Silvia Gerschman

As segmentações da oferta de serviços de saúde no Brasil: arranjos institucionais, credores, pagadores e provedores

A partir de revisao bibliografica e dados do Datasus, IBGE e agencias internacionais, sao discutidas segmentacoes e especializacoes na oferta de servicos de saude no Brasil. A leitura institucionalista do caso brasileiro destaca transformacoes que vem sofrendo o SUS, com enfase em relacoes publico-privadas e no papel e estrategias dos varios atores para formatar o sistema de saude segundo seus interesses e suas conviccoes. Os constrangimentos ao desenvolvimento das politicas sociais gerados pelo ajuste macroeconomico e consensos entre atores politicos de maior peso contribuem para a tendencia atual de especializacao do setor publico em tecnologias de cuidados de baixo custo e complexidade, enquanto o setor privado mais dinâmico passa a priorizar os segmentos de atencao de media e alta complexidade mais bem remunerados pela tabela SUS e mais valorizados por compradores de planos de saude privados. Um fortalecimento da presenca de conselhos de saude e de atores ainda pouco representados na arena politica poderia contribuir para uma maior atencao aos impactos potenciais desse padrao de especializacoes.

O Sistema Único de Saúde como desdobramento das políticas de saúde do século XX

Based on non-systematic search of bibliography and of national and international databases and research reports on Brazilian healthcare, this paper reviews health policies and the healthcare service market in Brazil along the 20th century, in an attempt to track the origins and structuring of the Brazilian public health system (Sistema Unico de Saude). Using a historical neoinstitutionalism framework, we discuss institutional arenas and specific relationships between payers, providers and creditors relevant to the various shapes assumed by health policies and the health system in Brazil. Institutional arrangements derived from interactions between successive political actors seem to have had a role both on present patterns of healthcare service supply and on restrictions and challenges faced by SUS.

Caracterização gerencial dos hospitais filantrópicos no Brasil

This paper presents the management characteristics of charity hospitals in Brazil, based on data from a national survey developed in 2001. The sample accounted for the random inclusion of 66 Brazilian Unified Health System (SUS) inpatient care providers with less than 599 beds and all 26 hospitals with at least 599 beds. It also included 10 institutions assumed as non-providers of services to the SUS. The analyses are descriptive, focusing on the classification of the hospitals according to their managerial development level, as well as selected issues regarding the utilization of specific managerial technologies, human resources, technical services, and services contracting. Distinct managerial levels were identified, but it is important to note that 83% of the SUS providers with less than 599 beds were classified as having incipient management. The authors discuss implications of the findings for inpatient care policies, considering the importance of charity hospitals for the Brazilian Health System.

Estudo de satisfação dos beneficiários de planos de saúde de hospitais filantrópicos

This paper presents the findings of research aimed at identifying and analyzing the argumentation and rationale that justify the satisfaction of consumers with their health plans. The qualitative method applied used the focus group technique, for which the following aspects were defined: the criteria for choosing the health plans which were considered, the composition of the group and its distribution, recruitment strategy, and infrastructure and dynamics of the meetings. The health plan beneficiaries were classified into groups according to their social class, the place where they lived, mainly, the relationship that they established with the health plan operators which enabled us to develop a typology for the plan beneficiaries. Initially, we indicated how the health plan beneficiaries assess and use the Brazilian Unified Health System (SUS), and, then, considering the types of plans defined, we evaluated their degree of satisfaction with the different aspects of health care, and identified which aspects mostly contributed explain their satisfaction.

Caracterização assistencial de hospitais filantrópicos no Brasil

OBJECTIVE To characterize the Brazilian philanthropic hospital network and its relation to the public and private sectors of the Sistema Unico de Saude (SUS) [Brazilian Unified Health System]. METHODS This is a descriptive study that took into consideration the geographic distribution, number of beds, available biomedical equipment, health care complexity as well as the productive and consumer profiles of philanthropic hospitals. It is based on a sample of 175 hospitals, within a universe of 1,917, involving 102 distinct institutions. Among these, there were 66 Brazilian Unified Health System (SUS) inpatient care providers with less than 599 beds randomly included in this study. Twenty-six of the twenty-seven SUS inpatient care providers with at least 599 beds, as well as ten institutions which do not provide their services to SUS, were also included. This is a cross-sectional study and the data was obtained in 2001. Data collection was conducted by trained researchers, who applied a questionnaire in interviews with the hospitals managers. RESULTS Within the random sample, 81.2% of the hospitals are located in cities outside of metropolitan areas, and 53.6% of these are the only hospitals within their municipalities. Basic clinical hospitals, without ICUs, predominate within the random sample (44.9%). Among the individual hospitals of the large philanthropic institutions and the special hospitals, the majority -- 53% and 60% respectively -- are level II general hospitals, a category of greater complexity. It was verified that complexity of care was associated to hospital size, being that hospitals with the greatest complexity are situated predominantly in the capitals. CONCLUSIONS Given the importance of the philanthropic hospital sector within the SUS [Unified Health System] in Brazil, this paper identifies some ways of formulating appropriate health policies adjusted to the specificities of its different segments.

