The organization of regional and integrated healthcare delivery systems: challenges facing Brazil's Unified Health System

This article examines the causes of the segmentation/fragmentation in the healthcare process and the benefits of the constitution of networks set up to rationalize expenditures, optimize resources and ensure care tailored to the needs of the users. Its main purpose is to analyze the current challenges facing Brazil's Unified Health System, in order to promote improved integration between services. Among the challenges, those related to the insufficiency of resources due to low public funding, the training and education processes and their effects on the availability of health professionals to work in the public health system and the difficulties in the decentralization of health services and actions in the context of the Brazilian Federation Pact should be stressed. The paper concludes that, besides the efforts to tackle these challenges, the organization of regionalized networks integrated with the Unified Health System also depends on the improvement of intergovernmental management in the health regions to bolster the agreement on responsibilities among the government areas and the qualification of primary healthcare to coordinate care and ensure its continuity at other levels of the system.     

Management of work, education, information, and communication in primary healthcare in cities in Southern and Northeastern Brazil

Decentralization in Brazil's Unified National Health System is challenging the management capability at the local level. Municipalities are required to operate health teams, provide infrastructure, technology, and supplies for the health services, and organize the work process. An epidemiological survey assessed the management of work, education, information, and communication in primary care services in 41 municipalities with more than 100,000 inhabitants each in the Northeast and South of the country. Health professionals and administrators were insufficiently trained for their daily responsibilities, and the infrastructure and management tools were deficient. Precarious work contracts (lack of formal job stability) for health workers is a serious problem in Brazil's primary care system. The work supervision was weakly linked to health care and planning. Continuing education for the health team was limited, and health information focused only on collection of data to send to the State and Federal management levels. Thus far health communication has been ineffective as a tool to connect primary care managers and professionals to the population and society.     

Misdirections in the professional training used to prepare psychologists in Brazil to work in the public health-care system]

In Brazil, the practice of psychologists in public health-care institutions is hampered by the professional training that they have received. That training is inadequate in meeting the requirements of primary health care, in satisfying the needs of the patients who use the public health-care system, and in overcoming the social inequalities that exist in Brazil. This piece is intended to identify the factors that make it harder to provide adequate psychological care in public health-care institutions, especially in the local Basic Health Units of Brazil's public health-care system, the Unified Health System. These hindrances to providing good care mainly originate in training that points psychologists in the direction of very restricted models of health care. These narrow models prevent the psychologists from responding appropriately to the needs of their patient clientele and of the public institutions. These limited models also make it hard for psychologists to adapt to the dynamic conditions that they will face in the Unified Health System.     

Decentralization of workers' health surveillance in the city of Campinas, São Paulo State, Brazil: a process evaluation

This study evaluates the decentralization of workers' health surveillance to district teams in Campinas, S?o Paulo State, Brazil, from 1990 to 2006. The history and context of this process were retrieved from documents at the Municipal Health Department in order to establish evaluation criteria and define facilitating factors and obstacles in guideline implementation, as well as to measure the gap between guidelines and reality. The evaluation used qualitative techniques with stakeholders' focus groups. The results showed that decentralization was defined according to the prevailing political options and according to the principles of the Unified National Health System (SUS). Facilitating factors included the increase in technical capability and integration among the teams, and obstacles included excessively centralized planning with limited participation, insufficient resources, and lack of clarity between the services concerning roles and responsibilities. The discussion of these results with health system administrators, social actors, and participating health professionals has contributed to the analysis and organization of transformative measures in regional public practices in workers' health surveillance.     

Constructing the "management pact" for Brazil's National Health System (SUS): from supervised decentralization to network management

Over time, the implementation of Brazil's National Health System (SUS) has encountered management problems. Initially, steadily rising pressures calling for State reform and trimmer costs affect the universal healthcare that is the purpose of this system. Conflicts then flare up between the decentralization principle and the network concept, viewed here as not merely links among different spheres of management, but rather the model through which access to a right is exercised through a network. Operating decisions on healthcare have been decentralized, while the budget transfers underwriting these decisions remain unchanged. From the civil service standpoint, the decentralization of healthcare management was halted by the issue of the Operational Healthcare Directive in January 2001. From the management standpoint, the introduction of the network concept - which is the most effective weapon against verticalizing decision structures - must deal with operating and financial bottlenecks that prevent players in different organizations from speaking the same 'language', which is the most effective way of building up inter-organizational links. Effective interaction among these languages will be attained only through constructing management pacts.     

