Governance arrangements for specialized assistance in health regions in Brazil

Case studies were carried out which included seven health regions in the Brazilian territory, involving the secondary data systematization and 128 interviews with SUS leaders (2015 to 2016). The analysis was done in a comparative perspective, considering: public and private participation; assistance concentration; power relations and regional conflicts.

Results:

the public provision service and expenditure were high in the Medium Complexity and in the private, High Complexity. The main responsibility for the public provision service was in the cities so, that the specialized assistance was strongly concentrated in the pole cities. The level of influence from the providers in health decisions was high, and the offer considered to be insufficient and inadequate in relation to services and medical professionals. Conflicts were evident in the intergovernmental and public-private relations.

Conclusions:

the diversity of agents and arrangements - multilevel, hybrid and polarized - characterizes governance regionalization in SUS, which is conditioned by the scarcity and the inequality context in the distribution of services.

Key words
Health policy; Health services administration; Regionalization; Health management; Public Health System

		Health Region	Quantity		Expenditures		Responsable Governmental Entity (%)
			Proc./AIH	% Public	R$ per capita	%Public	Federal		State		City
			Proc./AIH	% Public	R$ per capita	%Public	Nº	R$	Nº	R$	Nº	R$
Ambulatory Assistance	Medium Complexity	Baixada Cuiabana	8714,74	71.98	64.85	68.62	7.37	8.63	12.80	24.75	79.83	66.62
		Barretos	12692,02	40.36	104.70	34.92	-	-	11.00	20.14	75.97	81.59
		Carbonífera/C. Doce	5633,15	33.56	40.36	34.05	-	-	-	-	97.80	97.23
		Manaus/A. R. Negro	12426,18	89.56	80.57	85.93	1.92	1.92	75.47	74.51	14.87	12.13
		Juazeiro	2864,72	63.06	19.56	58.10	-	-	27.49	26.48	70.17	71.58
		Petrolina	5049,63	64.48	29.93	57.59	11.66	15.04	65.07	62.12	20.43	19.53
	High Complexity	Baixada Cuiabana	399.53	15.77	57.81	3.78	0.87	1.84	82.66	47.16	16.48	51.00
		Barretos	1389,70	1.58	218.95	2.07	-	-	-	-	-	-
		Carbonífera/C. Doce	62.02	0.47	10.67	0.64	-	-	-	-	-	-
		Manaus/A. R. Negro	135.63	49.50	23.85	34.42	4.06	5.53	95.04	94.24	0.90	0.23
		Juazeiro	89.10	8.74	17.15	12.60	-	-	54.47	96.41	45.53	3.59
		Petrolina	108.58	40.89	28.93	56.15	10.28	2.83	85.54	96.90	4.18	0.27
Hospital Assistance	Medium Complexity	Baixada Cuiabana	64.53	44.95	73.36	57.55	11.78	13.45	12.02	10.70	76.20	75.85
		Barretos	80.09	16.65	67.66	9.80	-	-	18.88	16.39	80.21	82.86
		Carbonífera/C. Doce	24.71	3.72	16.62	2.78	-	-	-	-	100.00	100.00
		Manaus/A. R. Negro	44.97	97.33	41.51	97.40	4.57	4.50	90.35	91.93	5.09	3.58
		Juazeiro	53.72	59.35	39.32	51.65	-	-	30.61	50.82	67.75	46.75
		Petrolina	52.89	97.04	40.94	97.97	23.83	29.19	68.79	66.15	4.92	2.63
	High Complexity	Baixada Cuiabana	6.07	13.89	31.25	6.91	11.93	8.95	38.75	42.84	49.32	48.21
		Barretos	21.34	0.16	89.07	0.03	-	-	-	-	-	-
		Carbonífera/C. Doce	-	-	-	-	-	-	-	-	-	-
		Manaus/A. R. Negro	2.49	80.49	10.63	57.11	7.24	7.03	92.76	92.97	-	-
		Juazeiro	0.78	50.41	4.16	27.06	-	-	100.00	100.00	-	-
		Petrolina	1.68	81.50	5.50	50.96	45.32	48.00	54.68	52.00	-	-

Health region	Spec/inhab.		% Spec. in SUS	Legal sphere (attenda at SUS)				Conc. Pole
Health region	TotalSUS	SUS	% Spec. in SUS	Fed.	St.	City	Priv	Conc. Pole
Baixada Cuiabana	13.72	7.70	56.11	17.3	7.8	34.1	40.7	94.87
Barretos	16.30	14.00	85.61	-	10.5	21.3	62.2	72.36
Carbonífera/C. Doce	4.64	2.60	56.08	-	-	78.3	21.7	64.55
Manaus	8.66	7.16	82.73	6.1	41.1	15.8	36.9	98.93
Juazeiro	4.66	3.56	76.34	-	19.6	41.8	38.1	94.09
Petrolina	8.43	4.29	50.85	11.9	44.3	15.7	28.1	96.12

	Health region (City.)	Medium Complexity		High complexity
	Health region (City.)	Quantity	Expenditures	Quantity	Expenditures
Ambulatory Assistance	Baixada Cuiabana (Cuiabá)	78.60	82.07	92.51	89.68
	Barretos (Barretos)	56.17	67.14	96.60	96.00
	Carbonífera (Camaquã/Guaíba)	56.75	61.28	97.57	97.72
	Manaus (Manaus)	95.84	96.63	100	100
	Juazeiro (Juazeiro)	79.69	86.21	100	100
	Petrolina (Petrolina)	91.04	90.58	100	100

