State inequality of interfederative pact strategies |
“The PPI was a little more complicated, because the PPI of the State of Pernambuco is, let's say, frozen since 2005 [...] for us there is no discussion. It is not dynamic in Pernambuco. The PPI in Bahia, on the other hand, is more dynamic. There's a system, they can... Even with a budget, let's say, static, they can somehow talk [...]” (Interstate Regulation Manager I). |
Absence of strategies by the state secretariats to institute revisions of inter-federative agreements |
“There was no reason why, to this day, the PPI of the state of Pernambuco we do not discuss. Now it was placed for people who needed to be taken back. The following is done: the municipalities only replicate the amounts they have received since 2005” (Interstate Regulation Manager II). |
“Because then, what you have to program, is the same resource. It didn't advance, you discuss programming with the same resource you have. The State of Bahia is now reviewing the PPI since 2012. There in the manual, the first thing it says is saying this, that there is no new resource [...]” (Municipal Regulation Manager). |
Asymmetrical capacity for regional management among the |
“Pernambuco, I really like the way they work, because they are regionalists. All of Pernambuco is regionalist. Unlike Bahia, which is municipalist. The refusal goes to the municipality and the municipality manages with this amount. Not the State, the State of Pernambuco does not release the high complexity resource” (Interstate Regulation Manager II). |
“In the management of Pernambuco, GERES works effectively with the municipalities to monitor, manage, identify difficulties and solve them. Management is efficient. On the Bahia side, we have a Regional Health Center. There is one person for three health micro-regions and who has no political power. He alone will do nothing; You don't have the ability to know the entire health region, right? So, this is a very important differential” (Interstate Bed Regulation Manager II). |
Recentralization of regional management strategies in Bahia |
“The Regional Health Centers were so emptied that today they are just relays of processes, from here at the secretariat. The central level decides. They are work makers. They are task workers” (Regional Health Base Manager II). |
State management strategies influenced by technical action and party-political action |
“You go to a meeting with Pernambuco and Bahia. Pernambuco shows population statistics, population by beds, services, a whole picture of actions. It has a numerical and situational observation of each place, he has by municipality, by microregion; he demonstrates a knowledge if not of needs, but at least of what is being done. We realize that if they have Bahia, they don't, but I believe they don't, because if they did, they would show a demonstration of knowledge and knowledge. It is as if Bahia had a very political and technically ineffective role. It (Bahia) is very political, but little technical” (Hospital Director II). |
Different state strategies for hiring personnel responsible for the management of health regions |
“In Pernambuco, the position is technical, despite being a commissioned position, it is open to competition. It is a commissioned position, but there are some selection processes. It has an open call for everyone, there are prerequisites with four stages, one of which was the elaboration of an action plan for a health region, focusing on the main indicators - first stage and eliminatory. Then there was a curriculum analysis and an interview” (Regional Health Manager I). |
Limited management capacity to regulate beds on the interstate border |
“CRIL has no difficulty in the regulation process. The problem is the shortage of vacancies, as we have no guarantee that the Juazeiro Regional Office will perform the trauma-orthopedic surgeries that were contracted. We have no way of expanding SOTE's surgeries; resume surgeries at the hospital in S. do Bonfim; regular patient for the CHESF hospital in Paulo Afonso, etc. If there is no service, there is no way to regulate it” (Interstate Regulation Manager II). |
Absence of strategies to implement a system to regulate interstate access |
“So what happens? We have a system that is national, which is SISREG, so everyone was trained, everyone uses it. However, let's say, we need to regulate a nebulization, which we don't do here yet. So, when the HU, which is a high-complexity reference, asks us, we include both in Bahia and Pernambuco, in the state centrals, which are other systems. So, in Bahia we use SUREN and in Pernambuco we use SISREG for ICU beds, but for urgency and emergency cases it is by email. So we use several systems and they don't talk to each other, there's no interaction per unit. So, this is also a hindrance to the regulation process here” (Municipal Regulation Manager). |