Cristiani Vieira Machado

Política de saúde nos anos 90: relações intergovernamentais e o papel das Normas Operacionais Básicas

This papers examines the Brazilian health policy during the 90s with a effective focus in the challenge posed by the implementation of the Sistema Unico de Saude (SUS). Among the main conclusions the work underlines the new role of the local administrations ¾ effectively managing budgetary resources and instruments¾ nevertheless the huge problems emerging from the new rules of the system. The Federal Government, however, was empowered with new regulatory functions and could set up mechanisms to transfers responsibilities and resources to states and local government levels if these programs were linked to social activities. The decentralization program is governed by SUS operational rules, that are carried out in a country which federative model is still being defined and with a very centralized tax system.

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.

Serviço de Atendimento Móvel de Urgência: análise da política brasileira

OBJETIVO: Analisar a conformacao da politica de atencao movel as urgencias no Brasil. PROCEDIMENTOS METODOLOGICOS: Com base no referencial da analise de politicas publicas, foram realizados: revisao bibliografica, analise de documentos e dados oficiais e entrevistas com dirigentes federais relacionados a formulacao e implantacao do Servico de Atendimento Movel de Urgencia (Samu) no Brasil na decada de 2000. ANALISE DOS RESULTADOS: O Samu teve prioridade na agenda federal a partir de 2003. Nos primeiros anos de implantacao predominaram servicos de abrangencia municipal; em 2008, os de abrangencia regional tornaram-se mais relevantes. A cobertura estimada alcancou 53,9% da populacao em 2009, residente em 20,5% dos municipios brasileiros. A implantacao variou entre os Estados e houve menos ambulâncias de suporte avancado do que o recomendado, tanto no conjunto do Pais como em varios Estados. CONCLUSOES: O Samu foi adotado nacionalmente a partir de 2003, com a elaboracao de normas federais. A implantacao da politica compreende desafios como realizacao de investimentos adequados, insercao do servico em uma rede articulada de atendimento de urgencia, conformacao de sistemas de informacoes apropriados, capacitacao dos profissionais. O enfrentamento desses desafios permitira que o Samu se configure como uma estrategia estruturante da atencao a saude no Sistema Unico de Saude.OBJECTIVE To analyze the configuration of mobile emergency health care policy in Brazil. METHODOLOGICAL PROCEDURES The study was based on public policy analysis. Bibliographic and document review, analysis of official data and interviews with federal administrators related to formulation and implementation of the Mobile Emergency Care Service (SAMU) in Brazil in the 2000s were performed. ANALYSIS OF RESULTS Priority was given to SAMU at the federal level since 2003. During the first years of implementation, municipal level services predominated; in 2008, services with regional scope became more significant. Estimated coverage reached 53.9% of the population in 2009, in 20.5% of Brazilian municipalities. Implementation varied between States, and there were less advanced support ambulances than recommended, both nationally and in several States. CONCLUSIONS SAMU was adopted nationwide since 2003 upon development of federal norms. Implementation of the policy involves challenges, including adequate investment, integration of the service into an established urgent care network, arrangement of appropriate information systems and personnel capacity. Addressing these challenges will allow SAMU to become a key health care strategy in the unified health system.

A política de atenção primária à saúde no Brasil: notas sobre a regulação e o financiamento federal

This article analyzes the Federal implementation of primary health care policy in Brazil from 2003 to 2008, considering the government functions of health planning, regulation, financing, and health services delivery. The methodology included literature and document review, interviews with key policy actors, budget analysis, and health database analysis. The analysis showed a reduction in direct Federal health services delivery and weaknesses in Federal planning. Federal performance mainly involved regulation, based on norms linked to financial mechanisms. As for funding, the results showed a slight increase in the share for primary care in the Federal budget, adjustments, and creation of new incentives, some aimed at equity. Although some progress occurred, a remaining challenge is to reconure the Federal regulatory model and ensure a greater supply of resources for primary health care in Brazil.