Hospitais filantrópicos e a operação de planos de saúde próprios no Brasil

OBJECTIVE To describe the management performance of philanthropic hospitals that operate their own health plans, in comparison with philanthropic hospitals as a whole in Brazil. METHODS The managerial structures of philanthropic hospitals that operated their own health plans were compared with those seen in a representative group from the philanthropic hospital sector, in six dimensions: management and planning, economics and finance, human resources, technical services, logistics services and information technology. Data from a random sample of 69 hospitals within the philanthropic hospital sector and 94 philanthropic hospitals that operate their own health plans were evaluated. In both cases, only the hospitals with less than 599 beds were included. RESULTS The results identified for the hospitals that operate their own health plans were more positive in all the managerial dimensions compared. In particular, the economics and finance and information technology dimensions were highlighted, for which more than 50% of the hospitals that operated their own health plans presented almost all the conditions considered. CONCLUSIONS The philanthropic hospital sector is important in providing services to the Brazilian Health System (SUS). The challenges in maintaining and developing these hospitals impose the need to find alternatives. Stimulation of a public-private partnership in this segment, by means of operating provider-owned health plans or providing services to other health plans that work together with SUS, is a field that deserves more in-depth analysis.

Municipalização e inovação gerencial: um balanço da década de 1990

O presente trabalho tem por objetivo analisar as inovacoes gerenciais que se produziram no setor da saude no processo de descentralizacao da politica de saude. O trabalho se valeu dos resultados da pesquisa sobre municipalizacao e inovacoes na implementacao da politica de saude no Estado do Rio de Janeiro. Apos exaustivo mapeamento da situacao do Sistema Unico de Saude (SUS) no Estado do Rio de Janeiro, foram selecionados cinco municipios do Estado que apresentavam um bom desempenho no que se refere ao modelo de gestao: Angra dos Reis, Duque de Caxias, Niteroi, Resende e Volta Redonda. O artigo, na sua primeira parte, indaga atraves das entrevistas realizadas com os gestores municipais do sistema de saude a maneira como acontece o processo decisorio nas secretarias municipais de Saude dos municipios estudados. A segunda parte se valeu daqueles resultados relacionados a operacionalizacao dos servicos de saude municipais, atraves da percepcao dos profissionais de saude na atividade direta de assistencia aos usuarios. De fato, explorar as inovacoes politicas incorporadas ao sistema municipal de saude, junto com a problematica do exercicio da assistencia direta aos pacientes nos pareceu um bom contraponto para estabelecer parâmetros ou indicadores que permitam, no futuro, avaliar as politicas de saude no âmbito local.

Políticas comparadas de saúde suplementar no contexto de sistemas públicos de saúde: União Européia e Brasil

This paper analyzes the supplementary healthcare policies adopted in recent years in Brazil and in European countries. The proposed approach is a comparative analysis of the private health plan and insurance policies in the context of the European Union and Brazilian public health systems. This comparison allowed establishing parameters and categories capable of showing the differences and similarities between these experiences. These variables served as a basis for analyzing the Brazilian case using recent results of studies on private health insurance in the context of the Unified Health System (SUS), the Brazilian Public Health System. The main topics investigated were: the contracts and agreements between the public and the private sector, the attributions of the private health care services in the public system, the production, available capacity and financing of the public and private health systems and finally, the regulations regarding reimbursement of the SUS in those cases, where users covered by the private sector made use of the public services. We conclude retaking the discussion of the theoretical and conceptual perspective in the comparative analysis of health system policies based on the insights originated by this work.

Las reformas del Estado, de las políticas sociales y de salud: Un balance del final del milenio

This study reflects on reforms in health systems and social policies within the framework of the so-called public sector reforms. The point of departure is a review of various explanations for the crisis in the Welfare State, present in the literature from the 1990s. Social policies, at the heart of the crisis, are heavily challenged. What we intend to demonstrate is that this argument plays a specific role, that of introducing neoliberal changes into economic policy, in which the economic tools used generate abstention by the state from the social sphere, deregulation of national economies in favor of the free market, and the fundamentally oversized role of the international financial market. Within this context we analyze the social security and health system reforms. The final part of the article deals with current difficulties in social policies, focusing the debate on a mapping of possible alternatives for developing social and health policies.

Estrutura e qualidade assistencial dos prestadores de serviços hospitalares à saúde suplementar no Brasil

This study aimed to characterize inpatient care providers for health plans in Brazil, considering that knowledge on healthcare providers is still incipient, particularly in relation to healthcare structure and quality. A national survey was performed, focusing on 3,817 hospitals. A stratified sample of 83 hospitals was selected, and data were collected from September to December 2006 using interviews with hospital administrators. Hospital care was characterized using variables related to installed capacity and services output, as well as practices and structures for healthcare quality assurance and control. The final sample consisted of 74 hospitals, representing an estimated universe of 3,799 hospitals. Inpatient care providers for health plans, mainly for the Unified National Health System (SUS), showed limited presence of structures and practices for improving management and healthcare quality.