The State-Form in the Context of the Polycrisis of Capital and Health Inequality: An Analysis of the Limitations of Public Health Policies in Brazil

The article explores the relationship between the State-form and the polycrisis of capital, analyzing how health inequalities are deepened by the limitations of public health policies in Brazil. It is argued that the State-form, understood as a process derived from the value-form, prioritizes capital accumulation. This perspective is applied to examine the limitations of policies aimed at the Unified Health System (SUS) in reducing inequalities. Key issues include the defunding of SUS, the commodification of healthcare, and the impact of restrictive fiscal policies on the health system. The analysis reveals the interconnections between economic, ecological, and social crises, suggesting that the contemporary capitalist model exacerbates the precariousness of access to healthcare, especially among the most vulnerable populations.

• Health Inequalities
• State-Form
• Polycrisis
• Public Policy
• Brazil

1. Introduction

Contemporary capitalism finds itself in a unique context, characterized by the confluence of interconnected crises that encompass economic, ecological, geopolitical, and health dimensions, defined by some authors as a “polycrisis” ( Robinson, 2023 ; Roberts, 2023 ). This situation highlights the structural contradictions of the capitalist system, whose logic of accumulation occurs to the detriment of social and environmental sustainability. At the heart of this dynamic, the State emerges as a process of social and economic relations and is “responsible” for guaranteeing the accumulation of capital, even if this implies making life more precarious and deepening social inequalities.

In Brazil, these contradictions are strongly reflected in the health sector. Despite the implementation of the Unified Health System (SUS), which aims to universalize access to health, chronic underfunding and the increasing commodification of the sector have hampered the system’s ability to reduce inequalities in access to health services. Public policies, under the aegis of a restrictive fiscal logic, reinforce the prioritization of the interests of capital over social demands. In this sense, this article analyzes the State-form in the context of the polycrisis of capital, discussing the limits of public health policies in mitigating health inequalities, with an emphasis on the Brazilian situation.

Based on the theory of State derivation, this article aims to understand how capitalism shapes public policies in a system that prioritizes the expansion and centralization of capital to the detriment of social well-being. The State-form, as a manifestation of capital in its entirety, acts to guarantee accumulation, even when this means reducing the fundamental rights of the population. In the Brazilian case, recent economic and political choices, such as the approval of Constitutional Amendment 95 (which froze public spending for 20 years), exemplify how the State operates within the contradictions of its own structure, prioritizing fiscal adjustments and the commodification of services instead of universalizing and improving public health.

The article is structured in three parts. The first part addresses the concept of polycrisis as a backdrop for understanding the growing precariousness of living conditions and the weakening of health systems. The second part seeks to understand the nature of the capitalist State, based on its approach as a State-form, highlighting its contemporary context and the precariousness of the state process, particularly in Brazil. The third part, based on the understanding of the State-form, aims to understand the limitations of Brazilian public policies, with a special focus on the health area, indicating how much these policies fail to reduce inequalities in access to health services.

2. The Polycrisis of Global Capital

Capitalism finds itself in an unprecedented context. As Roberts argues, from 2008-2007 onwards, a period of prolonged capital depression began, in which post-crisis economies remained in a state of depressed growth, with reduced production and investment and lower job creation than in previous periods. In other words, economies remained—and remain—in a persistent recession ( Mendes, 2024 ). This period, therefore, was conceptualized by Roberts (2016; 2023) as the “Third Great Depression” and configures the current phase of the “polycrisis of global capital”, which reflects the complexity and interconnectivity of contemporary crises. “The word [polycrisis] expresses the coming together and interlocking of various crises: economic (inflation and slump); environmental (climate and pandemic); and geopolitical (war and international divisions)” ( Roberts, 2023 ).

Previously associated solely with the economic dimension, the contemporary crisis has spread beyond this environment: it has taken on a multi-faceted character whose dimensions reach political, military and ecological issues ( Mendes, 2024 ).

The format in which global capitalism has been structured has accentuated the centralization and concentration of capital itself in the hands of the transnational capitalist class (TCC), which has led to the outbreak of social, political, ecological, health, military and other inequalities, challenging the molds on which the structure of current global capital is based. Robison warns that:

In addition to the structural crisis of overaccumulation, dominant groups face a political crisis of state legitimacy, capitalist hegemony and widespread social disintegration; an international crisis of geopolitical confrontation and an ecological crisis of historic proportions. ( Robinson, 2023: p.1 ).

