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Journal ArticleDOI

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

01 Nov 2012-Ciencia & Saude Coletiva (ABRASCO - Associação Brasileira de Saúde Coletiva)-Vol. 17, Iss: 11, pp 2881-2892

AbstractThis 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.

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Journal ArticleDOI
TL;DR: The characteristics identified a regionalized system with a conflictive pattern of governance and intermediate institutionalism and 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.
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.

63 citations


01 Jan 2014
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.

52 citations


Journal ArticleDOI
Abstract: O desenvolvimento socioeconomico, a oferta e a complexidade das acoes e dos servicos de saude no contexto regional podem ser considerados condicionantes estruturais para o exito do atual processo de regionalizacao da saude no Brasil. O presente estudo tem como objetivo identificar os condicionantes estruturais do processo de regionalizacao por meio da construcao de uma tipologia das regioes de saude no Brasil. Foi construida tipologia das regioes de saude brasileiras a partir de fonte de dados secundarios disponivel. A identificacao das dimensoes e dos grupos - que compoem a tipologia - foi realizada por meio de analise fatorial e de agrupamentos/clusters. Tambem foram identificados o tipo de prestador de acoes e os servicos predominantes na regiao tanto para a producao ambulatorial quanto para a internacao. As regioes foram classificadas em cinco grupos, de forma independente, de acordo com suas caracteristicas socioeconomicas e de oferta de servicos de saude. A caracterizacao das regioes de saude brasileiras, a partir da tipologia apresentada, demonstra heterogeneidade do territorio nacional e a complexidade de organizar sistemas de saude regionais. A tipologia proposta pode auxiliar na investigacao e no melhor entendimento desse cenario contraditorio e complexo, apoiando o urgente desenvolvimento de politicas publicas regionais integradas que envolvam, concomitantemente, desenvolvimento economico e social; e o fortalecimento dos espacos de governanca regional, a fim de promover a organizacao de sistemas de saude regionais alicercados nos principios do SUS e numa gestao compartilhada e solidaria que tenha como imagem-objetivo a garantia do direito a saude.

40 citations


Cites background from "Regionalização e acesso à saúde nos..."

  • ...…decentralization to the municipalities, and another, in the 2000s, with greater emphasis on regionalization, designed to overcome the obstacles arising from highly unequal service provision, but still with little impact on the functional organization of the health system (Lima et al., 2012)....

    [...]

  • ...…and fair integration of such programs and services according to the supply and needs found in a particular social-sanitary context, optimizing human and technological resources in the regional health complex, catalyzing shared policies and responsibilities between the actors (Lima et al., 2012)....

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Journal ArticleDOI
TL;DR: The implementation of regional-based IHN policy in Brazil is hampered by the decentralized organization of the health system to the municipal level, suggesting the need to centralize certain functions to regional structures or states and to define better the role of the government levels involved.
Abstract: BACKGROUND Regional-based Integrated Healthcare Networks (IHNs) have been promoted in Brazil to overcome the fragmentation due to the health system decentralization to the municipal level; however, evaluations are scarce. The aim of this article is to analyse the content of IHN policies in force in Brazil, and the factors that influence policy implementation from the policymakers' perspective. METHODS A two-fold, exploratory and descriptive qualitative study was carried out based on (1) content analysis of policy documents selected to meet the following criteria: legislative documents dealing with regional-based IHNs; enacted by federal government; and in force, (2) semi-structured individual interviews were conducted to a theoretical sample of policymakers at federal (eight), state (five) and municipal levels (four). Final sample size was reached by saturation of information. An inductive thematic analysis was conducted. RESULTS The results show difficulties in the implementation of IHN policies due to weaknesses that arise from the policy design and the performance of the three levels of government. There is a lack of specificity as to the criteria and tools for configuring and financing IHNs that need to be agreed upon between involved governments. For their part, policymakers emphasize the difficulty of establishing agreements in a health system with disincentives for collaboration between municipalities. The allocation of responsibilities that are too complex for the capacity and size of the municipalities, the abandonment of essential functions such as network planning by states and the strategic role by the Ministry, the 'invasion' of competences among levels of government and high political turnover are also highlighted. CONCLUSIONS The implementation of regional-based IHN policy in Brazil is hampered by the decentralized organization of the health system to the municipal level, suggesting the need to centralize certain functions to regional structures or states and to define better the role of the government levels involved.

32 citations


Cites background or result from "Regionalização e acesso à saúde nos..."

  • ...Very few analyse the factors that influence healthcare networks implementation (de Lima et al. 2012)....

    [...]

  • ...This coincides with the few published evaluations, which show that despite the high number of municipalities that signed the Health Pact (de Lima et al. 2012)—the number differs by state and Pernambuco is somewhere in the middle (Ministério de Saúde 2012)—few have planned and developed healthcare…...

    [...]

  • ...…that signed the Health Pact (de Lima et al. 2012)—the number differs by state and Pernambuco is somewhere in the middle (Ministério de Saúde 2012)—few have planned and developed healthcare networks or implemented the necessary tools for doing so (PDR, CIR, etc.) (de Lima et al. 2012)....

    [...]

  • ...As signalled by some authors (de Lima et al. 2012), it is unlikely that CIRs can operate without funding and an administrative structure, and without defining those competences of the states and/or municipalities that are to be transferred, or how they should be co-ordinated among these entities to…...

    [...]


Journal ArticleDOI
Abstract: Public policy can be understood as the translation of government proposals and the aspirations of society. Driven by the advances and challenges of social transformation, the need for the coordination of agendas and limited social participation in the drafting of the 2006 National Health Promotion Policy (PNPS), the Ministry of Health and the Thematic Group on Health Promotion/Abrasco proposed the PNPS review. This article describes the steps in that process. It involves policy analysis conducted by literature review and document analysis from the "internal triangulation" standpoint. The revision process adopted multiple approaches on data gathering (Regional Workshops and Health Councils, Intra/Intersectorial Delphi and Electronic Questionnaire). It also used heterogeneous sources of information, different local contexts (five regions of Brazil) and peer validation. The results were systematically ordered with the aid of an analytical matrix organized by objectives, principles, guidelines, themes and actions, resulting in a draft of the new PNPS. Lastly, a national seminar was organized in which the results of the process and a synthesis of the revised text were presented, making it possible to identify process gains and the next steps for the actors involved with the new PNPS.

29 citations


References
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289 citations


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Journal ArticleDOI
01 Mar 2003
TL;DR: It is concluded that progress has been made in terms of equity since the establishment of SUS, particularly as reflected in the decentralization of health care policy.
Abstract: This article analyses the issue of equity in the area of health, particularly with regard to health care policy. It presents recent information on the allocation of financial resources and the supply and utilization of health care services throughout a selected group of municipalities in Brazil, and concludes that progress has been made in terms of equity since the establishment of SUS, particularly as reflected in the decentralization of health care policy.

93 citations


Journal ArticleDOI
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.

81 citations