Policy, Planning and Management of Health Care Regions and Networks in Brazil
Prof. Ana Luiza d’ÁvilaVianaPh.D
Among the most urgent challenges in the current stage of implementing the Brazilian Unified Health System (SUS) are ensuring expanded access and adequacy of the services offered by means of regionalizing and consolidating the health care networks.
In the 1990s national policy focused on decentralization, and more specifically, municipalization, as the key strategy for constructing the SUS.Despite the positive results of this process – including increased access to health care, the incorporation of innovative management and care practices and the arrival of new actors who afford political and financial sustainability to the sector – problems remain in relation to the fragmentation and disorganization of health services, given the existence of thousands of isolated local systems.One can summarize that the decentralization model in the SUS has been important for increasing service coverage and public resources from subnational levels of government. However, it has not been able to resolve the regional inequalities that affect access to and use of services, as well as in public spending. Moreover, it has failed to ensure the integration of services, institutions and practices throughout the country, and the formation of more cooperative arrangements in health care.
In the 2000s, the focus shifted to regionalization as the organizational strategy to lift health care over the limitations resulting from decentralization.Especially the difficulties in managing the coordination and federative cooperation of a health system with such profound inequalities (distribution of professionals, equipment and resources, guaranteed access) and the fragmented systemic and regional logic in the functioning of the health system.
Despite having been established by the 1988 Federal Constitution, regionalization only began to be regulated in the sphere of national health policy in 2001, with the publication of the Operational Standard for Health Care (NOAS).The definition of a ‘health region’ appeared for the first time in the NOAS, the main objective of which was the fair allocation of funds and access to health services and actions.Regionalization was, therefore, defined as the macro-strategy to enhance decentralization.Thus it involved integrated planning, incorporating the notions of territoriality both in the definition of the intervention priorities and in the formation of “functional health systems”.
The Pact for Health in 2006 sought to strengthen intergovernmental agreements in the processes of political and territorial organization of the SUS.It proposed redefining collective responsibilities of the three federal management bodies, and establishing priorities, objectives and targets to be achieved within the sector.It also proposed strengthening co-management by implementing collegiate instances in health regions defined in the Regionalization Master Plans:the Regional Management Boards (CGR).Formed by representatives of the state health departments (from the central level or regional state structures) and the municipal health secretariats of each region, the CGRs have represented the creation of a permanent channel for intergovernmental negotiation and decision-making at a regional level.
From December 2010, new guidelines were formulated to stimulate the configuration of health care networks and the regionalization process in Brazilian states.Ministerial Directive # 4279, of 2010 (Brazil, 2010), defined the regions as areas of territorial and population coverage under the responsibility of the health care networks, and the regionalization process as a fundamental strategy for its configuration.Furthermore, it established other components for the operation of the networks.
In 2011, Presidential Decree 7.508, which regulates Law 8.080, of 1990, again highlighted the health regions, establishing instruments to bring the regions into effect:the health map (including both public and private services in the regions); Organizational Public Action Contracts – COAP (based on the defined rules and legal agreements between federative entities in the regions); health plans; the National List of Health Services and Actions (RENASES), the National List of Essential Medications (RENAME), and the Intermanagerial Committees (instances of regional governance of the networks, including the Regional Intermanagerial Commissions – CIR – to replace the CGR).
The technical, political and regulatory advances related to health regionalization in Brazil in the last ten years have confirmed the growing importance of this strategy within the scope of health policy, focusing on the inductive role of the federal government and broad adhesion by states and municipalities.
The meanings and relationships between regions and care networks suggest that progress in the regionalization process may have a positive effect on access to health care services.It is therefore necessary to identify the conditions that favour or hinder regionalization in the states and the formation of health care networks, in order to understand possible obstacles in reducing inequalities in universal health care in Brazil.
The key questions include:
- Are there any identifiable and significant (technical and political) changes in the implementation of the SUS resulting from the process of health care regionalization?
- Has the establishment of health regions contributed to reducing inequalities in health?
- How do regionalization strategies relate to the formation of health care networks?
- What are the current limits and challenges for regional health planning in Brazil?
- What successful experiences and new proposals have there been for the health regionalization process in Brazil and the world?
The research study entitled Policy, Planning and Management of Health Care Regions and Networks in Brazil has the primary aim of assessing, based on various theoretical and methodological approaches, the organization, coordination and management processes engaged in constituting health care regions and networks, and their impact on the improvement of access to, and the effectiveness and efficiency of SUS services and actions.The idea is to identify the conditions that either favour or hinder regionalization in the states and the formation of health care networks.This allows us to understand potential obstacles in reducing inequalities in the universalization of health care in Brazil.