Marx did not formulate a well-developed theory of crisis in his work, but it influenced authors such as Callinicos (2014) and Roberts (2018) , who appropriated the laws of capitalism, addressed by him, to understand crises. Nevertheless, the law of the tendency of the rate of profit to fall is, for both authors, one of the main reasons that sustains the causes of capital crises, according to Marx. “The fall in the rate of profit is, in every respect, the most important law of modern political economy, and the most essential for understanding the most difficult relations.”.

Regarding the economic dimension of the polycrisis, the two factors that are considered “causal” are the law of the tendency for the rate of profit to fall and the bubble cycles in the financial market, as argued by Callinicos (2014) . The first factor is intrinsic to the structure of the capitalist system and is the result of overproduction and overaccumulation. Consequently, the search for greater productivity results in pressure to increase constant capital (machinery and technology), not in the same proportion as variable capital (labor force). Since the labor force generates surplus value in the economy—from which profit derives—its reduction leads to a fall in the rate of profit.

Roberts (2016) demonstrates this trend between 1950 and 2019, in which the profit rate of advanced countries, despite showing short periods of recovery, such as from the 1980s (“Neoliberal Recovery”), shows its collapse (Graph 1). After the 2007-2008 crisis, profit rates were unable to return to pre-crisis levels, falling from 7.4%, in 2007, to 6.8%, in 2019, as shown in Figure 1 .

Acting as a countertrend to this movement of capitalism, interest-bearing capital—in its most perverse form, fictitious capital—is expanding, with the trading of government bonds, shares, derivatives and other financial assets. The expansion of this capital appears to “compensate” for the fall in the profit rate and maintain the overaccumulation of capital. This capital, as observed, in 2008, during the subprime crisis, due to its fictitious nature and the apparent ease of accumulation, can generate financial bubbles.

These economic tensions are further accentuated by the geopolitical nature of the polycrisis, which has intensified in the current decade with the war between Russia and Ukraine in 2022 and the “Cold War” between the United States and

Figure 1

Figure 1. G20 countries’ world profit rate (%)—from 1950 to 2019. Source: Penn World Tables. Roberts (2022) .

China ( Robinson, 2023 ). These events suggest a possible rupture in the global accumulation system, since the center of the hegemony of capital power seems to be increasingly shifting to the West of the map, that is, China has taken a key space in the accumulation dynamics, however, it is not certain that it will become the new hegemonic power. Robinson warns us: “rather, we are moving towards political multipolarity at a time of acute crisis in global capitalism—prolonged economic turbulence and political decay. We are facing the decomposition of capitalist civilization” ( Robinson, 2023: p. 2 ).

This dynamic can be understood as an inherent consequence of the greedy nature of the global capitalist accumulation system, the ecological aspect that makes up the concept of polycrisis has accelerated this rupture. Mendes (2024: p. 8) presents some authors who discuss the relationship between the unlimited expansion of capitalism and the emergence of pandemics. For example, the advance in agroindustry that promotes large-scale production and induces monocultures of animals in precarious conditions, which, in turn, favors the transmission of diseases in environments with weakened immune responses. The COVID-19 pandemic can be understood as a response to this agro-industrial model.

According to the UN report, “Adaptation Gap Report 2024: Come hell and high water—As fires and floods hit the poor hardest, it is time for the world to step up adaptation actions”, evidence indicates that, by the end of the century, the world is heading for an average global warming of up to 3.1˚C—already considering the current policy scenario¹. As a result of this warming, societies face and will face increasing and possibly irreversible climate risks—social and ecological. Thus, the set of factors of the current capitalist mode of production, the destruction of biodiversity, the climate emergency and the pandemic effects of diseases, configure the threat and precariousness of human existence.

