Adelyne Maria Mendes Pereira

Bio: Adelyne Maria Mendes Pereira is an academic researcher from Oswaldo Cruz Foundation. The author has contributed to research in topics: Health care & Per capita. The author has an hindex of 7, co-authored 17 publications receiving 152 citations.

Regionalização e acesso à saúde nos estados brasileiros: condicionantes históricos e político-institucionais

Abstract: This article examines the healthcare regionalization process in the Brazilian states in the period from 2007 to 2010, seeking to identify the conditions that favor or impede this process. Referential analysis of public policies and especially of historical institutionalism was used. Three dimensions sum up the conditioning factors of regionalization: context (historical-structural, political-institutional and conjunctural), directionality (ideology, object, actors, strategies and instruments) and regionalization features (institutionality and governance). The empirical research relied mainly on the analysis of official documents and interviews with key actors in 24 states. Distinct patterns of influence in the states were observed, with regionalization being marked by important gains in institutionality and governance in the period. Nevertheless, inherent difficulties of the contexts prejudice greater advances. There is a pressing need to broaden the territorial focus in government planning and to integrate sectorial policies for medium and long-term regional development in order to empower regionalization and to overcome obstacles to the access to healthcare services in Brazil.

Federalism and health policy: the intergovernmental committees in Brazil

Abstract: OBJECTIVE To analyze the dynamics of operation of the Bipartite Committees in health care in the Brazilian states. METHODS The research included visits to 24 states, direct observation, document analysis, and performance of semi-structured interviews with state and local leaders. The characterization of each committee was performed between 2007 and 2010, and four dimensions were considered: (i) level of institutionality, classified as advanced, intermediate, or incipient; (ii) agenda of intergovernmental negotiations, classified as diversified/restricted, adapted/not adapted to the reality of each state, and shared/unshared between the state and municipalities; (iii) political processes, considering the character and scope of intergovernmental relations; and (iv) capacity of operation, assessed as high, moderate, or low. RESULTS Ten committees had advanced level of institutionality. The agenda of the negotiations was diversified in all states, and most of them were adapted to the state reality. However, one-third of the committees showed power inequalities between the government levels. Cooperative and interactive intergovernmental relations predominated in 54.0% of the states. The level of institutionality, scope of negotiations, and political processes influenced Bipartite Committees’ ability to formulate policies and coordinate health care at the federal level. Bipartite Committees with a high capacity of operation predominated in the South and Southeast regions, while those with a low capacity of operations predominated in the North and Northeast. CONCLUSIONS The regional differences in operation among Bipartite Interagency Committees suggest the influence of historical-structural variables (socioeconomic development, geographic barriers, characteristics of the health care system) in their capacity of intergovernmental health care management. However, structural problems can be overcome in some states through institutional and political changes. The creation of federal investments, varied by regions and states, is critical in overcoming the structural inequalities that affect political institutions. The operation of Bipartite Committees is a step forward; however, strengthening their ability to coordinate health care is crucial in the regional organization of the health care system in the Brazilian states.

Crise, condicionantes e desafios de coordenação do Estado federativo brasileiro no contexto da COVID-19

Abstract: When COVID-19 struck Brazil, the pandemic exacerbated the scenario of political, economic, and social instability that had marked the country since 2015. The political and institutional reality reveals a crisis of coordination with a strong federative dimension, manifested in various ways in public policies: impasses in cooperation between levels of government; lack of definition and juxtaposition of attributions and roles; difficulties with timely execution and integration of actions and services; leadership by some state and local governments, alongside negligence and omission by others; and insufficient transparency and conflicting information on COVID-19. As the pandemic worsened and the health system was overrun in various cities, the clashes between the president, governors, and mayors became increasingly evident and heated, compromising the State’s response capacity and creating mistrust and insecurity in the population. In early June, 2020, Brazil had the second highest number of cases and deaths, following only the United States 1. This article aims to extract reflections on the crisis of Brazil’s federative State, seeking to contribute to the understanding of the conditioning factors and challenges for coordinating public policies and the Brazilian Unified National Health System (SUS) in the context of COVID-19. The article draws on two underlying arguments. The first is that the factors constraining the State’s action in its federative dimension are varied, and originated before the pandemic emerged. Although the political tensions that have become more acute with COVID-19 are relevant, we highlight other political and institutional aspects (characteristics of the federative system) and historical and structural ones which also limit the government levels’ cooperation and performance. The second argument relates to the need for integration between areas of public policy and cooperation between levels of government for the development of more effective measures to mitigate the social, economic, and health harms from COVID-19. Given the pandemic’s inherent dynamics, strategies and instruments for coordination involving multiple dimensions, actors, and decisionmaking and action scales are essential for implementing more comprehensive and integrated policies and actions. 1 Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil. 2 Universitat de les Illes Balears, Palma, España.

