Adenilda Maria Siqueira de Andrade, Alberice Maria Mendes, Cristiane S. Miguel Cabral de Vasconcelos, Maria Eliza da Mota Reinaux Paes Barreto
O Brasil vem redefinindo o perfil do seu sistema de saúde, reformulando papéis e funções de saúde pública na tentativa de construir responsabilidades locais. Este panorama originou um novo arranjo para o sistema municipal de saúde no qual busca-se a integralidade das ações de saúde a partir da dinâmica do financiamento. Trata-se de um estudo descritivo de base bibliográfica e documental. O estudo apresenta uma revisão sobre o processo da descentralização administrativa/financeira na saúde, sua repercussão no fortalecimento da atenção básica tendo a estratégia saúde da família como elemento propulsor da forte expansão observada nesse componente da atenção à saúde, bem como as conseqüências da descentralização na gestão dos trabalhadores de saúde. Discute o papel das Normas Operacionais do SUS, em especial da Norma Operacional Básica - NOB/96 com a implantação do Piso da Atenção Básica (PAB) como referencial para a ampliação dos investimentos na atenção básica, o papel relevante da Lei de Responsabilidade Fiscal que além de impor limites aos gastos, também estabelece diretrizes para a elaboração, execução e avaliação do orçamento público, e o Pacto pela Saúde firmado entre as três esferas de governo com a atenção voltada para os princípios e diretrizes articulados e integrados nos Pactos pela Vida, em Defesa do SUS e de Gestão. Destaca-se o forte papel indutor do nível federal de gestão do SUS, que através de mecanismos de financiamento reordena as ações e serviços de saúde no nível local
This paper analyzes the policy model of the Brazilian Ministry of Health from 1990 to 2002. The methodology included interviews with key actors in the national health policy, document review, and analysis of the Federal budget and official databases. The Brazilian Ministry of Health underwent major changes under the influence of the health reform agenda and the liberal State reform agenda prevailing in the 1990s, shaped by two movements: institutional unification of national policy control and political/administrative decentralization. The Federal role was diminished in terms of direct services provision, and there were changes in financing and regulation. The model in the late 1990s featured strong Federal induction of States and municipalities and the adoption of market regulation strategies. There is no record of a long-term planning effort, which favors distortions in the Federal intervention model and hinders solutions to structural problems in the Brazilian health system.
This thesis examines the Brazilian municipalism after the Constitution of 1988. It verifies the municipalities performance in the provision of local health services vis--vis the decentralization of this policy due to the creation of the SUS (Unified Health System). It argues that the process of health services decentralization developed during the 90's presented two different steps: the step of autonomist decentralization, between 1990 and 1998, when the municipalities were totally free to choose their own local health policies; and the step of the driven decentralization, after the creation of the Basic Assistance Floor -PAB, when the municipalities started receiving targeted incomes, which could be used exclusively for specific health programs, determined by the Health Department. However, as we demonstrate, the both steps were incapable to decrease the extant regional inequalities in what regards the supply, the access and the financing of municipal health services. To summarize, we demonstrate that the inequalities in health produced by our federalism were not balanced through the outline of policies that municipalized the health services.
<abstract language="eng">The constitution of Brazil directs that the country’s health system, the Unified Health System (Sistema Único de Saúde), be politically and administratively decentralized. Nevertheless, handing over competencies, responsibilities, and resources to subnational levels, especially to municipal governments, has been a slow process, lasting almost two decades. Advances have been brought about by the Unified Health System, which, from a analytical perspective, is a public and universal system. Despite that, the decentralization process needs to overcome norms that keep all levels of management dependent on Brazil’s federal Government. The subnational levels have consistently faced difficulties in performing their macromanagement functions with autonomy, especially when it comes to financing and to the establishment or organization of health care networks. Boldness and responsibility will be needed to prevent Brazil’s health decentralization process from leading to fragmentation. New political agreements between different levels of government, with a reassignment of responsibilities and the enhancement of a culture of technical cooperation, are fundamental requisites to making the Unified Health System have a health policy that is truly public and universal.