Parallel to this, the 2023 World Economic Forum discussed the “polycrisis” of capitalism and highlighted the lack of consensus on how to stabilize it in the face of growing inequality, aggravated by the growing fortunes of billionaires in contrast to the hunger of almost a billion people ( Robinson, 2023 ). The concern of the “Davos Elite” (Robsustained the global economy in this period of polycrisis. It has promoted privatized wars and social control systems for the benefit of its existence, or rather, the existence of the relationship of its dominance over the value-form. The force of state violence, as well as its selfishness before the collective, is part of the current accumulation model that deepens economic, social and environmental instabilities.

Thus, the analysis of the interconnected dimensions of the capital crisis is central to understanding its impacts on ecological destruction, the worsening of inequalities, and the perpetuation of a model of accumulation that threatens human survival and the State. In particular, in terms of health inequities in this context of the polycrisis of capital, with its respective dimensions, it is worth mentioning some evidence. But first, it is important to argue that reflection on health inequities requires a more scientifically robust explanation, from a perspective of the political economy of health. This perspective includes the social determination of the health-disease process, that is, in which health and disease patterns are produced by social and economic conditions, structures, cultural values and priorities of political and economic systems. Thus, from this perspective, several studies have shown that the global capitalist crisis, with the growth of inequalities and unemployment, has led to an increase in the number of suicides and mental health problems in the world ( Bambra, 2011 ). To give you an idea, studies reveal that mental health, stress and depression among men in England deteriorated in the years following the subprime crisis of 2007-2008, as well as increasing during the following periods of recession, especially in Spain, Greece and Ireland ( Houdmont et al., 2012 ; Gili et al., 2013 ; Corcoran et al., 2015 .). There is also evidence of increases in self-harm and psychiatric morbidity ( Barnes et al., 2017 ). Furthermore, several studies have identified that during periods of recession, suicide mortality rates increased ( Barr et al., 2012 ).

In highlighting the impacts of the crisis within the State, from the perspective of the debate on the derivation of the State², it is a key element in guaranteeing the system of capital accumulation, that is, it plays, in this context, a pro-capital role, in which the validity of social welfare policies is not respected and which manages to override the basic rights guaranteed by the Brazilian Constitution of 1988³. The “[...] State is a capitalist. It may look like a potentially neutral State within a capitalist society, but that’s not true. It’s a capitalist State” ( Holloway, 2025 , p. 1, own translation). Holloway illustrates this State in the context of the “Welfare State”.

The growth and, especially, the subsequent retrenchment or restriction of state social services that characterize the “Welfare State” have brought an enormous growth in struggles over the State’s role in housing, health, transport, education, among others. ( Holloway, 2025 , own translation).

Since the State, in its State-form (an expression that reveals the essence of the social relations of the capitalist State), is a particular form of capital and its relations that aim to guarantee the accumulation system, it does not aim at social well-being due to its “goodness” and neutrality, quite the opposite. Understanding the State-form, therefore, opens up ways to understand the inequalities between the social relations of the system.

3. The State-Form, Its Contemporaneity and the Precariousness of the State Process in Brazil

In order to understand the role of the capitalist State, both in the formation and in the reduction of inequalities in Brazil, it is necessary to appropriate the dialectical methodological rigor of contradictions, present in the theory of the derivation of the State. Some authors revisit Marx’s works to, from his perspective, formulate the role of the State as a political form that derives from the value-form. This is to say that the State is solely driven by the logic of capital accumulation, which constitutes an illusion to opt for the institutional path as a way to overcome capitalism. However, it is important to consider that we do not deny here the role that the institutional route—the action of the State through public policies – can play in improving, to a certain extent, the living and working conditions of the working class, guaranteeing social rights. Although the political struggle of the working class, especially with regard to the experiences of Western Europe in the early 20th century, allowed, under intense struggle, the possibility of building large social protection systems from the second half of that century onwards, known as “Capitalist Social States”, this cannot be used as an argument to say that the State “ceased” to be capitalist ( Boschetti, 2016 ). We therefore reinforce the idea that public policies are limited in their capacity to solve the problems of the working class, which means that the capitalist State tries not to allow their contents, even if they are social rights, to promote to some degree the instability of capitalist social relations that could be a threat to this mode of production. In turn, for Huwiler & Bonnet (2022) , it can be said that although public policies have their limits, they also present flaws in their execution because, although they are a product of the capitalist State, they are not always capable of reproducing capitalist social relations in an “optimal” way. Thus, whether by “trial” or “error” in their execution, as Huwiler & Bonnet (2022) argue, public policies present moments of inadequacy for the reproduction of capital, and these moments can be an important void for political action based on the communist horizon of the working class in an attempt to create tensions against the limits of the capitalist State, causing its extinction.

