EXPLORING THE ROLE OF NEW DEVELOPMENTALISM IN STRENGTHENING

HEALTHCARE SYSTEMS: THE BRAZILIAN EXPERIENCE

Thalita Borges Oliveira1

Abstract: The healthcare sector, crucial for societal well-being and economic stability, relies
on Brazil's Unified Health System (SUS). However, SUS's effectiveness hinges on securing a
stable supply of crucial inputs. Brazil's healthcare sector, beyond its economic role,
contributes significantly to research and development. In recent decades, Brazil has faced
challenges in productive deconcentration, causing a mismatch between domestic supply and
demand. This has led to heightened fragility and import dependence, exacerbated during the
Covid-19 crisis. The pandemic highlighted the need for policies supporting local production,
especially within the Health Industrial Complex (CEIS), facing import dependency
challenges. The fragility in the production base affects healthcare accessibility during
international crises, causing shortages in essential products. The absence of domestic
production in high-tech healthcare items intensifies inequality and jeopardizes universal,
high-quality healthcare services. The CEIS, covering chemical, biotechnological, mechanical,
electronic, and materials domains, plays a central role in fortifying the healthcare supply
chain. This research aims to answer whether increasing local production within the CEIS can
reduce vulnerabilities in the Brazilian healthcare system.

1
PPGE/IE-UFRJ
INTRODUCTION
In the Latin American landscape, Brazil has emerged as a significant economic and
social force, shaping its trajectory under diverse influences, from national-developmentalism
to neoliberal principles. However, it was during the tenure of Luiz Inácio Lula da Silva
(2003-2010) that a new approach, known as New Developmentalism, gained prominence.
This perspective, guided by a more integrated vision of development, transcended the
dichotomy between neoliberalism and national-developmentalism, seeking to balance
economic growth with social inclusion.
Within this panorama, a fundamental question arises concerning the role of the health
sector as a vital element in constructing a more prosperous and equitable Brazil. Over the past
six decades, health in Brazil has witnessed a complex coexistence between the
decommodification of access and the commodification of supply, culminating in the
formation of the Health Industrial Economic Complex (CEIS). This complex is not only an
indicator of scientific and technological advances but has also established itself as a strategic
component for capital accumulation and national development.
Unlike its predecessors, New Developmentalism recognizes the need for an
interdisciplinary approach that goes beyond traditional economic indicators. In this
perspective, health ceases to be viewed merely as a result of economic growth to become a
driving force behind that growth. The health sector is understood as a fundamental right, the
development of which is inseparable from broader economic and social development. In this
context, the Lula government outlined policies that sought to integrate economic
development with the promotion of social well-being, transforming the health sector into a
strategic component of this vision.
The Unified Health System (SUS), created in the 1980s, became the institutional
expression of this integration. During Lula's government, there was significant consolidation
and improvement of SUS, reinforcing the principles of universality, equity,
comprehensiveness, and primary care. The Ministry of Health strengthened the federative
pact, encouraged social participation, and implemented innovative initiatives such as the
Brazil Smiling Program, SAMU, and the Popular Pharmacy Program. These were not
isolated measures but coordinated efforts to create a solid foundation for health in Brazil.
The CEIS, an integral part of this movement, emerged as a crucial domain in the third
technological revolution, characterized by biotechnology and new information and
communication technologies. However, the complexity of the health sector is not limited to
its technological dimension. The coexistence of contradictory movements, such as the
decommodification of access and the commodification of supply, highlights the need for a
more holistic approach. The dynamic interaction between economic, political, and social
processes has shaped modern healthcare systems, demonstrating that health and development
are intertwined in a virtuous relationship.
Continuing on this journey, this study aims to deepen the understanding of the health
sector's role in national development, highlighting not only its achievements but also
persistent challenges. The analysis will extend beyond national borders, exploring Brazil's
relevance in the global health context and examining how the COVID-19 pandemic has
exposed vulnerabilities in the healthcare system and the country's productive base.
Additionally, the importance of building a robust productive and technological base, trends in
the medical products industry, and production linkages impacting not only the health sector
but the entire economy will be addressed.
This study is not just a retrospective analysis but a reflection on how Brazil can shape
its future, using health as a catalyst for sustainable development and national autonomy. New
Developmentalism offers an integrated framework for this journey, inviting constant
reassessment of policies and practices to create a society where access to health is not just an
indicator of economic progress but a fundamental right that drives progress in all its
dimensions.