The constitution of Brazil directs that the country's health system, the Unified Health System (Sistema Unico de Saúde), be politically and administratively decentralized. Nevertheless, handing over competencies, responsibilities, and resources to subnational levels, especially to municipal governments, has been a slow process, lasting almost two decades. Advances have been brought about by the Unified Health System, which, from a analytical perspective, is a public and universal system. Despite that, the decentralization process needs to overcome norms that keep all levels of management dependent on Brazil's federal Government. The subnational levels have consistently faced difficulties in performing their macromanagement functions with autonomy, especially when it comes to financing and to the establishment or organization of health care networks. Boldness and responsibility will be needed to prevent Brazil's health decentralization process from leading to fragmentation. New political agreements between different levels of government, with a reassignment of responsibilities and the enhancement of a culture of technical cooperation, are fundamental requisites to making the Unified Health System have a health policy that is truly public and universal.
Este é um trabalho sobre desenhos institucionais e seus resultados redistributivos, que toma como objeto de análise a política de saúde no Brasil. O modelo de descentralização do Sistema Único de Saúde – SUS –caracteriza-se por concentrar autoridade no governo federal, assim como financiar a política de saúde através de um sistema abrangente de transferências interregionais. Este sistema pretendeu, em período recente, acentuar seus objetivos redistributivos com a introdução do Piso da Atenção Básica – PAB, na Norma de Operação Básica – NOB98. Este trabalho pretende examinar a extensão em que um sistema descentralizado, cujo desenho institucional concentra autoridade no governo central para implementar políticas com finalidades redistributivas, logra reduzir as diferenças regionais no acesso aos serviços públicos. Para isto, testaremos inicialmente a extensão do processo de descentralização da política de saúde no Brasil, para em seguida analisarmos a extensão da equalização na provisão de serviços de saúde. PALAVRAS-CHAVE: política de saúde, descentralização, federalismo, desenhos institucionais, Brasil LOCAL CONDITIONANTS OF DECENTRALIZATION OF HEALTH POLICIES This paper is about institutional designs and ist redistributive results, and has as its object of analysis the Brazilian Health Policy. The decentralization model of the SUS – United Health System has as its characteristics to concentrate authority on the Federal governmet and financing the health policy through an ample system of interregional transferences. This system intended, in recent times, to increase its redistributive objectives with the intriduction of the PAB – Basic Attention Floor int the NOB98 – Basic Operation Procedure. This paper intends to examine the extension to which a decentralized system, which institutional design concentrates authority on the central government to enforce policies with redistributive intentions, achieves reduction of the regional differences in access to public services. To do this, we will initially test the extent of the decentralization process in Brazilian health policy, and after that we will analyse the extent of equalization on providing health services. KEY WORD: health policy; decentralization; federalism; institutional designs; Brazil. CONDITIONS LOCALES DE LA DECENTRALISATION DES POLITIQUES DE SANTE Cet article sur les schémas institutionnels et les résultas de leur redistribution a pour objet l’analyse de la politique de santé au Brésil. Le modèle de décentralisation du SUS est caractérisé par la concentration de l’autorité dans le gouvernement fédéral, ainsi que par le financement de la politique de santé par un vaste système de transferts interrégionaux. Ce système prétendait récemment souligner ses objectifs de redistribution grâce à l’introduction du PAB, à la NOB98. Cet article prétend examiner jusqu’à quel point un système décentralisé, dont le schéma institutionnel concentre l’autorité dans le gouvernement central pour mettre en oeuvre des politiques à finalité de redistribution, réussit à réduire les différences régionales pour l’accès aux services publics. Pour cela, on examinera d’abord l’étendue du processus de décentralisation de la politique de santé au Brésil, pour analyser ensuite à quel point il est équitable lors de la fourniture des services de santé. MOTS-CLES: politique de santé, décentralisation, fédéralisme, schémas institutionnels, Brésil. Publicação Online do Caderno CRH: http://www.cadernocrh.ufba.br