Shared local health system management and community participation in Brazil

The introduction of the Unified Health System (SUS) by the Brazilian government has helped enhance community participation. A survey in 12 municipalities in different States of the country focused on the decentralization process implemented by the Federal government (Basic Operational Ruling NOB01/93). Based on the ruling's implementation, community participation has improved in the municipalities, the number of local health councils has increased, and more local people have become involved in the process. Another important aspect of the new health policy has been the direct influence of the local health councils in managing the system. Local health councils have thus been an efficient channel for community involvement. This paper discusses how the population has been represented in such councils in the wake of the decentralization process. The authors ask, what is the relationship between social democracy and political democracy, and what kind of state reform should be carried out?     

Health decentralization in the state of Mato Grosso, Brazil: financing and care model]

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.     

The Brazilian national health system: an unfulfilled promise?

In 1988, Brazil became one of the first countries in Latin America to frame access to health care as a constitutional right. However, it would be misleading to call Brazil's Unified Health System (Sistema Único de Saúde, or SUS) a public health system that provides universal access and comprehensive care. This paper reveals a strong contradiction between the re‐distribution model set out in the Brazilian Constitution and the inadequate level of public spending on health care. The law states that health care is a basic social right, allocated by need rather than means. Meanwhile, in 2003, Brazil spent US$ 597 per capita on health, or 7.6 per cent of its gross domestic product (GDP), while the average country from the Organization for Economic Cooperation and Development (OECD) spent US$ 3145, or 10.8 per cent, and Argentina spent US$ 1067, or 8.9 per cent of its GDP. Copyright © 2010 John Wiley & Sons, Ltd.     

Management policy-making for work and education in health: the case of the Bahia State Health Department, Brazil, 2007-2008

The construction of Brazil's Unified National Health System (SUS) has raised a set of challenges for the health sector's administrators and personnel, including issues of work management and continuing education for health workers, in view of the financial, political, and organizational constraints in the process of changing the healthcare model. The current study aimed to analyze the process of formulating the Health Work and Education Management Policy by the Bahia State Health Department. Public policy cycle was used as the theoretical framework. The study analyzed data from institutional documents and records of participant observation by one of the authors. The results include mapping the governmental and nongovernmental stakeholders that participated in the process. The analysis highlights a series of problems in the SUS in Bahia related to work management and health workers' profile, taken as the point of departure for priority-setting in the State Strategic Agenda and Health Plan for 2008-2011.     

Evaluation of under-reporting of AIDS cases in the city of Rio de Janeiro based on data from the hospital information system of the Unified Health System]

Data from the Hospital Information System (SIH-SUS) were linked to data from the AIDS Case Reporting System (Sinan) to assess the level of under-reporting of AIDS cases in the city of Rio de Janeiro. A high level of unreported cases(42.7%) was observed for patients treated in hospitals under Brazil's Unified Health System in the city of Rio. Bivariate analysis showed an association between reporting to the Sinan and age, principal diagnosis, and type of hospital.     

Public health structures in Spain: a changing panorama]

In the last years the health care system in Spain has undergone very important transformations. However, the public health services have not followed a comparable process. Until 1979 public health structures were based in central services and their provincial units, on one side, and in the resources of local governments on the other. From then on began the process of transferring responsibilities and resources to the regional governments of Autonomous Communities (AC), which today manage most public health services, while the central government keeps as its responsibility the development of basic norms, the administration of public health services at borders and customs, and the general health coordination. The situation in 1995 resembles that of a Federal Country, although the Kingdom of Spain is not formally defined as such. The role of central government services is visibly reoriented towards coordination and the building of consensual and shared structures for health information, for need evaluation, and for policy formulation and evaluation. Although the General Health Law of 1986 considered public health as a main axis for all health agencies, its actual development has been more patchy. Several AC with an Autonomous Health Service have kept public health services separated from it. Besides, many public health functions and activities are developed today from other structures. The processes of change reveal two contradictory aspects. On one side, structures have been upgraded after decentralization, and teams reinforced, with trained and full-time staff. However, there is some dilution of public health responsibility in the periphery, and a lower visibility of the health authority.     

Epidemiological surveillance in the Chagas disease control program in Minas Gerais State, Brazil (1984-1998)

This paper describes the surveillance phase of the Chagas Disease Control Program in Minas Gerais State. Surveillance was conducted by the County Health Services with community participation in the planning, decision-making, and maintenance processes and is intended to be sustainable in the context of Brazil's Unified National Health System (SUS).     

