João Henrique Gurtler Scatena

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.

Avaliação da vigilância de contatos de casos novos de tuberculose no Estado de Mato Grosso - Brasil

Objective: To evaluate surveillance of contacts of new tuberculosis cases in the state of Mato Grosso from 1999 to 2004. Methods: This was a descriptive epidemiological study based on data from the Tuberculosis Case Registry Database. The number of new tuberculosis cases, the number of contacts (estimated, investigated, and uninvestigated), and the tuberculosis incidence rate were analyzed by age bracket. The mean rate of contacts investigated for each case of tuberculosis by age bracket was calculated per year of study. The cases of pulmonary tuberculosis with and without contacts investigated were analyzed by sputum smear microscopy results. Results: In 2004, there were 41.3 cases of tuberculosis per 100,000 inhabitants in the state of Mato Grosso. The south-central region presented the highest incidence rate (57 cases/100,000 inhabitants) and a 15% rate of contacts investigated. Among those younger than 15 years, 63 contacts (60.5%) were investigated, whereas among those aged 15 or older, 389 (8.9%) were investigated. In 1999, the mean rate of contacts investigated statewide was 0.02 (0.5%), and, in 2004, it reached 0.42 (10.5%). The percentage of contacts investigated was 40% higher among the contacts of contagious cases (OR = 1.4; 95% CI: 1.08-1.83). Conclusions: The percentage of contacts investigated is very low, principally among adults. The adoption of the standards for investigation of tuberculosis contacts proposed by the Brazilian National Ministry of Health Department of Health Surveillance has not ensured that this group at highest risk of developing active tuberculosis be given priority at health care facilities in the state of Mato Grosso.

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.

Sustentabilidade financeira e econômica do gasto público em saúde no nível municipal: reflexões a partir de dados de municípios mato-grossenses

Brazils Unified National Health System is financed according to a model known as fiscal federalism, the fund-sharing rules of the Social Security Budget, Ministry of Health norms, and Constitutional Amendment 29 (EC-29), which links Federal, State, and municipal resources to health. This article discusses the sustainability of public spending on health at the municipal level. Twenty-one municipalities were studied, using municipal budget data. From 1996 to 2006, total current per capita revenues increased by 280% above the accumulated inflation and Gross Domestic Product, varying by size of municipality, which also defined the composition of the municipal budgets. Meanwhile, the budget comprising the basis for EC-29 increased less (178%), thus placing limits on the municipal share of health spending. The results observed in these municipalities are believed to reflect the reality in thousands of other Brazilian municipalities, thus jeopardizing the capacity for municipal investment in health, especially beginning in 2008. The situation may become even worse, considering the repeal of the so-called Bank Transaction Tax (CPMF), Bills of Law 306/08 and 233/08 (currently under review in the National Congress), and the world recession stemming from the U.S. financial crisis.

A descentralização da saúde no Estado de Mato Grosso, Brasil: financiamento e modelo de atenção

This piece analyzes the funding of the public Unified Health System (UHS) in the state of Mato Grosso, Brazil, in order to identify the model of care that has been taking shape there since 1994. We studied 16 municipalities, selected according to their size, degree of involvement with the UHS, and socioeconomic and health conditions. We found that between 1994 and 1998 there were large increases in health spending, due to higher municipal expenditures and to rising intergovernmental transfers for outpatient care. However, the health care system taking shape in a large number of Mato Grosso municipalities is increasingly focused on an individual, curative, specialized, and highly technological type of care. Indicative of this trend is the fact that the biggest increases in spending for outpatient care--up to 300% in some municipalities--have come from diagnostic and therapeutic procedures that are of medium or high complexity. Since the resources for health care are limited, and since the model of care adopted by many municipalities continues to shift resources from primary health care to more complex procedures, we believe that the financial viability of the Unified Health System is coming into question. Although this study was limited to the state of Mato Grosso, other Brazilian municipalities are no doubt facing similar situations. The same is probably true for municipalities in other South American countries that have adopted decentralization of the health care system as one of the strategies for State reform.O presente trabalho analisa o financiamento do sistema publico de saude no Brasil, o Sistema Unico de Saude, no Estado de Mato Grosso, buscando identificar o modelo assistencial que vem se conformando a partir de 1994. Para isso, foram estudados 16 municipios, selecionados segundo porte, envolvimento com o Sistema Unico de Saude e nivel socio-sanitario. Observou-se que entre 1994 e 1998 a contrapartida financeira municipal e as transferencias para atendimentos ambulatoriais foram as responsaveis pela elevacao dos gastos com saude. Contudo, o modelo de assistencia a saude que vem se definindo em grande parte dos municipios mato-grossenses se volta cada vez mais para a assistencia individual, curativa, especializada e com alta incorporacao tecnologica. Aponta para isso o fato de que, em relacao a assistencia ambulatorial, os maiores incrementos de recursos financeiros aconteceram no segmento de complementacao diagnostica e terapeutica de media e alta complexidade, atingindo ate 300% em alguns municipios. Como os recursos para a saude sao escassos e o modelo de assistencia adotado por muitos municipios ainda desloca recursos da atencao primaria a saude para o segmento de atencao de maior complexidade, acredita-se que a inviabilidade financeira do SUS e uma possibilidade que nao pode ser descartada. Embora o universo de estudo tenha se limitado ao Estado de Mato Grosso, certamente situacoes parecidas estao se configurando em inumeros municipios brasileiros e, provavelmente, tambem em municipios de outros paises latino-americanos, nos quais a descentralizacao foi incorporada como uma das estrategias de reforma do Estado.