ABSTRACT - The Portuguese National Health Service (SNS), a universal, centralized and public owned health care system, exhibits an extraordinary record of equalization in the access to health care and health gains in the late thirty years. However, the most recent history of the Portuguese health reform is pervaded by the influence of decentralization and privatization. Decentralization has been present in the system design since the 1976 Constitution, at least in theory. Private ownership of health care suppliers and out-ofpocket expenditures, on the financing side, both have a long tradition of relevance in the NHS mix of services. The initial aim of this study was to demonstrate expected parallelism between health reforms and public administration reforms, where a common pattern of joint decentralization and privatization was observed in many countries. Observers would be tempted to consider these two movements as common signs of new public management (NPM) developments. They have common objectives, are established around the core concepts of gains in effectiveness, efficiency, equity and quality of public services, through improved accountability. However, in practice, in Portugal, each movement was developed in a totally separated way. Besides those rooted in the NPM theory, there are few visible signs of association between decentralization and privatization. Decentralization, in the Portuguese SNS, was never intended to be followed by a privatization movement; it was seen merely as a public administration tool. Private management of health services, as stated in the most recent SNS legislation, was never intended to have decentralization as a condition or as a consequence. Paradoxically, in the Portuguese context, it has led invariably to centralized control. While presented as separate instruments for a common purpose, the association between decentralization and privatization still lacks a convincing demonstration. Many common health care management stereotypes remain to be checked out if we want to look for eventual associations between these two organizational tools.
ABSTRACT - The Portuguese National Health Service (SNS), a universal, centralized and public owned health care system, exhibits an extraordinary record of equalization in the access to health care and health gains in the late thirty years. However, the most recent history of the Portuguese health reform is pervaded by the influence of decentralization and privatization. Decentralization has been present in the system design since the 1976 Constitution, at least in theory. Private ownership of health care suppliers and out-ofpocket expenditures, on the financing side, both have a long tradition of relevance in the NHS mix of services. The initial aim of this study was to demonstrate expected parallelism between health reforms and public administration reforms, where a common pattern of joint decentralization and privatization was observed in many countries. Observers would be tempted to consider these two movements as common signs of new public management (NPM) developments. They have common objectives, are established around the core concepts of gains in effectiveness, efficiency, equity and quality of public services, through improved accountability. However, in practice, in Portugal, each movement was developed in a totally separated way. Besides those rooted in the NPM theory, there are few visible signs of association between decentralization and privatization. Decentralization, in the Portuguese SNS, was never intended to be followed by a privatization movement; it was seen merely as a public administration tool. Private management of health services, as stated in the most recent SNS legislation, was never intended to have decentralization as a condition or as a consequence. Paradoxically, in the Portuguese context, it has led invariably to centralized control. While presented as separate instruments for a common purpose, the association between decentralization and privatization still lacks a convincing demonstration. Many common health care management stereotypes remain to be checked out if we want to look for eventual associations between these two organizational tools.
Ana Luiza d’Ávila Viana, Luiza Sterman Heimann, Luciana Dias de Lima, Roberta Gondim de Oliveira · 5 authors
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.
This dissertation starts from the presupposition that Mental Health, Primary Care and their articulations are propositions originated specific historical contexts and social conditions, implying necessarily in a translation when their assimilation occurs in Brazil and the state of São Paulo.The investigation developed along two lines: the building of the Mental Health field and its links with health and Primary Care in general and the articulation of Mental Health and Primary Care in the state of São Paulo.The study concludes that Mental Health emerges in historical conditions which favor public policies of social inclusion, through the extension of care, In this way it integrates hygiene and therapeutic propositions, and continues to exert a normative social hygiene.The integration of preventive and medical practices, taken as part of specific levels of prevention, makes possible the articulation of Mental Health to Primary Care and public health services.In the state of São Paulo, Mental Health in Primary Care emerges in the context of political redemocratization in 1982, as part of the implementation of specific forms of financing health care ("Ações Integradas de Saúde -AIS"), the decentralization of the governmental programs and the importance of Primary Care as a political banner.This implementation occurs in specific conditions in the state of São Paulo, with the inclusion of multiprofessional mental health teams in public primary health care services, as an experience of psychiatric reform.