NEW DEVELOPMENTALISM AND THE HEALTH SECTOR IN BRAZIL: AN

INTEGRATED VIEW
In Brazil, during the Lula government (2003-2010), the construction of what Oliva
(2010) calls New Developmentalism began, an approach seeking a development pattern
distinct from both neoliberalism and previous national-developmentalism. This new
paradigm, oriented toward the social as well as the economic, reflects a more comprehensive
and integrated vision of progress. In this context, there is a growing concern to consider
fundamental sectors, such as health, as essential elements for national development.
According to Viana and Elias (2007), in the last sixty years, the health sector has
witnessed a crucial phenomenon: the dual coexistence between the decommodification of
access and the commodification of supply, resulting in the formation of the Health Industrial
Economic Complex (CEIS). This complex not only represents technological and scientific
advances but also positions itself as a vital component for capital accumulation. Within the
New Developmentalism context, the transformation of health into a right and the formation of
comprehensive social protection systems align with the broader vision of progress, where
economic development intertwines with the promotion of social well-being. Thus, the
attention given to the health sector within this new paradigm reflects the understanding that
health plays a crucial role in the advancement and sustainability of development.
Simultaneously, the Health Industrial Economic Complex (CEIS) is seen as having
enormous potential to leverage technological and scientific advances, emerging as a crucial
domain for capital accumulation. This complex is closely linked to technological innovation
and globalization, standing out as a central component of the third technological revolution,
grounded in biotechnology and new information and communication technologies (VIANA;
ELIAS; 2007).
Although these three movements - decommodification of access, commodification of
supply, and the formation of the industrial health complex - did not arise simultaneously or in
a coordinated manner, they coexist in a complex and contradictory manner within the current
healthcare system. Considering that modern healthcare systems are the result of the complex
interaction of economic, political, and social processes, it is evident that the relationships
between health and development are understood as a dynamic and virtuous process that
combines economic growth, fundamental changes in the production structure, and improved
living standards for the population (VIANA; ELIAS; 2007).
Analyzing the evolution of the health sector in Brazil, it becomes evident that the
transformations in recent decades have been shaped by these movements. The Lula
government, during its tenure, through a New Developmentalism approach, directed the
development strategy beyond the economic, considering social aspects as fundamental. This
period witnessed a substantial emphasis on social policies, with state intervention to stimulate
the domestic market and promote social inclusion (BRAVO, 2006).
From 2003 onward, the Ministry of Health in Brazil strengthened the federative pact
and emphasized social participation, based on health councils and conferences, and the
principles of universality, equity, comprehensiveness, and primary care in the public health
system. In Lula's first term, health already presented innovative proposals. In addition to
expanding the Family Health Program (PSF), strengthening primary care, improving
intergovernmental relations, and expanding access to SUS were emphasized (MENICUCCI,
2011).
Among the innovative initiatives were the Oral Health Policy (Brazil Smiling
Program), the Mobile Emergency Care Service (SAMU), and the Popular Pharmacy Program.
The management also sought changes in the healthcare delivery model, focusing on reception
and humanization. Actions aimed at specific groups, such as women, children, adolescents,
workers, and the elderly, were implemented. The first term also witnessed the approval of the
Elderly Statute. The creation of the Health Pact stood out, promoting institutional reforms,
establishing commitments and goals, and redefining resource distribution. The Pact aimed to
strengthen governance and promote integration among different government levels
(MENICUCCI, 2011).
According to Menicucci (2011), in the second term (2007-2011), the emphasis was on
the continuity and improvement of SUS, with a focus on investments in research and
technological development in the health sector. Minister Temporão introduced controversial
debates on topics such as abortion, alcohol advertising, and health judicialization. The More
Health program proposed investments to strengthen the health industry and link health to
economic development. The expansion of the Family Health Program (PSF) continued to be a
priority, with the creation of new teams and Family Health Support Centers (NASFs). Other
initiatives included expanding access to specialized services, infrastructure actions, doubling
SAMU coverage, and implementing regulatory complexes.
However, even in the face of these advances, persistent challenges in the health sector
demand continuous attention. Issues related to prevention, primary care, emergency care,
specialized services, and diagnostic tests persist, highlighting the need for broader and more
efficient approaches (OLIVA, 2010). The relationship between the phenomena observed in
the last sixty years and current transformations in the health sector in Brazil will be explored
in the next section, focusing on understanding the role of the Health Industrial Economic
Complex (CEIS) in this dynamic context.