In returning to the fundamental argument that the state-form derives from the value-form, it should be remembered that the movement of capital develops through contradictions, tendencies and countertendencies. This movement can be understood as a process, that is, capital is a relationship in process (movement), whose value-form synthesizes the social relations present in capitalism. These relations are based on exploitation and domination between classes, ensuring capital accumulation. That is, one class, the dominant one, appropriates the value-form through relations that synthesize the time of socially realized work, materialized in a product and condensed into a representative unit, the commodity form – money being the universal commodity in the process of capital accumulation.

Although the value-form tends to be initially interpreted as a merely economic category, Ávalos (2021) , who renews the derivationist debate on the State, argues that its meaning must be understood as the foundation of political existence. In this sense, the State-form derives from the value-form, being the political moment in the totality of capital. Still in Ávalos (2021) , capital is a “relationship in process”, always in transformation and movement⁴, but remaining as capital. Similarly, the State can be understood as a procedural relationship, which manifests itself as domination and forced subjection (alienated labor). This relationship is rooted in the process of production and reproduction of life, with the State as the political moment of this domination.

The political form of the State comprises the relations of capitalist production and, thus, has the function of ensuring the commodity form and the value-form, that is, it intervenes politically and economically to ensure the accumulation of capital – with “capital” being the value that is valorized, the social relations that comprise the State, the mediator of social relations in capitalism, derive from the value-form. The State-form, as a deduction of the value-form, highlights the link between Hegel’s logic and the critique of political economy. Ávalos explains this idea:

At the core of the value-form is the negative role of the State, an essential element of the State-form. In line with Ávalos (2021) , the State can be seen as negative capital, since, instead of seeking profit, its function is to guarantee the reproduction of capital. It acts in times of crisis, in the trends and counter-trends of the capitalist system. In line with Ávalos, Holloway clarifies: “First of all, if the existence of the State derives from capital, it is clear that the State must promote the reproduction of capital. In other words, it has to ensure the maximum possible return on capital. If this does not happen, capital will go elsewhere” ( Holloway, 2025 : p. 3, own translation). For this to happen, the State will spare no effort, nor will it be neutral. On the surface, it may seem that it will act in favor of humanity and the common good, but in its essence, it will always be on the side of the expansion of capital. And it is under this analysis that the current polycrisis situation emerges, and, mainly, the formation of an unequal society.

The polycrisis has revealed itself in the current context by conditioning the social order of the capitalist system through the increase in the “precariousness” of states and the accentuation of inequalities, promoted by the nature of the mode of production of capital. From the perspective of Ávalos (2015) , it can be understood that, in the current Brazilian situation, the figure of the Leviathan-State prevails over the figure of the Res Publica-State⁵, that is, the interests of a sovereign and supreme State are above the collective and community interest. In this case, this imbalance in the “stateness” of the Brazilian State exposes social, economic and political inequalities. In other words, the Brazilian state process is precarious due to the lack of balance between the principles of the Leviathan-State and the Res Publica-State, and as a result, it exposes a State that is weak for the accumulation of capital and for the well-being of society.

Since the State, analyzed in terms of its State-form, must guarantee the accumulation of capital, the value-form that appropriates human labor through the exploitation and dominance of one class over another, its nature foresees inequality between the classes—dominant and dominated. In its contradiction, it tries, through the balance of the materialization process of its structure, to mitigate these inequalities, but fails due to the lack of rationality⁶ in its actions. In the Brazilian case, it also fails when faced with a structure that finds a state base strengthened in supreme unity, a Leviathan-State sovereign to the Res Publica-State.

4. Public Health Policies and Their Limits in Reducing Inequalities in Access to Health Services in Brazil

Based on these contradictions inherent to the capitalist system, allied to the structure of the State in Brazil, public policies are limited in terms of attempts to reduce inequalities, especially in access to health services.

