences.

Managing the FpV as a policy network

Policy networks mobilise actors and organisations to attain common goals by way of shared power and horizontal relations - which involves consensus building and collective decision making¹¹. The FpV took shape as a policy network that emerged during the COVID-19 pandemic from relations among various social actors, rights councils, scientific bodies, social movements, members of parliament, political parties, professionals and trade unions.

In order to understand the FpV as a policy network it is necessary to understand the related dynamics, structure, actors, social relations, coordination strategies and processes of interdependence, as well as the power and management relations among the various actors that make up the network – all of which will be addressed in this section.

The FpV cannot be confused with an organisation with a defined structure and context and, accordingly, must be examined on the basis of a theory that considers inter-organisation networks, whose formation and coordination mechanisms are not embodied in formal by-laws, but must be constructed cooperatively by the participants. As participation is voluntary, each node of the network must take part in building a shared overall goal. Consensus-building is thus a permanent process requiring horizontal relations, without which a network, even one mediated by a coordinating body, tends to come undone when participants no longer feel their interests are being contemplated.

This is not to say there are no differences - that, in fact, is a precondition for networks to exist – nor competition and conflicts. Unlike hierarchical organisations, in networks, conflict resolution has to be a key objective, collective solutions must be negotiated and progressive consensuses constructed¹², ¹³, ¹⁴.

There are advantages to the FpV’s process of organisation and development into a policy network:

• a. the plurality of social actors and/or technical and scientific entities has given greater depth to its analysis of the conjuncture and the health situation and to its construction of collective confrontation strategies with the participation of all the actors involved in analysing COVID-19 (scientific entities, rights councils, social movements, professionals and trade unions in fields including health, education and social assistance);

• b. guided by the progressive consensus building among the various actors and entities, all the actors involved gained stronger political autonomy, which made for greater engagement and political commitment to the common goals of confronting COVID-19 and the Bolsonaro government; and

• c. shared management by the FpV operating group and extended plenary fostered a process of participation and protagonism on the part of the social actors and historical subjects in the network.

COMMON IDENTITY, GRADUALIST DYNAMIC, ACKNOWLEDGEMENT OF DIFFERENCES AND CONSENSUS BUILDING

The common identity among the actors of the FpV is given by their defending life, combating the pandemic and defending democracy and the SUS in the context of the Bolsonaro government and their recognition that the State had failed to fulfil its constitutional role in defence of life and health. As regards process, the FpV’s gradualist dynamic matured and settled into a policy network comprising a broad spectrum of social movements and entities, framed by horizontal, dialogical, processual relations based on respect for heterogeneity, solidarity and the common goals shared in the decision-making process. In its consensus-building and negotiation process, the FpV has managed to build decision-making spaces quickly, given the large network of actors it comprises. It has done so on the basis of progressive consensuses, which constitute a collective political process in which positions are mediated for decision-making purposes. As described by Túlio Franco, of Rede Unida:

[...] The decision-making process is that all discussions take place through the device of progressive consensus-building as a strategy for treating divergences – not for destroying opponents – and for building unity collectively. (Túlio Franco).

In this connection, the Front developed what, in the health sector, was a new form of organisation oriented by a ‘politics with a new aesthetic’, in the words of Túlio Franco, of Rede Unida. This was grounded in collective construction, multiplicity of actors and the defence of democracy and political and ideological diversity. The FpV’s consensus building permitted dialogue among actors on the basis of common goals and respect for political and institutional differences, but without disregarding the political plurality of the actors and subjects engaged in the network. This process strengthened internal democracy and participatory, democratic management. Conflicts that did arise on issues, such as whether or not to put forward a name for the Ministry of Health or health sector funding proposals, were discussed in a number of plenaries and, if no consensual position was reached among the members of the network, no position was expressed by the FpV.

MUTUAL STRENGTHENING OF LEADERSHIP ROLES

The many actors and forces that make up the FpV have common goals, as well as a progressive linking process. In this regard, Rovere¹⁵ specifies a set of levels of actions and values that gain in scope and depth. At the first level, he argues, entities recognise and accept one another as partners in dialogue. They then get to know each other and to dialogue, express mutual interest and thus reach the third level, at which they begin to work together, to collaborate. Lastly, it is appropriate for them to associate and thus form a network, when a relationship of trust is achieved in which the various actors share common goals and collective action¹⁵.

COORDINATING AND STRUCTURING THE NETWORK

In the first phase of its operating trajectory, the FpV had no coordinating body. As a result, the process of organising and managing interde-pendencies in the network was self-managed and led notably by 5 of the 11 entities that had mobilised to set up the network. Given the need for uninterrupted, rapid communication and for decision making among its multiple members, the FpV opted to set up a group on the WhatsApp multiplatform, instant messaging and voice call application. In addition to this means of communication and in view of the constraints imposed by physical social distancing measures, because of the pandemic, the FpV came to hold periodic meetings – called ‘plenaries’ – via virtual meeting platforms.

