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
TL;DR: In this article, the authors examined 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.
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.
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TL;DR: In this paper, a review of the 2006 National Health Promotion Policy (PNPS) is described, and the results are systematically ordered with the aid of an analytical matrix organized by objectives, principles, guidelines, themes and actions, resulting in a new PNPSP.
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.
33 citations
TL;DR: It appears that the regionalization process in the Brazilian Health System has been incremental decentralization/deconcentration of management and health actions and services.
Abstract: This article examines the regionalization process in the Brazilian Health System, identifying frameworks and challenges of this process from critical dialogue on the subject, contextualized by the experience of the management system and in the light of an established theoretical debate in the last decade. We used the thematic content analysis of legal and documentary surveys of the regionalization process in SUS, collated by elements of the historical and political context in the period. As evidence, it appears that the regionalization process has been incremental decentralization/deconcentration of management and health actions and services. There are important challenges, particularly in relation to ensuring access and system governance structure, which contributes to critical thinking and construction of new perspectives by those who lead their implementation.
27 citations
TL;DR: In this article, the authors analyze the fluxo of pacientes oncologicos de mama that sao atendidos fora of seu domicilio de residencia.
Abstract: Resumo: Este estudo busca analisar o fluxo de pacientes oncologicos de mama que sao atendidos fora de seu domicilio de residencia. Foram considerados as internacoes hospitalares e os tratamentos por quimioterapia e radioterapia para neoplasias malignas na mama, no âmbito do Sistema Unico de Saude, entre os anos de 2014 e 2016. Foi empregado o metodo de analise de redes, considerando o municipio de residencia e de tratamento como nos de um grafo, que consiste em um “estudo de redes organizacionais de sistemas de saude”. Alem disso, distância e tempo de deslocamento foram estimados por meio da melhor rota viavel, segundo a malha rodoviaria do projeto Open Street Maps. Os resultados apontam que 51,34% dos pacientes de câncer de mama no Brasil foram atendidos fora de seu municipio de residencia, seguindo fluxos que sao regionalizados e que preservam fronteiras estaduais, em geral, em direcao a capitais ou a cidades de grande porte. Por outro lado, os resultados tambem apontam excecoes especificas, visto que alguns municipios detem um grau de proeminencia que supera os limites estaduais. O tempo de deslocamento entre municipio de residencia e municipio de atendimento apresentou medianas proximas a tres horas, e 75% dos deslocamentos se dao em ate 324km para tratamento por quimioterapia, 287km para tratamento por radioterapia e 282km para internacoes. Esses resultados sao indicativos das dificuldades de acesso aos servicos de oncologia, o que potencialmente agrava a experiencia do adoecimento oncologico em termos de impacto no individuo e em sua familia.
25 citations
TL;DR: 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.
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.
23 citations
TL;DR: In this paper, the authors identify and analyze the development of regional strategies for care integration in the context of health regions, with special focus on the role of primary health care (PHC), analyzed the minutes and observed the meetings of the Regional Intermanagers Commission (CIR) in a period of one year and also eleven interviews with municipal, regional and state managers of Bahia, Brazil.
Abstract: This study aims to identify and analyze the development of regional strategies for care integration in the context of health regions, with special focus on the role of Primary Health Care (PHC). It was analyzed the minutes and observed the meetings of the Regional Intermanagers Commission (CIR) in a period of one year and also eleven interviews with municipal, regional, and state managers of Bahia, Brazil. The results indicate that PHC is an uncommon topic in the discussions of CIR, although the health region faces problems in common with other regions of Bahia and Brazil, such as the predatory dispute for doctors and poor coordination of care. The goal of forming Health Care Networks, coordinated by PHC, is still a distant goal against the urgent need to ensure access to specialized and urgency/emergency care in the health region, an issue that dominated the discussions of CIR, and PHC was limited only to city boundaries.
23 citations
References
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TL;DR: There are evidences in the international literature on health care networks that these networks may improve the clinical quality, the sanitation results and the user's satisfaction and the reduction of healthcare systems costs.
Abstract: The demographic and epidemiologic transition resulting from aging and the increase of life expectation means an increment related to chronic conditions. The healthcare systems contemporary crisis is characterized by the organization of the focus on fragmented systems turned to the acute conditions care, in spite of the chronic conditions prevalence, and by the hierarchical structure without communication flow among the different health care levels. Brazil health care situation profile is now presenting a triple burden of diseases, due to the concomitant presence of infectious diseases, external causes and chronic diseases. The solution is to restore the consistence between the triple burden of diseases on the health situation and the current system of healthcare practice, with the implantation of health care networks. The conclusion is that there are evidences in the international literature on health care networks that these networks may improve the clinical quality, the sanitation results and the user's satisfaction and the reduction of healthcare systems costs.
570 citations
TL;DR: The authors define a "neo-institucionalism" which constitui uma corrente de pensamento unificada, i.e., a set of metodos de analise diferentes apareceram nessa area no ultimo quarto de seculo.
Abstract: O neo-institucionalismo nao constitui uma corrente de pensamento unificada. Ao contrario, pelo menos tres metodos de analise diferentes apareceram nessa area no ultimo quarto de seculo: o institucionalismo historico, o institucionalismo da escolha racional e o institucionalismo sociologico. Todas elas tratam, por ângulos diferentes, do papel desempenhado pelas instituicoes na determinacao de resultados sociais e politicos. Expoe-se e examina-se a genese de cada uma dessas variantes do "neo-institucionalismo", assim como o que distingue suas maneiras de tratar dos problemas sociais e politicos.
321 citations
TL;DR: In this paper, the authors analyzed the process of reform in four areas of social policies that affect directly the interests of sub-national governments: basic education, social housing programs, basic sanitation and health.
Abstract: The article analyses the process of reform in four areas of social policies that affect directly the interests of sub-national governments: basic education, social housing programs, basic sanitation and health. As the study reveals, despite the varying degree of success achieved in the various policy initiatives and contrary to the expectations of the prevailing interpretations of the nature of Brazilian federalism, the federal government faced no insurmountable hurdles in implementing their reform agenda. The study aims at demonstrating that (i) in the absence of any constitutional mandatory requirement, the political autonomy of local governments - typical of federative States - actually enhances the veto power of local governments over policy initiatives proposed by the federal Executive branch. However, (ii) power resources available to the federal Executive branch - such as agenda definition and vetoing powers - in addition to control over resources that are essential to the political survival of the representatives increase the chances of success of the federal government. Furthermore, (1999), (iii) the constitutional authority of Brazilian states is far more limited than that of the North-American states; (iv) the category "federalism", however, is not sufficient to define the potential stability of specific policies, which depends upon how inter-governmental relations are structured in each particular policy. Specifically, (v) constitutional rules, legacies from previous policies and the political cycle frame the decision arenas in various ways, thus conditioning both the strategies and chances of success of the federative players.
108 citations
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
TL;DR: In this paper, the authors analyze 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.
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.
83 citations