Public policies are responses to a capitalist State in its procedural form ( Huwiler, 2022 ), which carries this same logic in its “DNA”. In other words, public policies reflect the arrangement of capital accumulation, and, in the case of social public policies, they are “social welfare” to a certain extent: that of the interest of capital. “Therefore, if the State is, as Holloway (1980) calls it, the “process-form” of social relations of domination in capitalism, it impregnates the public policy process with its own form” ( Huwiler, 2022 : pp. 22-23, own translation).

Additionally, one of the main, or perhaps the heart of limitations of public policies is the understanding that there is a separation between political and economic. The entire process of construction, formulation and adoption of public policies precedes this logic of separation and, despite being recurrent, it is not fixed. Huwiller is categorical on this idea:

Let’s take an example. When we look at the limits in formulating and adopting a policy, we assume that many of them are defined by this separation. A generalized nationalization of the means of production, for example, will not normally be considered as one alternative among others by the political staff. There may be an initiative by a government to nationalize a company, or even a demand from a sector of the bourgeoisie in this regard, for different reasons and in different contexts. But never, in principle, a generalization of such a measure, because that would undermine the separation between the political and the economic that characterizes the capitalist system. However, there are historical moments in which initiatives like these have been more frequent than at other times. Therefore, we say that this separation is not permanent, but changeable. ( Huwiler, 2022 : p. 23, own translation).

Public policies express social relations in their “procedural” form, that is, public policy as a process of a State. The State adopts a public policy as an action to solve problems (exogenous and/or endogenous⁷), that is, they happen with intention and not spontaneously. That said, public policies are a process aligned with the demands of the capitalist State and, because there is no rationality, it is a process with a “trial and error” mechanism, as Huwiler (2022) calls it. “This mechanism is the result of the existence of certain factors that limit the adequacy of public policies to the changing and contradictory demands of capitalist reproduction. This does not mean that there is no adequacy at all, but that there is a limited adequacy”. ( Huwiler, 2022 : p. 30, own translation)

Over the years of its existence, there were several moments when it became clear that the SUS was not a priority on the government's agenda and neither was it within Social Security. ( Marques & Ferreira, 2023 : p. 470).

This behavior was manifested, in 2016, through a state measure that demonstrates its indifference to the social demands proposed in the 1988 Constitution. This measure aligns with the interests of capital at a time when the importance of fiscal adjustments and zero deficits in public debt is being disseminated, especially in peripheral countries. The measure approved, Constitutional Amendment 95 (EC 95), became popularly known as the “Spending Ceiling” and consisted of freezing federal government spending for twenty years, including expenditures on health and education—but excluding public debt service, that is, interest and amortization costs. From that moment on, public health funding was limited by the ceiling established by CE 95, which was a 15% floor of the country’s net current revenue, in 2017, allocated to health ( Marques & Ferreira, 2023 : pp. 470-471).

Additionally, the SUS has undergone significant changes in its programs and policies, especially in the area of Primary Care, also known as Primary Health Care (PHC). These changes include the updating of the National Primary Care Policy⁸, in 2017, and the implementation of the Previne Brasil Program⁹, in 2019, which redefined the funding guidelines for primary care. Both health actions and services are beginning to decline, losing around 17.6 billion in resources between 2018 and 2019 ( Marques & Ferreira, 2023 : p. 471). These measures have dehydrated the roots of the SUS and begun a process of “dismantling”.

From that moment on, SUS has gone from being underfunded to suffering real defunding, that is, from a situation of insufficient resources to meet its objectives, it began to face a reduction in its availability ( Marques a& Ferreira, 2023 : p. 471).