Caracterização das vítimas de acidentes e violências atendidas em serviço de emergência: Município de Alta Floresta, MT (Brasil)

INTRODUCAO: Em Alta Floresta - MT, embora os acidentes e violencias sejam responsaveis por importante parcela da morbidade hospitalar e da mortalidade, principalmente entre a populacao jovem, nao se conhecia o que tais agravos representam, em termos de morbidade ambulatorial. OBJETIVO: Apresentar a caracterizacao das vitimas de violencias e acidentes em servico de emergencia no municipio de Alta Floresta - MT. MATERIAL E METODOS: Estudo descritivo dos registros de todos os atendimentos de emergencia ocorridos em tres meses de 2006, por meio de ficha de notificacao especifica para acidentes e violencias. RESULTADOS: Dos 7.394 atendimentos no periodo, 583 (7,9%) foram prestados as vitimas de acidentes e violencias, a maioria do sexo masculino, com idade entre 20 e 39 anos, branca, e com escolaridade inferior a 8 anos. Dentre as ocorrencias, predominaram os acidentes: foram 239 (41,0%) acidentes de transportes, destacando-se os de motocicleta; 153 quedas (26,2%) e 167 (28,7%) outros acidentes. Dentre os registros de violencias, 16 (2,7%) foram agressoes e 8 (1,4%) tentativas de suicidio. A suspeita de uso de alcool, entre maiores de 18 anos, foi registrada em 12,0% das vitimas de acidentes e violencias. No entanto, entre as vitimas de agressoes este percentual foi muito mais elevado (91,7%). Observou-se tambem importante relacao dos acidentes com a categoria trabalho. CONCLUSAO: O conhecimento adequado das caracteristicas das vitimas dos acidentes e violencias e imprescindivel para o processo de deflagracao de medidas efetivas que visem reduzir tais agravos.

O Pacto pela Saúde e o processo de regionalização no estado de Mato Grosso

The regionalization of health in the state of Mato Grosso started in the 1990s. In this work, it was analyzed the performance of the State Secretary of Health, in the period 2006-2011, by the dimensions: institutional, governance and impacts of regionalization, in order to identify whether the bases established in the presence of the Pact facilitated it or hindered it. Secondary data were used, documents and also interviews with state, region and municipal managers. The rules instituted facilitated, but the regionalized structures had their functions modified; the regionalization process was partially implemented and poses challenges to federal entities to advance in its consolidation.

Vigilância sanitária: estratégias para sua descentralização em Mato Grosso, 1996-2005

The decentralization process of sanitary surveillance services to states and municipalities was improved after NOB/96, when funding transferences were defined. In Mato Grosso, this responsibility was incorporated by the Sanitary Surveillance Coordination (Visa/SES) which developed strategies to decentralize at first, the basic actions to all municipalities of the state. The objective of this research is to describe and analyze the strategies adopted by Visa/SES in decentralization of Visa actions to municipalities and the main difficulties found. This research is a qualitative study with documental and interview analysis. The results show as main adopted strategies: several training to professionals from regional, central and local levels; development of technical material to municipals services; assessment with join inspections between three levels of management; creation of law documents. It was observed an active performance in the decentralization, the Visa/SES keeps performing the high and middle complexity actions in almost all municipalities and even those of low complexity, in some, which impede other important tasks as supervision and evaluation of this process, besides continuous support and organization of municipalities services.

Institucionalidade e governança da regionalização da saúde: o caso da região Sul Mato-Grossense à luz das atas do colegiado de gestão

O artigo trata das formas de fazer a regionalizacao da saude, objetivando analisar as dimensoes da institucionalidade e governanca na sua gestao. Fez-se pesquisa qualitativa retrospectiva em base documental (1995-2009). A politica estadual de saude foi indutora da regionalizacao. A institucionalidade constituiu-se nas instâncias consolidadas: Comissao Intergestores Bipartite Regional, transformada em Colegiado de Gestao Regional; representacao da secretaria estadual; central de regulacao; consorcio intermunicipal; e hospital regional. Refem de interesses diversos, a governanca da regionalizacao revelou-se incipiente e o planejamento restrito a aplicacao normativa de instrumentos legais do SUS.

A relação público-privada no SUS: um olhar sobre a assistência ambulatorial de média e alta complexidade na região de saúde da Baixada Cuiabana em Mato Grosso

El articulo aborda la colaboracion publico-privada en la atencion ambulatoria secundaria y terciaria en el SUS, en la Baixada Cuiabana (MT). En Brasil, la superposicion entre los sectores publico y privado de la salud y sus consecuencias son complejas y aun poco estudiadas. Se trata de un estudio cuantitativo y descriptivo, con base en datos secundarios de los Sistemas de Informacion del SUS, en cuanto a la estructura, la produccion y los costes de dicha asistencia. Los resultados muestran que el numero de establecimientos, la produccion y el volumen de los recursos estan concentrados en Cuiaba, con el sector privado/filantropico como principal proveedor. Este hecho podria sugerir que este sector tiene el poder politico y la presion en el SUS, tanto en la negociacion de sus contratos como en la prestacion de servicios ambulatorios mejor pagados.