HEALTH INDUSTRIAL ECONOMIC COMPLEX AND ITS NATIONAL AND

GLOBAL RELEVANCE
The goal of achieving a healthy population in the fullest sense of the word transcends
the simple function of a human and social resource and is not merely a byproduct of
economic growth. Health is a fundamental human right, requiring investment and innovation
from all economic agents, which can also shape the speed and direction of economic growth.
The objective, therefore, is not just growth per se but directing it for the benefit of people and
the planet. To achieve this transformation, there arises the need for a new economic
perspective that reconfigures health financing from an expenditure to an investment, based on
the vision of health as an interdisciplinary lens that spans various sectors, capable of
promoting both social well-being and economic resilience and stability (MAZZUCATO, M;
2023).
 After World War II, international organizations such as the WHO, Pan American
Health Organization (PAHO), United Nations International Children's Emergency Fund
(UNICEF), and Food and Agriculture Organization of the United Nations (FAO) coordinated
global health-related development initiatives, emphasizing programs to combat tropical
diseases in poorer nations. This was based on the notion that health is an economic asset and
investments in "human capital" were crucial for progress. (GADELHA, 2022)
At the national level, the sustainability of the health sector in Brazil is linked to both
social and economic national development. The sector contributes to GDP, employment,
innovation, and competitiveness. Despite governmental recognition, the fragility of the
productive base affects health and the global integration of the system. Overcoming this issue
requires breaking paradigms that separate economy and society (GADELHA; COSTA, 2012).
Despite the presence of a consolidated scientific base and a diversified productive
base (in Low Technology - Medium-Low Technology sectors) in the early 2000s, the health
products, particularly those of high technology, experienced a loss of competitiveness due to
denationalization processes. This resulted in industries that could drive the country's
economy and meet social needs, failing to establish and remain in the market, leading to
detrimental effects on both the population's health and national development (GADELHA;
COSTA, 2012).
In the COVID-19 pandemic, there was a "desperate" deepening of this dependence,
with thousands of avoidable deaths and the inaccessibility of basic health resources.
Considering these issues, the discussion about the need to expand the supply of health goods
and services to the population has been gaining strength in academia and especially among
public policymakers worldwide.
In this regard, the latest report from the World Health Organization, "Health for all:
Transforming economies to deliver what matters," positively highlighted the role of our
Health Industrial Economic Complex (CEIS) as a program that encompasses different
policies with the potential for health development in the social-economic context (WHO,
2023).
In addition to representing an annual market of over R$160 billion, the health sector
generates 14 million direct jobs and five million indirect jobs. In 2009, for example, health
contributed approximately 9% of GDP by stimulating domestic economic demand through
the final consumption of goods and services (GADELHA; COSTA, 2012).
The health sector forms a complex network of activities, encompassing fundamental
knowledge and innovation-based sectors, which drives global competitiveness by playing an
essential role due to its contribution of about 25% to national research efforts
(GUIMARÃES, 2006).
Productive and technological capacity plays a crucial role in addressing SUS's
challenges. Although the national production of vaccines has been successful since its
inception, the pandemic highlighted Brazil's vulnerability regarding essential products such
as ventilators, diagnostic tests, and personal protective equipment. The crisis emphasized the
importance of effective coordination between economic, productive, and technological
systems that encompass industrial activities and the health sector. These vulnerabilities
deepened the relevance of the material and economic base for society's well-being.
(GADELHA, 2022)
The pandemic crisis resulted in a significant increase in imports, reaching about USD
20 billion, exposing the need to balance the economy, quality of life, and universal access to
health services. The country demonstrated high dependence on the chemical and
biotechnological subsystem, especially in the pharmaceutical and drug sectors. In more
advanced segments, such as active pharmaceutical ingredients, dependence on imports
reached 90% of national demand, highlighting the disparity between health demands and the
existing production structure (GADELHA, 2022).
It is evident, therefore, that a more detailed examination of the health productive base
converges with the results found at the level of industrial classes regarding the fragility of the
production chain.
The trade deficit in the health sector is an indicator of the fragility of the national
productive and technological base, covering products with a high density of knowledge and
innovation. This affects everything from patented drugs to advanced electronic equipment
and hospital products. This fragile and little dynamic specialization is the result of a
subordinate insertion in international geopolitics, generating dependence. The lack of a
productive-technological base affects access to health services, aggravating inequality. The
COVID-19 crisis highlights these contradictions in the debate about health, sovereignty, and
development in Brazil (GADELHA, 2022).

