Roberta Gondim de Oliveira

Bio: Roberta Gondim de Oliveira is an academic researcher from Oswaldo Cruz Foundation. The author has contributed to research in topics: Health care & Health policy. The author has an hindex of 6, co-authored 13 publications receiving 243 citations.

Descentralização e federalismo: a política de saúde em novo contexto - lições do caso brasileiro

Abstract: The article analyses the processes of decentralization and deconcentration, along with the new emergence of federalism, as global phenomena and meaningful tendencies in the reestructuring of the unitary and centralized State, built under the Napoleonic tradition. In the Brazilian case, in particular, the article identifies the different phases and problems that arose during the decentralization process and within the re-configuration of the federative pact since the 80's, and evaluates the implications of this new order on the recent reform processes of the health policy. Furthermore, the article presents the conditions and limitations of healthsystem's decentralization, highlighting the risks to which it is submitted and taking into account unfavourable aspects of its context, characterised by federative conflicts and by the social and economic inequality inheritance.

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.

Desigualdades raciais e a morte como horizonte: considerações sobre a COVID-19 e o racismo estrutural

Abstract: A incidencia e mortalidade por COVID-19 em paises com fortes desigualdades sociais se diferenciam em termos populacionais. Em paises com historico e tradicao colonial como o Brasil, os marcadores sociais das diferencas tem profunda ancoragem na demarcacao racial, sobre a qual agem as dinâmicas e os processos politico-sociais fundados no racismo estrutural. Contrapoe-se a narrativas que propoem uma leitura sobre ser esta uma pandemia democratica, cujo argumento se alinha a retorica da democracia racial que corresponde a uma potente estrategia de manutencao do lugar de populacoes racializadas, como indigenas e negros, uma producao da colonialidade moderna. Este ensaio debruca sobre o comportamento da pandemia em relacao a populacao negra no Brasil, em dialogo com aportes decoloniais e de leituras criticas sobre o racismo. Discutem-se respostas governamentais e indicadores da doenca, segundo o quesito raca/cor, demonstrando a manutencao de tramas e enredos historicos que seguem vulnerabilizando e inviabilizando vidas negras. Aponta-se tambem para a importância de movimentos de resistencia locais, operados a partir do lugar que esses sujeitos ocupam, os espacos urbanos precarizados por acao/omissao do Estado - as favelas.

Mudanças significativas no processo de descentralização do sistema de saúde no Brasil

Abstract: This article discusses the trends and limits of the Brazilian health system decentralization process, identifying the three elements that constitute the strategic induction performed by the national system administrator in accordance with the guidelines contained in the Operational Norms of the Unified National Health System: systemic rationality, intergovernmental and service provider financing, and health care model. The effects of the Federal regulations are analyzed based on the results of the evaluation study focused on the implementation of the full management scheme at the Municipal level. The decentralization strategy induced by Basic Operational Norm 96 has succeeded in improving institutional conditions, management autonomy, and supply, as measured by the Federal resources transferred, installed capacity, production, and coverage of outpatient and hospital services, with the Municipalities authorized to conduct fully autonomous management, without altering the existing patterns of inequity in the distribution of funds to poorer Municipalities.

Desigualdades raciais e a morte como horizonte: considerações sobre a COVID-19 e o racismo estrutural./ Desigualdades raciais e a morte como horizonte: considerações sobre a COVID-19 e o racismo estrutural./ Racial inequalities and death on the horizon: COVID-19 and structural racism.

Abstract: COVID-19 incidence and mortality in countries with heavy social inequalities differ in population terms. In countries like Brazil with colonial histories and traditions, the social markers of differences are heavily anchored in social and racial demarcation, and the political and social dynamics and processes based on structural racism act on this demarcation. The pandemic's actual profile in Brazil clashes with narratives according to which COVID-19 is a democratic pandemic, an argument aligned with the rhetoric of racial democracy that represents a powerful strategy aimed at maintaining the subaltern place of racialized populations such as indigenous peoples and blacks, as a product of modern coloniality. This essay focuses on the pandemic's profile in the Brazilian black population, in dialogue with decolonial contributions and critical readings of racism. The authors discuss government responses and COVID-19 indicators according to race/color, demonstrating the maintenance of historical storylines that continue to threaten black lives. The article also discusses the importance of local resistance movements, organized in the favelas, precarious urban spaces underserved by the State and occupied by black Brazilians.

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.

Desempenho do PSF no Sul e no Nordeste do Brasil: avaliação institucional e epidemiológica da Atenção Básica à Saúde

Abstract: A pesquisa, desenvolvida dentro dos Estudos de Linha de Base do Proesf analisou o desempenho do Programa Saude da Familia (PSF) em 41 municipios dos Estados de Alagoas, Paraiba, Pernambuco, Piaui, Rio Grande do Norte, Rio Grande do Sul e Santa Catarina. Utilizou delineamento transversal, com grupo de comparacao externo (atencao basica tradicional). Entrevistou 41 presidentes de Conselhos Municipais de Saude, 29 secretarios municipais de Saude e 32 coordenadores de Atencao Basica. Foram caracterizados a estrutura e o processo de trabalho em 234 Unidades Basicas de Saude (UBS), incluindo 4.749 trabalhadores de saude; 4.079 criancas; 3.945 mulheres; 4.060 adultos e 4.006 idosos. O controle de qualidade alcancou 6% dos domicilios amostrados. A cobertura do PSF de 1999 a 2004 cresceu mais no Nordeste do que no Sul. Menos da metade dos trabalhadores ingressaram por concurso publico e o trabalho precario foi maior no PSF do que em UBS tradicionais. Os achados sugerem um desempenho da Atencao Basica a Saude (ABS) ainda distante das prescricoes do SUS. Menos da metade da demanda potencial utilizou a UBS de sua area de abrangencia. A oferta de acoes de saude, a sua utilizacao e o contato por acoes programaticas foram mais adequados no PSF.

Decentralization and Subnational Politics in Latin America

Abstract: 1. Decentralization and the revival of subnational politics 2. A sequential theory of decentralization and the intergovernmental balance of power 3. Argentina: the national dominance path to decentralization 4. Colombia: the subnational dominance path to decentralization in a unitary country 5. Brazil: the subnational dominance path to decentralization in a federal country 6. Mexico: the subnational response path to decentralization 7. Conclusion: decentralization, temporal analysis, and territorial politics Appendix: in-depth interviews.

Descentralização e coordenação federativa: a experiência brasileira na saúde

Abstract: This article deals with intergovernmental relations in health within the 20 years of implantation of the Unified Health System (SUS), in the light of the historical course of Brazilian federalism and its implications to health. Initially, a theoretical-conceptual review was carried out on the topic of federalism, social welfare and federative coordination of health, considering the international debate and the historical analysis of the Brazilian case. Following, the article analyzes the federal performance in the intergovernmental coordination of national health policy during the period of implantation of SUS, based on a research about the role of the Brazilian Ministry of Health from 1990 to 2002, which involved documental analysis and interviews with federal officers and other players in national politics. It was observed that health policies registered, in the past 20 years, changes in five relevant aspects that characterize federalism: institutional arrangements and rules for decisions in the federal government; the set of players with territorial basis; legal arrangements to define responsibilities among government levels; intergovernmental tax arrangements; informal arrangements among governments - vertically and horizontally.

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.