Políticas de saúde no Brasil nos anos 2000: a agenda federal de prioridades

This article analyzes Brazilian national health priorities from 2003 to 2008 under the Lula Administration. The study included a literature review, document analysis, and interviews with Federal health administrators. Four priorities were identified on the national health agenda: the Family Health Program, Smiling Brazil, Mobile Emergency Services, and the Popular Pharmacy Program. The first is a policy with high institutional density launched by the previous Administration, constituting an example of path dependence. The other three are innovations in areas where there had been weaknesses in Federal government action. The four policy priorities are strategies focused on solving key problems in the Brazilian health system. However, they display important differences in their historical development, political and institutional base, inclusion on the Federal agenda, and implications for the principles of the Unified National Health System. Although incremental changes have been introduced, national health policy has been characterized predominantly by continuity.

Configuração da atenção básica e do Programa Saúde da Família em grandes municípios do Rio de Janeiro, Brasil

This article analyzes the organization of traditional Primary Health Care and the Family Health Program (FHP) in the 22 municipalities of Rio de Janeiro State, Brazil, with more than 100,000 inhabitants each in 2005. The methodology included visits to the municipalities, interviews with health managers, and analysis of national databases. Four summary variables were defined: the Primary Health Care model and inclusion of the FHP; institutionalization of the FHP; organization of traditional primary care; and organization of the FHP. Classification of the municipalities according to the four variables showed widely diverse situations and the predominance of a parallel model for inclusion of the FHP. The municipalities with the best structural conditions for primary care are located in the interior of the State, besides those that have had the FHP implemented for more than six years and that practice various modalities of Primary Health Care organization. The majority of the municipalities with the worst situation in relation to the FHP are located in Greater Metropolitan Rio de Janeiro. In light of the results, the article discusses the challenges facing the FHP as a strategy for structuring primary health care in large cities, particularly in metropolitan areas.

Sistema de saúde universal e território: desafios de uma política regional para a Amazônia Legal

This article presents the results of a study on Federal health policy in the Brazilian Legal Amazon (BLA) from 2003 to 2005, aimed at backing the development of regional health policies. The region has peculiar dynamics, an extensive border area, and adverse social indicators. The methodology included documental and financial analysis, participatory observation, interviews with heads of various Federal Ministries and State and Municipal health secretaries from the BLA; characterization of geographic situations in the BLA; and field studies in 15 municipalities. Institutional consolidation of health policy proved to be low in the Amazon during the study period, due to structural, institutional, and political difficulties. The identification of six geographic situations was useful for systematizing land use differences with repercussions on health, and which should be considered when implementing public policies. There is a certain gap between Federal actions and territorial dynamics, expressed as a mismatch between the current policy and its recognition by local administrators. In addition to establishing a regional policy for the Amazon, there is an evident need for differentiated policies within the region.

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.

Saúde e territorialização na perspectiva do desenvolvimento

The relationship between health and development is complex and lies in the field of political economy, given that it involves different social, political, and economic interests. In the Brazilian case, this association is particularly relevant in terms of the territorial dimension, in light of the central role of healthcare services in the organization of the urban network and the demarcation of territorial schedules and limits. In the theoretical-conceptual field, this study explores analytical areas that approach the relations between health and development, as well as between health and the territorial issue; and analyzes the history of the decentralization and regionalization policy in the Unified National Health System (SUS) and Federal investments that constitute the basis for its spatial evolution. Based on this conceptual review and empirical data, the study attempts to establish theoretical and political-institutional connections between health and development. The aim is thus to support the discussion on challenges facing a new role for health in the Brazilian development model, historically marked by economic and social inequalities with strong territorial overtones.

Descentralização e regionalização: dinâmica e condicionantes da implantação do Pacto pela Saúde no Brasil

Decentralization and regionalization represent constitutional guidelines for the organization of the Unified Health System, which in the last 20 years has required the adoption of mechanisms to coordinate and accommodate federative tensions in Brazils healthcare sector. This paper analyzes the national implementation of the Health Pact between 2006 and 2010 involving a strategy that reconfigures intergovernmental relations in the sector. The study involved the analysis of documents, official data and interviews with federal, state and municipal managers in the Brazilian states. The content of the national proposal is initially discussed, including its implications for health policy. The different rhythms and degrees of implementation of the Health Pact are then reviewed, with respect to adherence by states and municipalities and the formation of Regional Management Boards. Lastly, the conditioning factors for the multiplicity of experiences observed in the country are identified and the challenges facing progress toward a decentralized and regionalized health system in Brazil are discussed.