Silvia Marta Porto

Methodological concerns and recommendations on policy consequences of the World Health Report 2000

Celia Almeida MDa, Paula Braveman MDc, Marthe R Gold MDd, Celia L Szwarcwald DrPhb, Jose Mendes Ribeiro MDa, Americo Miglionico MSe, John S Millar MDf, Silvia Porto PhDa, Nilson do Rosario Costa PhDa, Vincente Ortun Rubio PhDg, Malcolm Segall MRCPh, Barbara Starfield MDi, Claudia Travessos MDb, Alicia Uga PhDa, Joaquim Valente MDa and DrFrancisco Viacava MDb/ a National School of Public Health, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil/ b Health Information Department, Center for Scientific and Technological Information, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil/c Department of Family and Community Medicine, University of California, San Francisco, USA/d Department of Community Health and Social Medicine, City University of New York Medical School, New York, USA/e Consultant to Ministry of Health, Montevideo, Uruguay/ f Canadian Institute for Health Information, Ottawa, Canada/ g Department of Economics, Universitat Pompeu Fabra, Barcelona, Spain/h Health Unit, Institute of Development Studies, Sussex, UK/ i Johns Hopkins Medical Institutions, Baltimore, USA

Uma metodologia de avaliação do desempenho do sistema de saúde brasileiro

Este artigo e uma sintese de alguns dos principais resultados das discussoes realizadas ao longo de 18 meses entre pesquisadores de diversas instituicoes, afiliadas a Abrasco, e procura contribuir para a formulacao de uma metodologia que permita: a) compreender quais sao e como se inter-relacionam os fatores que influenciam a eficiencia, a efetividade e a equidade no desempenho do SUS; b) melhorar a formulacao de politicas e c) monitorar as desigualdades no acesso e na qualidade dos servicos recebidos pelos diferentes grupos sociais no Brasil. A metodologia desenvolvida nutre-se de elementos utilizados nas propostas de avaliacao de desempenho dos sistemas de saude canadense, australiano, ingles e a da OPS e tem o formato de um painel de controle (dashboard), onde podem ser visualizadas simultaneamente diferentes dimensoes da avaliacao. O artigo descreve a experiencia na adaptacao e desenvolvimento da metodologia e fornece sugestoes no sentido de aplica-la para melhorar a formulacao da politica de saude no Brasil.

Health sector reform in Brazil: a case study of inequity

Health sector reform in Brazil built the Unified Health System according to a dense body of administrative instruments for organizing decentralized service networks and institutionalizing a complex decision-making arena. This article focuses on the equity in health care services. Equity is defined as a principle governing distributive functions designed to reduce or offset socially unjust inequalities, and it is applied to evaluate the distribution of financial resources and the use of health services. Even though in the Constitution the term “equity” refers to equal opportunity of access for equal needs, the implemented policies have not guaranteed these rights. Underfunding, fiscal stress, and lack of priorities for the sector have contributed to a progressive deterioration of health care services, with continuing regressive tax collection and unequal distribution of financial resources among regions. The data suggest that despite regulatory measures to increase efficiency and reduce inequalities, delivery of health care services remains extremely unequal across the country. People in lower income groups experience more difficulties in getting access to health services. Utilization rates vary greatly by type of service among income groups, positions in the labor market, and levels of education.

O mix público-privado no Sistema de Saúde Brasileiro: financiamento, oferta e utilização de serviços de saúde

This paper analyzes the public-private mix in the Brazilian Health System from the perspective of health care delivery, utilization and financing. Moreover, this quantitative study based on secondary data from official databases contemplates the subsidies granted by the government to the private sector. It shows the existence of some inequalities favoring the population having private health plans, a result of the peculiar participation of the private sector in the Brazilian Health System not only offering supplementary care but duplicating the coverage offered by the public system (called SUS). The analysis is made on the basis of the classification of public-private mix in Health Systems developed by the OECD in 2004, that helps understanding the kinds of inequalities occurring in each type of public-private mix. The inequalities that occur in the Brazilian system must be understood as the result of the duplicated coverage offered by the private market and of the weak public funding for the SUS while granting important subsidies to the private sector.

Descentralização e alocação de recursos no âmbito do Sistema Único de Saúde (SUS)

Este artigo trata da descentralizacao do SUS, particularmente no que se refere a distribuicao e ao processo de alocacao de recursos para a saude, nas tres esferas de governo. Assim, apresenta, por um lado, o marco constitucional e legal desse processo e analisa as Normas Operacionais que vem orientando o processo de descentralizacao no SUS. Por outro lado, aborda a regionalizacao da alocacao de recursos efetivamente executada pelo Ministerio da Saude, incluindo tanto os gastos diretos como os repasses para estados e municipios. Finalmente, sao feitas algumas consideracoes de ordem geral.

