Agatha Eleone e Arthur Aguillar
The slowness of the vaccination process and the recent second wave of Covid-19 in Brazil have created a series of social issues. Entrepreneurs seek to purchase vaccines for themselves, their families and their employees. For the latter, the objective is to enable economic recovery as soon as possible. A considerable part of the elite is already flying to Miami, now that the US government has announced the vaccination of tourists. No wonder: in a world with an unequal prevalence of the disease, the vaccine works as a new health insurance that will allow us to sleep in peace, knowing that neither we nor ours will perish. In addition, it will also be a passport to the fulfillment of many repressed desires: trips, parties, going to restaurants and nightclubs are once again a possibility, already longed for after almost a year and a half at home – for those who had the privilege of being able to protect oneself from illness through isolation.
The possibility of looking for a private route to acquire vaccines and protect oneself from Covid-19 is what the late economist Albert Hirschman, a type of patron of economists who venture into interdisciplinarity, would call “the way out”. By analyzing the dynamics between quality between trains and highways in Nigeria, Hirschman created a typology to understand the dynamics of quality and effectiveness of public services.
Faced with a public service considered bad, such as the case of trains in Nigeria in the 1970s, a beneficiary of this service (for example, a large biscuit producer, like the father of the protagonist of the book Hibisco Roxo, by writer Chimamanda Ngozi Adichie) has , usually two options. He can simply stop using the train service (exit) and start using trucks to transport their production. Alternatively, he can also complain about the service (voice), exercising collective action through formal and informal complaints, protests and media activation, criticizing the quality of services. Hirschman shows us in his book Output, Voice and Loyalty that even if a biscuit producer may stop using the train (get out) to use the highways, he cannot opt out of both services, because after all, he still needs a way to transport his production. In this example, local entrepreneurs therefore have the option to opt out of the service. The theory raised by Hirschman proposes that the greater the possibility of leaving the public system, the less likely that local elites will use their voice and political connections to demand the improvement of a service.
Hirschman, a citizen of the world who has always been in touch with the greatest challenges of his time, whether helping Jews escape Nazi-occupied Europe, contributing as an economist to the Marshall Plan, or even as a participant in the World Bank’s first mission to a country in development, would certainly be interested in the dynamics between voice and output of public health systems in the face of the Covid-19 pandemic.
The first conclusion we reach from the framework of Output, Voice and Loyalty is that the process of bypassing the SUS in order to get vaccinated against Covid-19 embodies a natural human desire that can only be exercised by the richest layers of the population in the face of a public service of unsatisfactory quality: if possible, leave. The exercise of this desire, however, has obvious social consequences, since the richest are precisely the social group with the greatest capacity for collective action and mobilization (voice). When those capable of charging the public administration (whether by donating large sums to electoral campaigns, having space in the media or any other form of influence) fail to do so due to the option of leaving, all beneficiaries of the service lose.
The second conclusion is that in the case of the Covid-19 pandemic — and in general, most public health challenges —, exit, in fact, is a logical impossibility. This is because in an event of this type, the individual’s health does not depend only on their individual actions, but has an interdependent relationship with the actions of all other individuals that make up a society: even if a businessman manages to get the vaccine, that it does not significantly alter the transmissibility and vulnerability associated with Covid-19: a large part of the workforce will still be unable to carry out their activities; restrictive collective measures will still be needed to curb the disease; and the social vulnerability and food insecurity that stem from the economic downturn will continue to demand an active role for the state in strengthening social safety nets.
If we are convinced that the exit is a logical impossibility, it remains to exercise the voice. Here, we have a lot to do: it is possible to propose effective partnerships between private entities and the public service. At the level of public opinion, there is a long way to go in communicating risk with the population, in disseminating reliable information about the pandemic and in combating fake news. At the public management level, our municipalities need help with the acquisition of supplies, transport and storage of vaccines, as well as with epidemiological surveillance, a complex task that many small towns do not have the scale to perform. And at the macro level, it is necessary to hold the federal government accountable for its omission and negligence both in taking restrictive measures and in the process of purchasing and purchasing vaccines.
Hirschman, an economist who was fond of palindromes and other puns (drawing from them to important hypotheses about the interrelation of political and economic forces), would possibly notice the irony intrinsic to the present moment. The pandemic brought to light what had not been seen in the context of Brazilian health for a long time: “it forced the biscuit producers to use the train”. It is possible to fly to the US to vaccinate yourself and those closest to you by spending 450,000 reais (enough to buy 45,000 doses of Coronavac), like recently did a businessman. But you can’t take the company in the plane’s trunk. For those who do not have access to exit (today, the total set of people living in Brazil), only the voice.
Agatha Eleone, Public Policy Researcher at the Institute for Health Policy Studies (IEPS).
Arthur Aguilar, Coordinator of Public Policy at the Institute for Health Policy Studies (IEPS).