Hospital Assistance	Baixada Cuiabana (Cuiabá)	79.80	82.40	94.54	96.98
	Barretos (Barretos)	59.75	77.19	99.78	99.96
	Carbonífera (Camaquã/Guaíba)	56.61	62.28	-	-
	Manaus (Manaus)	95.26	97.11	100	100
	Juazeiro (Juazeiro)	66.21	77.90	100	100
	Petrolina (Petrolina)	92.66	95.99	100	100

	Categories of analysis	Health Regions
	Categories of analysis	Baixada Cuiabana (MT)	Barretos -North and South (SP)	Carbonífera/Costa Doce (RS)	Manaus/Alto Rio Negro (AM)	Petrolina (PE)/ Juazeiro (BA)
Degree of influence of providers	High degree of influence on health decisions	Public and private	Public and private	Public and private	Public	Public

Degree of dependence of specialized services	High degree of dependence on medical consultations	Public and private	Public	Public and private (outside the health region)	Public	Public and private
	High degree of dependence on diagnostic tests	Public and private sectors	Private	Private	Public and private	Public and private
	High degree of dependence of hospitalizations	Public	Private	Private	Public	Public

Sufficient/adequate offering and logistics system	Sufficiency/adequacy of offering MAC^* * Sufficiency in offering: specialized consultations, general hospital beds, beds for elective procedures, neurosurgery and cardiac surgery, adult ICU, neonatal ICU, Support Service for Diagnosis and Therapy (SADT) of medium complexity, Support Service for Diagnosis and Treatment (SADT) of high complexity.	Insufficient and inadequate	Insufficient and inadequate Exception: general hospital beds and SADT of MC.	Insufficient and inadequate	Insufficient and inadequate	Insufficient and inadequate
	Sufficient physicians in the region	Insufficient	Insufficient	Insufficient	Insufficient	Insufficient
	Sufficient logistical system fund^ Logistics System: medicines supply (SAF), computerized system for health services organization, central appointments for specialized consultations, central regulation for hospital beds, sanitary transport, tele-health.	Sufficient Exception: computerized system	Sufficient Exception: computerized system	Sufficient Exception: computerized system and sanitary transport	Sufficient	Sufficient Exception: computerized system

Types of regional conflicts	Agents involved in intergovernmental conflicts	Pole City, other cities in the region, the State Department of Health (SES)	Pole City, other cities in the region, the State Department of Health (SES) and Ministry of Health (MS)	Pole City, other cities in the region	Pole City, other cities in the region, the State Department of Health (SES) and Ministry of Health (MS)	Pole City, other cities in the region, the State Department of Health (SES), Ministry of Health (MS),cities outside the region
Types of regional conflicts	Agents involved in public-private conflicts	Public managers, private provider of SUS	Public managers, private provider of SUS	Public managers, private provider of SUS	Public managers, private provider of SUS	Public managers, private provider of SUS, health plans

Governance Arrangements	Health Regions
Governance Arrangements	Baixada Cuiabana (MT)	Barretos -North and South (SP)	Carbonífera/Costa Doce (RS)	Manaus/Alto Rio Negro (AM)	Petrolina (PE)/ Juazeiro (BA)
A multilevel Interdependence of functions and resources among various governmental entities with predominance sphere of the State and/or city in the provision and expenditures with MAC	Governmental interdependence with predominance of the city sphere	Governmental interdependence with predominance of the city sphere	Governmental interdependence with predominance of the city sphere	Governmental interdependence with predominance of the state sphere	Governmental interdependence with predominance of the state and city sphere
Hybrid Elevated dependence and/or in public and/or private provision and expenditures with MC and AC at SUS and high degree of influence of public and/or private providers in the decisions in the health region	Elevated public dependence in MC and private AC, with a high degree of public and private influence	Elevated private dependence in MAC, with a high degree of public and private influence	Elevated private dependency in MAC, with a high degree of public and private influence	Elevated public dependence in MAC, with a high degree of public influence	Elevated public dependence in MAC, with a high degree of public influence
Polarized Concentration of production and relative expenditures on MAC assistance from SUS in pole city and insufficient offering of MAC and medical specialists in the region Typology of regional governance arrangements in health	More than 80% of the provision and expenditures and 95% of medical specialists focused in the pole city with insufficient offering in the region	More than 55% of the provision and expenditures and 70% of medical specialists focused in the pole city with insufficient offering in the region	More than 55% of the provision and expenditures and 65% of medical specialists focused in the pole city with insufficient offering in the region	More than 95% of the provision and expenditures and 95% of medical specialists focused in the pole city with insufficient offering in the region	More than 65% of the provision and expenditures and 90% of medical specialists focused in the pole city with insufficient offering in the region
	Type 1: governmental interdependence with strong participation of the city sphere of the regional pole and public and private providers in health decisions in the region.	Type 1: governmental interdependence with strong participation of the city sphere of the regional pole and public and private providers in health decisions in the region	Type 1: governmental interdependence with strong participation of the city sphere, of the regional pole and public and private providers in health decisions in the region	Type 2: governmental interdependence with strong participation of the state sphere of the regional pole and public providers in health decisions in the region	Type 3: governmental interdependence with strong participation of the city and state sphere of the regional pole and public providers in health decisions in the region

Instituto de Medicina Integral Prof. Fernando Figueira Rua dos Coelhos, 300. Boa Vista, 50070-550 Recife PE Brasil, Tel./Fax: +55 81 2122-4141 - Recife - PR - Brazil
E-mail: revista@imip.org.br

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