Atenção primária à saúde na América do Sul em perspectiva comparada: mudanças e tendências

Abstract: Objetivou-se compreender as principais tendencias e os desafios para a organizacao da atencao primaria a saude (APS) na America do Sul, no marco dos processos de mudancas politicas da ultima decada movidos pela chegada ao poder de correntes de esquerda. Trata-se de um estudo de natureza comparada, desenvolvido a partir da analise de quatro casos - Brasil, Venezuela, Bolivia e Uruguai. Evidenciou-se que o novo contexto politico deslocou o foco das politicas para a universalizacao e para modelos assistenciais fundados em uma APS integral. Contudo, permanecem desafios relacionados ao contexto historico institucional de cada pais para a consolidacao da APS como estrategia estruturante de seus sistemas de saude.

30 anos de SUS: relação público-privada e os impasses para o direito universal à saúde

Abstract: RESUMO Este estudo analisou a relacao publico-privada nos 30 anos do Sistema Unico de Saude (SUS), bem como os impasses que repercutem na efetivacao do direito universal a saude. A pesquisa totalizou a participacao de 12 atores do Movimento da Reforma Sanitaria Brasileira (MRSB), que foram entrevistados no periodo de janeiro a marco de 2018. Utilizou-se um roteiro de entrevista com questoes semiestruturadas, pelo formulario on-line do Google (Google Forms). As entrevistas foram analisadas pelo metodo do discurso do sujeito coletivo, resultando em quatro ideias centrais: 1) Neoliberalismo e organizacao capitalista do sistema de saude; 2) A relacao publico-privada na construcao do SUS; 3) Estrategias de privatizacao e o financiamento do SUS; 4) Conjuntura e perspectivas em defesa do SUS. Como resultado da pesquisa, pode-se perceber a disputa de poderes nas esferas politica, social e economica na relacao publico-privada no sistema de saude brasileiro. As conjecturas postas contribuiram para o subfinanciamento da saude e consequente fortalecimento do mercado privado, que atua de forma paralela e competitiva ao SUS. Assim, a defesa da saude como direito passa pela radicalizacao de bandeiras do MRSB, como as reformas politica, tributaria e agraria, bem como a renovacao da luta social em defesa do SUS.

The Price for Federalism

Abstract: What is the price of federalism? Does it result in governmental interconnections that are too complex? Does it create overlapping responsibilities? Does it perpetuate social inequalities? Does it stifle economic growth? To answer these questions, Paul Peterson sets forth two theories of federalism: functional and legislative. Functional theory is optimistic. It says that each level of the federal system is well designed to carry out the tasks for which it is mainly responsible. State and local governments assume responsibility for their area's physical and social development; the national government cares for the needy and reduces economic inequities. Legislative theory, in contrast, is pessimistic: it says that national political leaders, responding to electoral pressures, misuse their power. They shift unpopular burdens to lower levels of government while spending national dollars on popular government programs for which they can claim credit. Both theories are used to explain different aspects of American federalism. Legislative theory explains why federal grants have never been used to equalize public services. Elected officials cannot easily justify to their constituents a vote to shift funds away from the geographic area they represent. The overall direction that American federalism has taken in recent years is better explained by functional theory. As the costs of transportation and communication have declined, labor and capital have become increasingly mobile, placing states and localities in greater competition with one another. State and local governments are responding to these changes by overlooking the needs of the poor, focusing instead on economic development. As a further consequence, older, big cities of the Rust Belt, inefficient in their operations and burdened by social responsibilities, are losing jobs and population to the suburban communities that surround them. Peterson recommends that the national government adopt policies that take into account the economic realities identified by functional theory. The national government should give states and localities responsibility for most transportation, education, crime control, and other basic governmental programs. Welfare, food stamps, the delivery of medical services, and other social policies should become the primary responsibility of the national government.