The State-form is being swallowed up by market logic in sectors of basic needs, with the dominance of private capital prevailing and the differences between classes accentuating. The State, as the guarantor of the establishment of the dominance of private capital, chooses to act in the search for what is convenient for the process of capital accumulation, in any sector, under any conditions, and without considering the social/community logic. It guarantees this process indirectly “through its own dismantling with the aim of reinforcing the expansion of private capital” ( Mendes, 2024 : p. 221). In this line, it is worth mentioning the words of Giovanella et al.:

Breaking with the universality of the SUS, as intended and implemented by the current [Bolsonaro] government based on the supposedly pro-equity discourse, is a fallacy. It is a process of “neoselectivity”, characterized by the provision of publicly funded health actions to extremely poor population strata, by private or public providers, separated from a perspective of health networks and regions, in line with the restrictive policies of fiscal adjustment and reduction of state intervention. The set of social policies reforms, including those in the health sector, undertaken in a voracious and hasty manner by the Bolsonaro government accentuates and crystallizes inequities, and strengthens the commodification also in the provision of PHC services ( Giovanella et al., 2020 : p. 1479, emphasis added).

This “commodification” of health is observed when the State allows private participation in health services. Palmeira et al explain:

[...] new possibilities of relationship between the State and private companies has come into force, in such a way that public and private sectors can participate, indistinctly, in the provision of health services within the SUS, resulting in the reduction of the state's duty, defined constitutionally, to promote health care for the Brazilian population. ( Palmeira et al., 2022 : p. 2).

The relationship between the State and the private sector in the health field involves several types of subsidies. One of the most relevant is "tax expenditure", that is, the amounts that the government stops collecting due to tax exemptions. These exemptions act as tax incentives for service providers and philanthropic health plan operators, as well as stimulating the acquisition of private services and plans. This is because the amounts spent on these services can be deducted from the income tax base, for both individuals and legal entities ( Ocké-Reis, 2018 ).

In this context, philanthropic institutions¹⁰—which include service providers and health plan operators—benefit from tax exemptions at federal, state and municipal levels. In 2015, the tax waiver related to Corporate Income Tax, added to the incentives granted to health plans, totaled R$12,5 billion. In comparison, in 2003, this amount was R$6,1 billion. This indicates that, in real terms, subsidies for consumption in the health insurance market doubled over the period ( Ocké-Reis, 2018 ).

These resources could be redirected to strengthen the SUS and reorient the care model, especially in primary and medium-complexity care. If they were applied to areas such as the Family Health Program (FHP), health promotion and prevention, emergency care units, specialized clinical practices and diagnostic and therapeutic support services, they could contribute significantly to the development of these areas. However, the State-form of a state with an unbalanced “stateness” —with the Leviathan-State bias prevailing in its way of acting—finds no motivation to convert these tax incentives into health benefits through spending. Therefore, in addition to the exemption of private companies from taxes—which reduces the costs of these companies without forcing them to reduce their prices – the simple and mistaken rhetoric that a country does not spend more than it collects, just like a family budget, prevails.

As a result of these actions, the results of access to health services have become precarious. SUS data indicate a proportional reduction in those who obtained care the first time they sought it, falling from 95.3% in 2013 to 67.9%, in 2019, according to Santos et al. (2008) . This setback indicates the weakening of SUS health services, especially in primary care, and infers the trend caused by the State-form.

Access to medicines through the Farmácia Popular Program and other public services fell by approximately 15 percentage points between 2013 and 2019. This decrease in access is especially detrimental to the elderly and chronically ill, who are the main users of this program, and tends to get worse as the demographic and epidemiological transition advances ( Palmeira et al., 2022 ). According to the Institute of Health Policy Studies ( IEPS, 2024 ), 40% of Brazilians in the lowest income bracket reported not being able to access essential medicines, compared to only 8% of the richest. This disparity reflects the centrality of the SUS in the lives of the poorest, who depend exclusively on the public system to access basic health services. In contrast, higher-income individuals use the private network, distancing themselves from the limitations faced by the public system. Regional and social inequalities remain, with the North and Northeast regions having the lowest access to health services, while people with lower socioeconomic status continue to face significant obstacles.

It is also worth highlighting the regional inequalities in access to and use of health services in Brazil, already recognized by the Ministry of Health, in initiatives such as the National Primary Care Policy (PNAB) and the Surveillance System for Risk and Protective Factors for Chronic Diseases by Telephone Survey (Vigitel). Reduced access to medical and dental consultations in the North and Northeast regions is directly related to the shortage of professionals in the public network, which, even with efforts to expand health services in the most vulnerable regions, still represents a significant difficulty in guaranteeing sufficient human resources ( Palmeira et al., 2022 ).

