Adelyne Maria Mendes Pereira

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

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.

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.

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

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.

Descentralização e regionalização em saúde na Espanha: trajetórias, características e condicionantes

ABSTRACT The article discusses the decentralization and regionalization of the Spanish health system from 1980 to 2012. Considering the historical institutionalism approach, the study analy -zed the trajectory, characteristics and conditions of these processes, in broader the context of democratization and reform of the State. The results suggest different degrees of power between the central and subnational governments in the political, administrative and fiscal/financial dimension. It is concluded that the return to democracy, the regionalist pressures, the political-territorial decentralization and the antecedent of the health system were the main factors that influenced the configuration of the health system in Spain. KEYWORDS Decentralization; Regional health planning; Health systems . Descentralizacao e regionalizacao em saude na Espanha: trajetorias, caracteristicas e condicionantes Decentralization and regionalization in health in Spain: trajectories, characteristics and conditions

Descentralização e regionalização da política de saúde: abordagem histórico-comparada entre o Brasil e a Espanha

This article discusses the processes of de centralization and regionalization of health policy in Brazil and Spain between 1980 and 2015. The study was developed with contributions of the historical institutionalism and of the historical com parative method, by means of three dimensions of analysis: State context; trajectory and institution ality of the decentralization and regionalization of health; and constraints. The study showed that,in both countries, the more general context of re-democratization and decentralization of the State conditioned the reforms of health systems and their political-administrative organization. In addition, historical, institutional and political factors have had a specific impact in each case, influencing the regional organization of services, the balance of power and the division of responsibilities between the governmental spheres in the management, financing and coordination of health policy. The study suggests that the way these factors interrelated over time is important for understanding the decentralization and regionalization of health systems in different contexts.Resumo Este artigo aborda os processos de descentralizacao e regionalizacao da politica de saude no Brasil e na Espanha entre 1980 e 2015. Valendo-se de contribuicoes do institucionalismo historico e do metodo historico-comparado, o estudo foi desenvolvido a partir de tres dimensoes de analise: contexto estatal; trajetoria e institucionalidade da descentralizacao e regionalizacao da saude; e condicionantes. O estudo evidenciou que, em ambos os paises, o contexto mais geral de redemocratizacao e descentralizacao do Estado condicionou as reformas dos sistemas de saude e sua organizacao politico-administrativa. Alem disso, fatores historicos, institucionais e politicos repercutiram, de modo especifico em cada caso, influenciando a organizacao regional dos servicos, o balanco de poder e a divisao de responsabilidades entre as esferas governamentais na gestao, financiamento e coordenacao da politica de saude. O estudo sugere que o modo como estes fatores se interrelacionaram no tempo importa para a compreensao da descentralizacao e regionalizacao dos sistemas de saude em diferentes contextos.

Governança regional do sistema de saúde no Brasil: configurações de atores e papel das Comissões Intergovernamentais

Resumo O foco da analise e o papel exercido pelas Comissoes Intergestores Regionais, considerando a diversidade de atores que influenciam a politica de saude em contextos regionais especificos. A pesquisa envolveu a realizacao de cinco estudos de caso em cada uma das macrorregioes brasileiras, com aplicacao de 128 questionarios a gestores, prestadores e representantes da sociedade civil, entre agosto de 2015 e agosto de 2016. Adotou-se a perspectiva comparada, considerando tres eixos de analise: configuracoes de atores (governamentais e nao governamentais; publicos e privados) nas decisoes e conflitos regionais, dinâmica de funcionamento e atuacao, e contribuicoes das comissoes para a politica e a organizacao do sistema de saude. Verificou-se a diversidade de atores com alto grau de influencia nas regioes e a funcao das Comissoes Intergestores Regionais na coordenacao das politicas e na resolucao de conflitos. Estas favorecem a negociacao intergovernamental e a organizacao do Sistema Unico de Saude frente a estrutura federativa brasileira. Contudo, possuem atuacao limitada como espaco de governanca regional da saude, sendo incapazes de incorporar as diversas configuracoes de atores publicos e privados com poder e influencia sobre as decisoes de saude.The analytical focus is on the role of the Regional Interagency Commissions (CIR), considering the diversity of actors that influence health policy in specific regional contexts. The research involved conducting five case studies in each of the Brazilian macroregions, with the application of 128 questionnaires to public managers, service providers and civil society representatives, between August 2015 and August 2016. The comparative perspective was adopted, by considering three analytical approaches: the configuration of actors (governmental and non-governmental; public and private) on regional decisions and conflicts, operation dynamics and contributions of commissions to health system policy and organization. The results showed the diversity of actors with a high degree of influence in the regions and the role of the Regional Interagency Commissions in policy coordination and conflict resolution. The commissions favor interagency negotiation and the organization of the Unified Health System vis-à-vis the Brazilian federative structure. However, they have limited scope as a space for regional health governance and are unable to incorporate the different configurations of public and private actors with power and influence over health decisions.