Avaliação de Desempenho de Sistemas de Saúde: um modelo de análise

This paper presents a review of the Dimension Matrix for Evaluation of the Brazilian Health System that was initially developed in 2003, as well as a conceptual update of some of the sub-dimensions for the evaluation of health service performance, namely effectiveness, access, efficiency and appropriateness of health care. It also describes the indicator selection process as well as the results obtained in each performance dimension. The behavior of the indicators used to assess the performance of health services in Brazil, with respect to each sub-dimension, was not uniform. Areas of marked improvement were found in indicators that are influenced by activities in the field of primary care. The most significant improvements were seen in the sub-dimensions of Effectiveness and Access. With respect to the Efficiency of health services, situations of high efficiency coexist with others with substandard performance. The performance of health services in the sub-dimension of Appropriateness of Health Care was the lowest of all indicators.

A utilização de serviços de saúde por sistema de financiamento

This article analyses, from micro-data of the National Sample Household Survey (PNAD/IBGE) from 1998 and 2003, the utilisation of health services according to different financing systems. In other words, it analyses if this utilisation has been done through the National Health System SUS (public and universal health insurance, financed by taxes), through private health insurance (premiums paid by the insured population and/or their employers) or through out-of-pocket payments. The main results are: 1) SUS finances most of inpatient and outpatient utilisation and its participation has strongly increased from 1998 to 2003; 2) although the absolute number of outpatient utilisation made through the three systems has increased, SUS expansion has been much stronger (it increased 44%) and it corresponded to a slower increase (6,2%) of out-of-pocket utilisation and 3) SUS is the main financing system of the two extremes of complexity of health care: primary care and high complexity services.

Uma analise da utilização de serviços de saúde por sistema de financiamento: Brasil 1998 -2008

This article analyzes the use of health services from the perspective of financing based on PNAD/IBGE micro-data related to 1998, 2003 and 2008. Among the main results, the following can be highlighted: 1) The Unified Health System (SUS) continues to be the major financing agent of most consultations and hospitalizations in Brazil; its participation increased significantly between 1998 and 2003 and remained almost stable between 2003 and 2008; 2) SUS participation in financing the use of the health services has been predominant in all Brazilian regions, especially in the North and North-East, which feature the most precarious socio-economic and health conditions; 3) SUS is the major financing agent of the two extreme levels of complexity of health care: primary care and high complexity services. 4) In spite of a significant rise in utilization rates of SUS services for consultations and hospitalizations, great inequities can still be observed between the population that exclusively uses SUS and that which has private health insurance; 5) There has been an increase in the use of SUS health services by part of the population with private health insurance plans.

Equidad y distribución geográfica de recursos financieros en los sistemas de salud

This study focuses on equity in health and specifically the geographic distribution of financial resources. The author reviews the main contemporary theories of social justice and discusses the concept of equity in general and specifically in the health field. Based on the discussion of selected international experiences (United Kingdom, Spain, and Italy), the Resource Allocation Working Party (RAWP) formula used in the United Kingdom is identified as the most adequate distributive methodology, sizing the relative needs based on the populations demographic and epidemiological profiles. Finally, the results are presented from a simulation performed for the Brazilian case, showing that a more equitable geographic distribution of financial resources would require a redistribution favoring the States of the North and Northeast. The article concludes by highlighting that a comparison of actual fund outlays by the Ministry of Health in 1994 and the results of the simulation with the RAWP methodology for the Brazilian case show that the principles written into Brazilian legislation were absent from the geographic distribution of financial resources.

Considerations on methodology used in the World Health Organization 2000 Report

The article analyzes the World Health Organization Report for 2000, with emphasis placed on the methodology used to analyze the indicators utilized to compare and classify the performance of the health systems of the 191 member countries. The Reports contribution was the compromise of monitoring the performance of the health systems of member countries, but because of the inconsistent way it was elaborated, and the utilization of questionable scientific evaluation methodologies, the Report fails to give a clear picture. A criterion-based methodology revision is imposed. The main problems in evidence are the choice of individual indicators of disparity in health that discount the population profile, the inadequate control of the impact of social disparities over the performance of the systems, the evaluation of the responsibility of systems that are only partially articulated to the right of the citizens, the lack of data for a great number of countries, consequently having inconsistent estimations, and the lack of transparency in the methodological procedures in the calculation of some indicators. The article suggests a wide methodological revision of the Report.