The fragility of the national productive and technological base in the health sector,
evidenced by the trade deficit and dependence on imports, compromises not only the ability
to meet the population's health demands but also the country's sovereignty and autonomy.
Therefore, the discussion about strengthening the production chain becomes highly relevant
in this context since strengthening local production and developing proprietary technology
are essential to reduce external dependence and ensure a more resilient and sustainable health
system. The pursuit of national autonomy and sovereignty thus involves investing in the
diversification and strengthening of the productive base, aiming to meet internal demands and
face challenges such as those brought by the COVID-19 crisis.
In this context, the CEIS aims to fill this gap not only by sustaining a research agenda
that addresses production and social and health well-being challenges but also by proposing
fundamental policies and tools to address these challenges through interconnections.
The diagram below provides a summary of these connections. In short, the need for a
profound change in Brazil's economic structure is being emphasized through a process that
strengthens national innovation, the productive base, and aligns its offering with social health
demands. That is, it is an alternative vision of the relationship between health and
development. The challenge of the contemporary Sanitary Reform is to combine SUS
principles, such as universalization and equity, with the transformation of the country's
productive and scientific base. The CEIS plays a strategic role in the reconstruction of the
national economy. (GADELHA, 2021)
Figure 1 - The Bases and Systemic Interactions of the CEIS

Source: Gadelha (2022)

THE MATERIAL AND TECHNOLOGICAL BASE OF CEIS

The Brazilian medical products industry originated in the 1950s and reached its peak
in the 1970s. Over the last three decades, it has faced significant challenges due to changes in
the national and international landscape. The market opening in the 1990s marked the
exhaustion of the import substitution model, creating a new competitive environment. Market
regulation, initiated in 1992 by the Ministry of Health and later by Anvisa, introduced
innovative concepts and established minimum quality standards
(GUTIERREZ;ALEXANDRE; 2004).
Despite regulatory and economic challenges, there have been substantial
improvements in the quality of produced technologies, evidenced by the innovation
highlighted in the Industrial Research of Technological Innovation (Pintec) by IBGE. The
industry's expansion from the second half of the 1990s was driven by the growth of domestic
demand, the expansion of the Unified Health System (SUS), and the influence of public
demand, resulting in generated jobs and an industrial production value of R$4.8 billion in
2012 (EDUARDO; OLIVEIRA, 2017).
The medical products sector in Brazil can be divided into two categories: high
technology and conventional. High-tech products are advanced, focused on therapeutic and
diagnostic uses, associated with high-risk research and development (R&D) activities. While
these products have growth potential, they face the challenge of rapid obsolescence. On the
other hand, conventional products include items such as syringes, gauze, and diagnostic
products, characterized by low profit margins and large production volumes. The
technological dynamics of the sector point to trends such as miniaturization, minimally
invasive smart devices, combined products, artificial organs, and information technology.
Products with higher technological intensity are mainly intended for the private and
supplementary health markets, increasing sector costs (EDUARDO; OLIVEIRA, 2017).
Constant technological evolution results in short product life cycles, creating
challenges such as obsolescence before the full realization of benefits. Additionally, the
analysis of the Pintec/IBGE research indicates that, although the medical equipment industry
has innovation rates above the national average, these rates are still below international
standards. Brazil seeks to overcome this lag through government policies, such as the
National Policy for Science, Technology, and Innovation in Health (PNCTIS), and
partnerships for productive development (PDPs) (EDUARDO; OLIVEIRA, 2017).
The creation of commercial, industrial, and technological offset measures, along with
policies like the Greater Brazil Program, reflects efforts to strengthen the national industry.
The use of the State's purchasing power aims to boost productive and innovative
development, reducing external dependence.