Furthermore, stratification by educational level reinforces inequalities in access to health services. Although there has been an increase in access to dental consultations, barriers such as low income, low educational level and scarcity of oral health services still prevent adequate coverage, especially among the elderly. The fact that 70% of the Brazilian population depends exclusively on the SUS to access health services highlights the insufficiency of free dental services, which are limited in number and make access difficult, generating pent-up demand.

Socioeconomic status also proves to be a decisive factor in accessing and using health services. Individuals with higher incomes or higher socioeconomic status have greater access to medical services and medications. In contrast, people with lower incomes or socioeconomic status face greater difficulties in accessing quality health services and depend more on the SUS to obtain medications, as previously shown. In addition, they tend to be more exposed to precarious housing conditions and limited access to basic sanitation.

This configuration illustrates the absence of a concern of the capitalist State in promoting equity or social welfare. By prioritizing private interests, such as tax subsidies for health insurance companies, and by “defunding” the SUS, the State reinforces structural inequalities, demonstrating that the dominant logic aims to sustain the expansion of capital, even to the detriment of the health of the vulnerable population. The logic of “dismantling” that has been undergoing for decades and the transfer of public health to commodification prevails.

Public health policies in Brazil are deeply influenced by the logic of the capitalist State in its form and process, characterized by the priority given to the interests of capital over social demands. This structure limits the capacity to address inequalities in access to health services, especially in more vulnerable regions and populations. The defunding of the SUS, intensified by policies such as Constitutional Amendment 95, reinforces the structural difficulties of the system, highlighting a scenario of commodification of health that favors the private sector and weakens primary care, resulting in a significant worsening of indicators of access and quality of services. The persistence of regional and social inequalities, coupled with the dependence of a large part of the population on the SUS, reinforces the need to rethink public health policies from an equitable perspective, which recognizes and confronts the structural contradictions of the current state and economic model and leads to a greater balance of Brazilian “Stateness”, implying reinforcement of the Res Publica-State.

5. Final Considerations

The analysis developed throughout the article reaffirms the central role of the State as a derivative form of capital, whose primary function is to ensure the continuity of accumulation, even if this implies the precariousness of fundamental social rights, such as access to health.

From this perspective, the Unified Heath System (SUS), conceived as a universal public health system in Brazil, suffers the direct impacts of the logic of fiscal adjustment and structural defunding, limiting its ability to meet social demands and perpetuating inequalities. The enactment of Constitutional Amendment 95 is a milestone in this trend, demonstrating how the restriction of public investment in health responds more to the demands of the financial market than to the needs of the population.

The defunding of the SUS not only restricts access to health services but also favors the consolidation of a model based on commodification and privatization, which deepens regional and socioeconomic inequalities. More vulnerable regions, such as the North and Northeast, face shortages of human resources and infrastructure, while groups with lower socioeconomic status depend exclusively on the SUS, often encountering significant barriers to accessing basic services. This disparity highlights a State that, far from acting as an agent of equity, reinforces the mechanisms of exclusion inherent in the capitalist system.

Furthermore, theoretical analysis reveals that the State, in its essence, is not neutral, but a process of mediation of the contradictions of capital, ultimately ensuring the reproduction of relations of exploitation and domination. In the context of polycrisis, these contradictions become more evident, with overlapping economic, ecological and social crises, intensifying the vulnerability of the population and restricting the State’s capacity to respond. The role of the State in managing these crises, by prioritizing fiscal adjustment and strengthening fictitious capital, perpetuates an unsustainable model of accumulation, compromising not only present well-being, but also the possibility of a more equitable future.

Given this scenario, it is imperative to rethink the state model and its public health policies, considering a perspective that goes beyond the logic of capitalist accumulation and places the focus on life and social well-being. Structural reforms in health financing, valuing the SUS as a universal and equitable public policy, and breaking with the commercialization of services are fundamental steps in tackling health inequalities. However, these changes require not only political will, but also social mobilization to confront the dominant interests that sustain the State-form as it stands today.