Política Nacional de Atenção Básica 2017: retrocessos e riscos para o Sistema Único de Saúde

Abstract: The article discusses the meanings and implications of the changes introduced by the National Policy of Primary Healthcare 2017, which promote the relativization of universal coverage, the segmentation of access, the recomposition of the teams, the reorganization of the work process and the weakening of the national policy coordination. It is argued that its review indicates serious risks to the achievements obtained with the strengthening of the Primary Health Care in Brazil. In the current conjuncture of strengthening neoliberal ideology, these changes reinforce the subtraction of rights and the process of deconstruction of the Unified Health System in progress in the Country.

Universal health system and universal health coverage: assumptions and strategies

Abstract: Resumo Nos ultimos anos, acirrou-se o debate internacional sobre diferentes concepcoes de universalidade em saude, polarizado nas propostas de sistema universal versus cobertura universal em saude. A concepcao de cobertura universal tem sido difundida por organizacoes internacionais e incorporada as reformas dos sistemas de saude de alguns paises em desenvolvimento, inclusive na America Latina. O artigo explora os pressupostos e as estrategias relacionados a proposta de cobertura universal de saude. Inicialmente contrastam-se as concepcoes de universalidade nos modelos de cobertura universal e de sistemas universais de saude. A seguir, contextualiza-se o debate internacional, incluindo exemplos de diferentes sistemas de saude. Por fim, discutem-se as implicacoes da concepcao de cobertura universal para o direito a saude no Brasil. A analise das diferentes concepcoes de universalidade e das experiencias de paises evidenciam que arranjos de seguros (privados ou sociais) nao superam as fortalezas de sistemas publicos universais de saude. A compreensao dos projetos em disputa no cenario internacional e fundamental para identificar possibilidades e ameacas a consolidacao do Sistema Unico de Saude no Brasil.

Regional governance: strategies and disputes in health region management.

Abstract: OBJECTIVE To analyze the regional governance of the health systemin relation to management strategies and disputes. METHODOLOGICAL PROCEDURES A qualitative study with health managers from 19 municipalities in the health region of Bahia, Northeastern Brazil. Data were drawn from 17 semi-structured interviews of state, regional, and municipal health policymakers and managers; a focus group; observations of the regional interagency committee; and documents in 2012. The political-institutional and the organizational components were analyzed in the light of dialectical hermeneutics. RESULTS The regional interagency committee is the chief regional governance strategy/component and functions as a strategic tool for strengthening governance. It brings together a diversity of members responsible for decision making in the healthcare territories, who need to negotiate the allocation of funding and the distribution of facilities for common use in the region. The high turnover of health secretaries, their lack of autonomy from the local executive decisions, inadequate technical training to exercise their function, and the influence of party politics on decision making stand as obstacles to the regional interagency committee’s permeability to social demands. Funding is insufficient to enable the fulfillment of the officially integrated agreed-upon program or to boost public supply by the system, requiring that public managers procure services from the private market at values higher than the national health service price schedule (Brazilian Unified Health System Table). The study determined that “facilitators” under contract to health departments accelerated access to specialized (diagnostic, therapeutic and/or surgical) services in other municipalities by direct payment to physicians for procedure costs already covered by the Brazilian Unified Health System. CONCLUSIONS The characteristics identified a regionalized system with a conflictive pattern of governance and intermediate institutionalism. The regional interagency committee’s managerial routine needs to incorporate more democratic devices for connecting with educational institutions, devices that are more permeable to social demands relating to regional policy making.

Regionalização e acesso à saúde nos estados brasileiros: condicionantes históricos e político-institucionais

Abstract: This article examines the healthcare regionalization process in the Brazilian states in the period from 2007 to 2010, seeking to identify the conditions that favor or impede this process. Referential analysis of public policies and especially of historical institutionalism was used. Three dimensions sum up the conditioning factors of regionalization: context (historical-structural, political-institutional and conjunctural), directionality (ideology, object, actors, strategies and instruments) and regionalization features (institutionality and governance). The empirical research relied mainly on the analysis of official documents and interviews with key actors in 24 states. Distinct patterns of influence in the states were observed, with regionalization being marked by important gains in institutionality and governance in the period. Nevertheless, inherent difficulties of the contexts prejudice greater advances. There is a pressing need to broaden the territorial focus in government planning and to integrate sectorial policies for medium and long-term regional development in order to empower regionalization and to overcome obstacles to the access to healthcare services in Brazil.