O uso do poder de compra do Estado orientado para a inovação reside em

seu potencial de articular a demanda para alcançar objetivos relacionados ao
 desenvolvimento nacional, a exemplo da sinalização para o setor privado
das necessidades públicas, que estimula o desenvolvimento de soluções
inovadoras para o perfil de demanda da sociedade. O uso de poder de
compra é uma política emblemática para o desenvolvimento da base de
CT&I em saúde, tendo em vista a complexidade que envolve a orientação de
trajetórias tecnológicas que sejam, a um só tempo, economicamente
competitivas e socialmente inclusivas (EDUARDO, OLIVEIRA, 2017)

However, the increase in the trade deficit in recent years reveals the loss of
competitiveness in the industry, especially in higher technological intensity products. The
dependence on imported inputs, reaching 50% in some segments, and the 24% trade deficit of
the Health Industrial Complex (CEIS) highlight technological lag. These challenges indicate
the need for innovative strategies and institutional improvement to strengthen the position of
the medical products industry in the global scenario (GADELHA, 2012).
Finally, the global medical equipment market has experienced significant growth,
especially in emerging countries, due to demographic and epidemiological changes. This
suggests opportunities for the health sector, but challenges persist, requiring continuous
efforts to improve innovation and competitiveness in the Brazilian medical products industry
(ROSSI; TEIXEIRA; DAVID, 2022).
In this context, the medical-hospital equipment sector encompasses various categories
such as furniture, electromedical equipment, surgical instruments, physiotherapeutic
equipment, and hospitality. Electromedical equipment, including electro electronic-based
devices, is highlighted for its high technological intensity, ranging from cardiac pacemakers
to monitoring equipment (GUTIERREZ;ALEXANDRE; 2004, 2004; PIMENTEL et al.,
2013).
In this sector, technological heterogeneity is evident, with segmented competition in
areas such as intensive care, neonatology, and surgical equipment. Large companies often
seek the integration of different technologies, while smaller companies occupy specific
niches in the market. In Brazil, the medical-hospital equipment segment represented 46% of
the industry in 2012, with a diverse production park of about two hundred companies.
Exports from this segment showed growth, but the country still faced a trade deficit in 2013
(EDUARDO; OLIVEIRA, 2017).
The dynamism of the sector is evidenced by meeting domestic demand, sustainable
exports, and higher technological content. Population aging, preventive medicine,
telemedicine, and home care are identified as future trends that will impact the medical
equipment industry. The incorporation of new technologies, such as chemical sensors,
biosensors, telemedicine, and automation, is highlighted. Robotic surgery, device
miniaturization, and the convergence of various knowledge areas, including ICTs,
nanotechnology, and engineering, are pointed out as areas of potential development.
Pressures to reduce costs and increased demand for preventive services drive innovation in
the medical equipment sector (GADELHA, 2022).

PRODUCTIVE LINKAGES IN THE HEALTH SECTOR

The effects of the health sector associated with CEIS can be observed through
different methods, approaches, or perspectives. This article adopts the input-output model
developed by the Industry and Competitiveness Group of the Institute of Economics of the
Federal University of Rio de Janeiro (GIC/IE-UFRJ) as the method. This model will allow
estimating the potential impacts of different scenarios of productive intensification of CEIS
on the final demand for the Brazilian economy. The choice of the method is justified by its
ability to cover the entire national production chain given exogenous demand shocks. In this
particular study, a demand vector for the mercantile and public health sector is created to
understand the effects of shocks in this sector on overall economic production.
To estimate the Investment vectors of the health sectors, data from Miguez and Freitas
(2021), Alves-Passoni and Freitas (2022), and Holguin et al (2023) were used. Initially, based
on the mercantile health data present in the estimated MAIs in Miguez and Freitas (2021), the
total health vector was estimated, taking into account a public health vector, which is not
available in the most recent MAIs. For this, the weighting between public and mercantile
health from Holguin et al (2023) was adopted, available in table 1. Thus, a public health
vector, a mercantile health vector, and from the sum of the two, the total Investment vector of
health were defined. The GIC classification at the level of 91 products and 49 activities was
used, aligned with the MAIs of Miguez and Freitas (2021), however, only a few products are
considered capital goods.