With a view, ultimately, to specifying consensuses and actions to be pursued by the FpV, it was decided that any consensual points would be made priority positions of the FpV, while the others would be left to be discussed later and acted on as individual positions of the entities concerned.

Accordingly, thinking then turned to the need to constitute a core directing body to manage the network. That coordinating body, which received the name ‘operating group’ or ‘operations’, was guided by the joint criterion of the representatives of the four founding entities and the National Health Conference.

The FpV has no bylaws or formal rules that determine how it is organised and functions. It is thus guided by a set of informal rules agreed on in the process of interaction with the actors that constitute the network and, accordingly, recognised and interpreted equally by all its members. The process of establishing these rules constituted an important tool for managing the FpV. Túlio Franco, of Rede Unida, made this clear:

[...] So, it’s like this, there is no structure. What is the decision-making body? ... It’s the plenary that is convened in that ‘Zap’. You can see that there are no regulations. What is the required quorum for the plenary to make decisions? What is the special quorum? There’s none of that. Is representation by entity? There’s none of that either. (Túlio Franco).

The absence of hierarchical power relations, which strengthened participatory, democratic relationships, was an important to the FpV as a strategy for building more horizontal relations among all the actors involved. Even considering that the participating organisations had different levels of resources, which could have assured greater centrality to some in the network, the Front’s key decisions were always submitted to the plenary, thus assuring the horizontality necessary for the network to function and endure. At the same time, its acceptance of divergent positions that failed to achieve consensus in the plenaries proved right, and these could continue to be advocated by each entity concerned.

The strengthening of participating organisations and leaderships was proved to be effective not only by the fact that shifts in the entities’ leaderships caused no adverse impact on the network, but also because leaders of the entities in the network operating group were later called on to hold positions in the new participatory architecture of the government that took office in 2023.

Relations between the FpV and the MRSB

The MRSB has been defined by its praxis in defence or a broad conception of health, by the right to health written into the constitution as a duty of the State and by its proposing and working for a comprehensive health system that is universal, public, decentralised and participatory. Its organisational plasticity at different political junctures, its multiplicity in fields including the anti-asylum struggle and the psychiatric reform and the popular health movement did nothing, however, to prevent its having built up a strong identity shared by individuals and organisations.

In the perception of operating group members, the FpV constituted an update to the MRSB or even its continuance in the recent conjuncture, which involved new actors, arenas and projects in dispute. Lúcia Souto, of Cebes, saw the FpV as having broadened the MRSB’s social base and served to update this actor’s political agenda:

My feeling is that it is an update to the Health Sector Reform Movement, updated by the involvement of many more entities, which gives it a far broader social base for that political struggle. I think that that social base of social movements, it really is interacting in the agenda and in updating that agenda of the Health Sector Reform Movement. (Lucia Souto).

Gulnar Azevedo e Silva, of Abrasco, noted that the FpV represents the reaffirmation of the health sector movement’s commitments, at the same time as it renews and broadens that movement. She also stressed that the entities have been strengthened in that trajectory, although with less political and ideological engagement:

[...] We took what had been built up back there, as if reworking it to open up to a new world [...] to new prospects [...] we face a different situation. We have a SUS that is not as it could have been created, but is what exists. That is what we have today. So what is it we have to do? And on the other hand, the entities have broadened a lot, they’ve grown a lot, and grown with less ideological engagement and commitment, but with greater penetration, understand? [...] So what is it that we have to do? Retrieve, restore that essence, think about that essence, about what can be done. (Gulnar Azevedo e Silva).

In the course of the interviews of this study, Túlio Franco, of Rede Unida, emphasised that the FpV is not just heir to the MRSB, but has also updated its composition by involving other actors from outside the collective health field, noting that the social base of the public health movement has been broadened by the participation of the Cry of the Excluded. Meanwhile, Rosana Onocko, of Abrasco, added that the FpV established itself as a social actor thanks to the consensuses it constructed and thus gained recognition from political authorities and other actors.