The research in funded by the Ministry of Science, Technology and Innovation (MCTI) and the Ministry of Health, through MCTI/CNPq/CT-Saúde/MS/SCTIE/Decit Process # 41/2013.The main objective of this funding is to “support scientific and technological research projects that make significant contribution to the scientific and technological development of Brazil and that lead to the production of knowledge for ensuring the universal right to health”.The work comes under Line of Research number 5 of the published project rules:“identification and analysis of innovative initiatives to improve the effectiveness and efficiency of the coordination and organization processes of care networks and health regions and their impact on the demand flows and structuring of service provision”.
The national study on health regions is based on the following aspects:
- System of regional governance
- Flows of demand and structuring of service provision
- Primary Health Care in health regions and networks
- Health care networks, clinical management, contracting, quality, monitoring and evaluation
- Human Resources
Two further dimensions guide studies focused on certain health regions:the health care subsystem for the indigenous population, and technological incorporation.
The primary methodologies used in the development of the investigation are qualitative approaches to evaluative research, including interviews, documental analysis, participant observation and vignettes1 in the selected health regions. For some aspects and dimensions quantitative techniques will be adopted, such as structured questionnaires or worksheets for processing and analysis of empirical information.
The study will involve the use of internationally validated evaluation instruments for comparative analyses.Other countries with experience in regional organization of universal health systems, such as Canada, the United Kingdom, France, Italy, Germany, Portugal and Spain will represent an important source of information for the research.
The study design is based on a multicausal perspective, combining and synthesizing top down and bottom up approaches in order to analyze the implementation of policies aimed at regionalization and formation of health care networks.
Top down approaches understand that the actors situated in a single, central decision-making instance exert control over the policymaking process.In the study, this approach aims to identify the direction, reach and limits of federal instigation in the process of health care regionalization.The data collection strategy in this approach is based on broad documental research and interviews with key actors from the central administration level.
The bottom up approach meanwhile admits that policy is not only defined from the central public administration level, but is based on analysis of the decision-making networks in which actors engage with each other in policy implementation.In this investigation the bottom up approach is therefore aimed at an in-depth study of determining factors and regional innovations.The fundamental information for this approach will be systematized based on a survey answered by state and municipal managers, as well as face-to-face interviews in the selected health regions.
There are currently 436 health regions established in Brazil.The health regions to be studied are selected to represent a nationwide sample in terms ofregional typology and other criteria defined according to the objectives of the analysis.The typology is grounded on local indicators grouped into two dimensions:the socio-economic situation and the supply and complexity of the health services.
It is believed that employing this framework combined with the two approaches described above will support a more coherent analysis of the conditioning factors imposed by the bureaucracy that engages the implementation process of health regionalization policy.Furthermore, it will be possible to ascertain in depth descriptions of the discussion on the formation of networks for the implementation of this policy (who the actors are, how they interact, in which situation, etc.).The proposed study is also designed to understanding the impact of national, state and even municipal politics in the making and implementation of policies and programs aimed at regionalization and at the arrangement of health care networks.
This is a polycentric study involving the simultaneous and controlled administering of a single protocol (instruments) in various institutions in different states and regions of Brazil.There are 182 research institutions involved in the work, distributed around the five Brazilian regions (1 in the North, 3 in the Northeast, 2 in the Mid-West, 2 in the South, and 10 in the Southeast).The work will be developed over a four-year period (2014-2017).
Organization that supports the polycentric study:
- Action planning and data monitoring council
- Steering committee (coordinators of the study dimensions)
- Assembly (researchers’ meeting)
The structuring of the national research network will support relations and partnerships between different institutions and researchers from all the Brazilian regions engaged in the areas and lines of research that correspond to the topics, scopes and objectives proposed here.
The main scientific contribution of the research will be the production of analyses of the various conditioning factors (territorial, economic, cultural, social, historical-structural, political-institutional, informational, regulatory and technological) for policymaking, planning and management of the health care regions and networks of Brazil.
1 The vignette method is used in qualitative and quantitative research in various disciplines and for different scopes (BARBERIS E., 2010).
2 Universidade de São Paulo (USP), UniversidadeEstadual de Campinas (Unicamp), Universidade Federal de São Paulo (Unifesp), Faculdade de CiênciasMédicas da Santa Casa de São Paulo (FCMSCSP), Instituto de Saúde da Secretaria Estadual de Saúde de São Paulo (IS/SES-SP), Hospital do Coração São Paulo (HCor), Fundação Oswaldo Cruz (Fiocruz-RJ), UniversidadeEstadual do Rio de Janeiro (UERJ), Universidade Federal do Rio de Janeiro (UFRJ), Instituto Leônidas e Maria Deane (Fiocruz Manaus), Universidade Federal do Mato Grosso (UFMT), Universidade de Brasília (UNB), Universidade Federal da Bahia (UFBA), Instituto de Medicina Integral Professor Fernando Figueira (IMIP), Universidade Federal do Ceará (UFC), Universidade Federal do Rio Grande do Sul (UFRGS), Universidade Federal de Santa Catarina (UFSC), Universidade Federal de Juiz de Fora (UFJR).