Table 1 - Participation of Public Health and Market-Driven Healthcare Investment in

the Total Healthcare Investment
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Public Health 42,30% 36,00% 33,00% 31,70% 27,60% 22,20% 24,50% 22,00% 25,50% 21,60%
Market-driven
57,70% 64,00% 67,00% 68,30% 72,40% 77,80% 75,50% 78,00% 74,50% 78,40%
Healthcare
Source: Holguín et al (2023)

After defining the total health vectors for the period 2010-2019, taking into account
the participation of the public health vector, some demand shock exercises are carried out for
the total health investment vectors, both national and imported.

Figure 1 - National and Imported Investment Share

Source: Own elaboration based on data from Miguez and Freitas (2021)

From the preliminary analysis of the data, it was noticed that the year 2013
experienced a sharp increase in the imports of capital goods in the health sector (Figure 1).
From this year onwards, the demand shock of the national and total health sectors lost the
ability to drive the production chain through direct and indirect effects. Table 1 reinforces the
argument that the decline in the national share of production of capital goods for the health
sector had a negative impact on the capacity of demand shocks in the sector to drive the
economy.
Table 2 - Health Investment Sector Demand Shocks and Their Effects on National
Production

Source: Author Elaboration

The first variable (variation in the effect of the shock of total health year by year)
shows us that, in addition to experiencing a constant decline since 2010, intensifying in 2013,
the variation in the increase in production as a result of the shock became negative in 2015. In
other words, there was a reduction in the potential for stimulating the economy through the
vector of health Investment.
Regarding products directly related to the Health sector, it is observed that, in general,
there was a reduction in the impact of the national shock from 2014 onwards, the year in
which the Brasil Maior Plan was also concluded. However, the product with the highest
Investment, having the greatest capacity to drive the production chain, as well as innovation
potential and the creation of technological content—measuring, testing, and control
equipment, optical and electromedical—is also the one that suffers the most from a
significant increase in imports (Table 3).

Table 3 - Share of domestic production in healthcare products relative to total sector

production (imported + domestic) 2010-2019 after the simulation
Source: Author Elaboration

Finally, new vectors of health capital goods of national, imported, and total supply
were developed, but with a change of 50% of the imported content to the vector of local
production. The data presented in Table 4 provide a summary of the results obtained from this
simulation.
It is initially noticed that there is a greater increase of about 17% in the production of
the entire economy as a consequence of an increase in the share of capital goods produced
nationally, suggesting the high relevance of local production. Furthermore, it is observed that
when compared to the initial situation with the data from Miguez and Freitas (2021), there is
a significant increase in production over time.
Overall, regardless of the participation of national production in the total production
of capital goods, the years from 2014 onwards showed little productive dynamism, at least in
terms of the ability of the health sector to drive the economy.
FINAL CONSIDERATIONS: TOWARDS A SUSTAINABLE AND AUTONOMOUS
HEALTH
The panorama of the health sector in Brazil reflects not only the complexities of the
interaction between health and development but also the opportunities to shape a more
sustainable and autonomous future. New Developmentalism, as an integrated approach,
offers a vision that goes beyond mere economic growth, incorporating social and
technological dimensions.
The CEIS, as an expression of this vision, represents a strategic response to
contemporary challenges. The pursuit of a solid productive and technological base, anchored
in innovation, is crucial to address not only domestic health demands but also to position
Brazil as a relevant player in the global health scenario. Productive deepening, the promotion
of research and development, and effective coordination among the various elements of the
system are essential steps to build a sustainable and autonomous health, integrated into the
broader project of national development.

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