Similarities with and differences from the Brazilian Health Sector Reform Movement

Similarities and differences can be identified between the FpV and the MRSB in various aspects, remembering that several of the interviewees mentioned that the FpV is an updated MRSB. The memberships of both comprise mostly health professionals who have little penetration in broader social movements. A move was made to broaden the FpV’s political action beyond the health sector by its leadership’s participating in other broader fronts, such as the Frente Brasil Popular and the Povo Sem Medo, as well as including the Cry of the Excluded in the network. That issue was considered a past difficulty of the MRSB, in that it had a limited grassroots support base, sustained mainly by academia and with limited power to activate via social and community channels, referred to in the literature as the “phantom of the absent class”^{16 (310)}. Note, however, that the existence of an epistemic community assures the FpV certain advantages in the field of action, because it shares a common political culture, which predisposes the FpV to unity, common diagnoses of problems and consensus building on its proposals.

The health sector movement, historically, and the FpV, in the present conjuncture, continue to adopt common strategies, in different arenas, both mobilising alliances and seeking to expand their capacity for political influence. These are: a) technical and scientific production regarding the Brazilian Health Sector Reform and the SUS; b) dialogue with the Executive, Legislature and Judiciary; and c) influence on the communications media of the organisations themselves and partners, which debate crucial health policy issues.

Interacting with the Legislature, the FpV worked with the parliamentary health caucus composed of representatives of progressive parties, as had been the case previously with the health sector movement¹⁷, while, in the present conjuncture, it was able to inform the work of the Parliamentary Commission of Inquiry into the Pandemic in the federal Senate.

To summarise, the main differences between the FpV and the MRSB identified in this study fall into two main categories: a) the characteristics of their constituent subjects; and b) the action strategies they apply. Thus, the FpV’s political action is centred on the leading role played by the collective subjects that make up the network, as a result of the progressive strengthening of its component organisations. The second difference found was greater recourse to judicial proceedings calling for collective tutelage in defence of the right to health, which has often been used by the FpV in recent times¹⁸. In its trajectory, the MRSB did not often make use of the Judiciary as a channel for its actions¹⁹, ²⁰.

The FpV’s sustainability, prospects and challenges

When considering the prospects for the FpV in 2023, the study participants spoke of the importance of the Front’s continuing its activities in the new political conjuncture. In order for the FpV to organise its work in areas that will enable it to further the process of formulating and organising the network, it will have to organise politically and strengthen its technical and scientific production, institutional relations and dialogue with social movements and, lastly, preserve its political autonomy and independence. Another important challenge to be met to assure the network’s sustainability is a political formulation that will enable debates to be pursued in greater depth in the health sector and in other fields of knowledge and other operating scenarios.

In that light, following the 2022 electoral process and the election of the Lula-Alckmin platform - the Brazil of Hope Coalition (Coligação Brasil da Esperança) –, the FpV contributed to the transitional presidential cabinet to support its health group in understandi ng the key challenges in the health policy context and in the debate over a healthcare project for Brazil²¹. On this topic, Lúcia Souto, of Cebes, reflected that:

Particularly, I think we should continue to be bold in the agenda even if we don’t win [...] we will be disputing this popular field, like the minister of health we propose, who should express a commitment to defending the universal right and have no conflict of interest [...] the dispute for us is to broaden the critical awareness of Brazilian society. (Lúcia Souto).

In that context, the FpV, starting with the new government, specified its strategic activities as institutional participation, stronger political participation and intensifying the struggle for the right to health. In addition, the defence of life, democracy and the SUS continue to be central in the new political and health conjuncture.

Final remarks

This study found that the FpV had its origins in the MRSB. Accordingly, the FpV was characterised as updating the health sector movement by broadening its social support base. In that respect, the FpV is understood to be a continuation of the MRSB in a conjuncture that involves new actors, arenas and projects in dispute. It is thus a political subject, in the sense of subject as a political actor in movement²². The FpV has been active in multiple arenas, including the Executive, Judiciary and Legislature, although civil society has been the prime locus of its presence and operation. In that conjuncture, the FpV’s main strategies have been technical and scientific action and political operations.

The existence of an epistemic community in common among several of the social actors included in the Front and actions centred on a specific political conjuncture have made for construction of a stronger policy network directed to the common goals of the defence of life, democracy and the SUS. Accordingly, the prospects that emerge for the FpV are framed, considering the 2023-2026 Lula government, by the importance of strengthening social participation in health and disputing key projects of power in the State. In that context, in the early months of 2023, note particularly release of the final CNLDPS report directed to discussing a response to the challenges facing the SUS and strengthening the process of mobilisation and political alliance-building for the 17^th National Health Conference.

The challenge of maintaining a position of critical autonomy from the government, in which several members of the operating group are participating on policy councils, has become crucial to the network’s survival.

• Financial support: non-existent

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Edited by

Responsible editor: Lenaura de Vasconcelos da Costa Lobato

Publication Dates

• Publication in this collection
  24 June 2024
• Date of issue
  Apr-Jun 2024

History

• Received
  23 Oct 2023
• Accepted
  26 Mar 2024