Ana Luiza d’Ávila Viana

Política de saúde e eqüidade

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.

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

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 80s, 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 healthsystems 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.

Modelos de atenção básica nos grandes municípios paulistas: efetividade, eficácia, sustentabilidade e governabilidade

Dentro dos Estudos de Linha de Base do Proesf, a partir de uma extensa analise de dados secundarios e entrevistas com os principais atores do sistema de saude municipal, identificaram-se modelos de atencao basica e graus de efetividade, eficacia, sustentabilidade e governabilidade dos sistemas municipais de saude e de atencao basica dos municipios paulistas com mais de 100 mil habitantes. O artigo apresenta e discute ainda os principais obstaculos externos e internos (setoriais) enfrentados para a estruturacao da Atencao Basica nesses municipios. Os obstaculos externos sao decorrentes do perfil de urbanizacao e de velhos e novos problemas sociais expressos em situacoes de extrema desigualdade inter e intramunicipais, sabendo-se que o seu enfrentamento depende de uma serie de politicas publicas intersetoriais, principalmente, no campo social e do trabalho. Ja os obstaculos internos ou setoriais sao decorrentes da forma como se distribuem os servicos e as tecnologias em saude e do padrao de organizacao dos servicos, cuja solucao depende de politicas de saude especificas voltadas principalmente para a problematica das regioes metropolitanas e para maior eficacia e sustentabilidade dos sistemas municipais e de atencao basica.

Descentralização e coordenação federativa: a experiência brasileira na saúde

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.

Saúde e desenvolvimento

Considerando que os modernos sistemas de saude sao o resultado da complexa interacao de processos economicos, politicos e sociais, o objetivo do trabalho e discutir a relacao entre saude e desenvolvimento no Brasil, mostrando que o esgotamento do modelo liberal de politica economica abre nova perspectiva para a retomada do desenvolvimento, entendido como combinacao entre crescimento da economia, mudancas na estrutura produtiva e melhora das condicoes de vida da populacao. O complexo produtivo da saude joga papel decisivo nesse processo, pois constitui um campo em que inovacao tecnologica e acumulacao de capital geram oportunidades de investimento, trabalho e renda, alem de produzir avancos importantes para melhorar o estado de saude das pessoas. A recente adocao de politicas publicas voltadas para articular, de forma positiva, aspectos da politica economica e da politica social revela que a questao do desenvolvimento nacional ganhou nova centralidade na agenda governamental, o que abre a perspectiva de maior integracao entre a logica economica e a logica sanitaria. Entretanto, e preciso reconhecer que o Brasil ainda nao logrou alcancar uma associacao virtuosa entre saude e desenvolvimento.

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

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.

Condicionantes estruturais da regionalização na saúde: tipologia dos Colegiados de Gestão Regional

An explanation is required for the delay in implementing the regionalization strategy and the fragile nature of the combined decentralization and regionalization initiatives in Brazil. The article raises some hypotheses to clarify this intricate issue and reviews the structural conditioning factors of the regionalization process ongoing in the states. A national typology of the health care regions is prepared, differentiating them according to the degree of socio-economic development and the characteristics of the health care network and of the municipalities that form the Regional Management Boards (CGR), formally implanted by January 2010. Factorial and cluster analysis models were used to build the typology. Five major socio-economic groups of CGRs were identified, described according to their regional distribution, population, health care spending, profile of services offered (including the public-private sector mix) and health service coverage. The results obtained serve as guidelines for the constitution of health care networks and new initiatives at the regional level, in order to improve the regionalization policy and favour the construction of diverse and flexible regulatory instruments that are more in tune with the regional state of affairs.

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.

Atenção básica e dinâmica urbana nos grandes municípios paulistas, Brasil

The Baseline Studies on the Project for Expansion and Consolidation of the Family Health Strategy created primary health care indicators and models for the 62 municipalities with more than 100,000 inhabitants in Sao Paulo State, Brazil, and identified varying patterns for these indicators and models in relation to different urban dynamics in the State. The studies showed the need to reflect on health in relation to urban land use. The main objective was to gain a better understanding of how urban dynamics influence the health systems profile, organization, and operation, based on which it was possible to extract some hypotheses and discussions regarding how urbanization in Sao Paulo State creates challenges for the expansion and consolidation of primary health care and the Family Health Program in these municipalities.

Tipologia das regiões de saúde: condicionantes estruturais para a regionalização no Brasil

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.