Health promotion in Brazil

The evolution of health promotion within the Brazilian health system is examined, including an assessment of the intersectoral and development policies that have influenced the process. Particular attention is paid to the legal characteristics of the Unified Health System. Human resources formation and research initiatives in health promotion are outlined, with a summary of the obstacles that need to be overcome in order to ensure the effective implementation of health promotion in the future. Up to the end of the 20th Century health promotion was not used as a term in the Brazilian public heath context. Health promoting activities were concentrated in the area of health education, although targeting the social determinants of health and the principle of intersectoral action were part of the rhetoric. The situation has changed during the last decade, with the publication of a national policy of health promotion, issued by the Ministry of Health and jointly implemented with the States and Municipals Health Secretaries. More recently there has been a re-emergence of the discourse on the social determinants of health and the formation of intersectoral public policies as the basis of a comprehensive health promotion. Health promotion infrastructure, particularly around human resources and financing, requires strengthening in order to ensure capacity and sustainability in health promotion practice.     

Decentralising the health sector: issues in Brazil

The health sector in Brazil has undergone important changes, particularly with the development of the Unified Health System (SUS). Decentralisation is an important principle of SUS and advances have been made in transferring responsibilities and resources to the local government units, known as municipios. This article describes the changes introduced, focusing on the system of municipio classification and the funding mechanisms introduced through the basic operating rule (BOR) of 1996. The paper then moves on to analysing three key issues of decentralisation in Brazil that are related to the policy process, the system of decentralisation and the output of decentralisation. Firstly, the formal process by which decisions on health sector reform are made is discussed with particular attention being paid to the negotiated and relatively open policy space. Secondly, the role of the states is discussed within the decentralised system. Thirdly, the impact of decentralisation on equity is discussed with particular reference to the resourcing of the Municipal Health Funds. The article concludes by emphasising the political nature of health sector decentralisation and the need to develop the conditions for effectiveness in decentralisation programmes.     

The federal government discourse during the political decentralization process and the obstacles to implement the Brazilian Public Health Care System

A discourse analysis carried out on basic operating standard Norma Operacional Básica do Sistema Unico de Saúde (NOB-SUS 01/96) of the Brazilian public health care system aiming at locating signs that could allow to identify lines of thought which have influenced health care policies prioritized by the federal administration. The author points out a peculiarity in the kind of discourse employed by the ministry directive: its structure is based on isolated aspects of legislation and on ideas advocated by other discourse communities, articulated with redefined legal principles - an effort towards authorizing the official reasoning in favor of the relevance in keeping the decentralization process under the control of the federal administration. The analysis concludes that an infra-legal standard can neither grant state and federal administrations a hierarchical superiority (mediation function) over municipal administrations, nor can it transfer the legal responsibilities pertaining to Health Councils over to inter-administration commissions (Comiss?es Intergestores) , thus making the former mere decision ratifiers. This study found that granting privileges not contemplated in the legislation to state and federal administrations surfaced again and more strongly so in 2001 in yet another operating standard.     

Pharmaceutical care in primary health care: the experience of 3 Brazilian States

In the context of recent changes in the Brazilian drug supply system at the national level, mainly the deactivation of CEME (a government agency under the Ministry of Health that dealt with drug supply policy) and the increasing decentralization of activities under the Unified National Health System (SUS), three Brazilian States - Paraná, S?o Paulo, and Minas Gerais - have established programs for the distribution of essential drugs for primary health care. A nationwide program for the procurement and supply of 32 drugs for primary health care (the so-called "Basic Pharmacy Program") is currently being implemented by the Ministry of Health, to be decentralized subsequently. This article discusses the establishment of State-level drug policies for primary health care through the analysis of the three pioneering programs encompassing drug selection, procurement, storage, distribution, and use.     

The consolidation of private health plans in Brazil: challenges for the regulator

The effects of the financial consolidation of Brazil's private health plan market warrants investigation, as this trend could enhance the power of large plans and affect the financing of the National Health System. From the standpoint of the political economics of this sector, while reflecting on the features of this consolidation, this paper discusses whether this more powerful market clout might require the State to adopt a more active stance, especially if it wishes to enforce the normative principles of the National Supplementary Health Regulator in order to protect consumers, ensure regulated competition and defend the public interest.     

Decentralization and regionalization: dynamics and conditioning factors for the implementation of the Health Pact in Brazil

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 Brazil's 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.     

Engaging citizens: lessons from building Brazil's national health system

Brazil's Sistema Unico de Saúde (SUS), a universal, publicly-funded, rights-based health system, designed and put in place in an era where neo-liberal reforms elsewhere in the world have driven the marketization of health services, offers important lessons for future health systems. In this article, we focus on the innovative institutional mechanisms for popular involvement and accountability that are part of the architecture for governance of the SUS. We argue that these mechanisms of public involvement hold the potential to sustain a compact between state and citizens and ensure the political momentum required to broaden access to basic health services, while at the same time providing a framework for the emergence of "regulatory partnerships" capable of managing the complex reality of pluralistic provision and multiplying sources of health expertise in a way which ensures that the needs and rights of poor and marginalised citizens are not relegated to the periphery of a segmented health system.