NOTES

¹Moreover, the UNEP Report states that: “the world is approaching +1.5˚C (global mean surface temperature compared to pre-industrial levels) much earlier than even the latest IPCC assessment report estimated. Science is becoming ever clearer on the associated irreversible observed impacts and projected risks” […], starting with the most sensitive natural and social systems, such as women and the poor, who are disproportionately affected by climate impacts […]. Climate impacts (extreme events as well as slow-onset events) also have the potential to change the trajectories of societies in fundamental ways ) […]” ( UNEP, 2024: p. 4 ).

² Carnut (2023) points out that the debate on the derivation of the State is part of a tradition of analysis on the relationship between Capital and the State, with the latter deriving from the former. This debate took place in the former Federal Republic of Germany, between 1970 and 1974, mainly in West Berlin and Frankfurt, and within the Conference of Socialist Economists (CSE), in the United Kingdom, during the same period. Even today, forty years after its development, this debate is little known in Latin America, even among the Marxists who originated it. Since its inception, this debate has been consolidated into a complex materialist theory of the State.

³See more in Art. 193 & Art. 194 of the 1988 Constitution of the Federative Republic of Brazil ( Brazil, 1988 ).

⁴“Capital is an effective, but dysfunctional form of domination” ( Holloway, 2022 , preface). In line with Hollway, although capital is in constant process, it is important to emphasize that this process is dysfunctional, which indicates the limitations of the State as a guarantor of social “well-being”.

⁵“According to Ávalos, in order to guarantee the process of capital accumulation, the State materializes and structures itself in a process called “Stateness” (“Estatalidad”). It condenses two contradictory principles, which, in balance, guarantee Stateness, which implies guaranteeing a certain harmony in the development of the nation-state. These principles are the Leviathan-State, in which the State is positioned as the supreme power, as a “biblical monster”, feared and sovereign. The “[...] establishment of this supreme power is the result of an agreement of all with all those who have to regulate their behavior according to the norms dictated by it; that is, that the unitary and supreme power is sustained by a pact, contract, agreement, accord, voluntary of all human beings who are considered, in principle, as universally free and equal”. ( Ávalos, 2015 : p. 59, own translation). And the second principle, that of the Res Publica-State, where the State expresses itself as community power, a relationship of public concentration of community power. “[...] it [Res Publica-State] rejects the concentration of power because it maintains that the communitarian entity of the whole is the true subject of the governing body and the sole reason for the existence of the people assigned to this work” ( Ávalos, 2015 : p. 59, own translation).

⁶The term rationality is used in the same sense as that used by Huwiler & Bonet (2022) , who address the less rationalist interpretation of the public policy formulation process. Classical literature on the subject often assumes full rationality of the agents involved. However, according to the authors’ Marxist perspective, this is an erroneous understanding, since the public policy process is structured based on “trial and error”. Thus, the formulation of public policies presents limits to the idea of rationality.

⁷“Both cases would, however, be responses to problems: in the first case, responses to predominantly external demands, for example, in the face of the demand for the legalization of abortion by the feminist movement, or in the face of the demand for a reduction in retentions by agricultural companies; in the second, responses to issues predominantly internal to the state apparatus, such as a reorganization of an area of the state apparatus due to overlapping tasks or a modernization policy.” ( Huwiler, 2022 : p. 28, own translation).

⁸See Almeida et al. (2018) .

⁹See Seta et al. (2021) .

¹⁰“A Philanthropic Entity is a charitable social assistance entity (originally defined in the Organic Law of Social Assistance, Law No. 8,742 of 12/08/1993, Art. 3, as “social assistance entities are those that provide, on a non-profit basis, assistance and advice to beneficiaries covered by Law, and those that act in the defense and guarantee of their rights”) and/or education and/or health, without profit (defined in Law No. 9,718 of 11/27/1998, Art. 10, § 3, on Federal Tax Legislation, as being “the entity that does not present a surplus in its accounts or, if it does present a surplus in a given fiscal year, allocates said result entirely to the maintenance and development of its social objectives”), which complies with the requirements of CNAS Resolution 32/99. The granting or renewal of the Philanthropy Certificate is regulated by the Organic Law of Social Assistance, Law No. 8,742/93, by Decree 2,536 of 04/06/98 and by CNAS Resolution 32/99” ( Santos, et al. 2008 : p. 1437, own translation).

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