SUS management in interstate health regions: assessment of the government’s capacity

Aleluia, Ítalo Ricardo Santos; Medina, Maria Guadalupe; Vilasbôas, Ana Luíza Queiroz; Viana, Ana Luiza D’Ávila

doi:10.1590/1413-81232022275.10392021EN

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FREE THEMES • Ciênc. saúde coletiva 27 (05) • May 2022 • https://doi.org/10.1590/1413-81232022275.10392021EN copy

SUS management in interstate health regions: assessment of the government’s capacity

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

This study displays an assessment of SUS management in a Brazilian interstate health region. An evaluative study was conducted with levels of regional analysis and data production, combining interviews with key informants and documentary analysis. Sources and data were compared and linked to analytical categories of the Government Triangle, showing a cutout of the outcomes and the government’s capacity assessment. There is a low capacity for government in interstate health regions when managers and co-management spaces are unable to influence regional political decisions, limiting themselves to normative and ratifying government strategies. Disparities in the management capacity among the border states prevent the sustainability of coordinating state decision-making goals, exposing that management strategies are not enough to institutionalize interstate regionalization. There is a predominance of low SUS governance capacity in interstate health regions, and its political pattern becomes an unclear project restricted to the ideological level. The broad documentary appreciation with the use of powerful theoretical referential are methodological contributions of this research for the political analysis of SUS management in spaces that were the least examined, such as interstate borders.

Key words:
Unified Health System; Regional Health Planning; Health Policy

Analytical categories	Definition	Operationalization	Detailing
Government project	Set of ideas, proposals, objectives or forecast of actions of the actor(s) that govern(s).	Ideas, proposals, objectives and actions thought and/or elaborated by the actor(s) that govern for the political design and dynamics of the RIS.	Previous situation that stimulated the first proposals of conformation of the regional design; characteristics of decision-making processes for the formulation of regional political design; objectives and axes of regional design; ideas and proposals for organizing health services; ideas and proposals for inter-federal articulation and regional management; correspondence between the proposals idealized for the region and the proposals of the federative entities, from the perspective of the actor(s) that govern the Region.
Governability	Degree of control of the actor(s) that govern(s) the relevant and decisive variables for their government project.	Main political aspects (degree of autonomy and type of political support received by the actor(s) that govern(s) the regional space) that represented obstacles or facilities for the realization of the ideas, proposals and objectives idealized for the RIS.	Critical points that made it impossible to comply with the proposals for the organization of services and management of the RIS; achieved and unachieved proposals in relation to the RIS project; actions and proposals for less and greater governance; correspondence between the actions thought and the goals devised by the federations for the region; facts that represented alliance or opposition to the proposals of the actor(s); correspondence between interstate decisions and statewide decisions.
Governing	Leadership capacity, skills, methods, techniques or expertise of a social actor (individual, group of individuals or an organization), to lead, direct, maneuver and overcome difficulties to achieve a given project.	Strategies and driving capacity of the actor(s) to implement the regional design and circumvent the critical points of implementation of the idealized proposals for RIS.	Institutionality of regional and interstate inter-management commissions to operationalize the political design of the interstate region and circumvent its implementation obstacles; management capacity of the State Health Departments for the integration of planning, agreement, management and regulation of access in the RIS; ability to articulate decisions between states for the implementation of health actions and services in the interstate territory.

Evidence	Excerpts
Absence of strategies by the Inter-management Commissions for inter-federative articulation and implementation of an interstate health policy	“Then, in this discussion of the network, they thought about interstate integrated planning, an integrated budget, but it seems that it did not work. It didn’t manage to plan an interstate PPI; an interstate budget” (Interstate Regulation Manager).
Institutional dynamics centered on the municipal at the expense of the interstate	“However, in my perception, we are still very much in the perception of the local focus. The municipality would have to see the implementation of that service from a network perspective or from a regionalization perspective. We have difficulties with the management because it does not want to open up to the regionalized service, even having the profile” (Regional Health Manager I).
Low institutionality of the CIRs fostered by the lack of support from the states	“Several meetings were scheduled and canceled, but the fact is that they did not take place and there was this evasion by the states. Bahia, in particular, evaded decisions a lot, in the sense of knowing that there were some obstacles that he would need to advance in some services” (Regional Health Manager).
Asymmetries of power between representations in the CIRs	“Petrolina has a much greater political force. Petrolina has, from the A family, a mayor, who is a mayor and a state deputy, he left his charge of deputy to be mayor of the city. There is a federal deputy who is now a minister and there is a senator, only from Petrolina. There are two more federal deputies. So, this whole federal issue, of course, makes it easier for the municipality” (Representative of Economic Group I).
Low institutionality and stagnation of CRIE activities	“I think the managers lost, as I told you, they discredited the collegiate. Because as there is no resource, there is no new resource, credibility was lost and managers had no interest in meeting, the network was collapsing and services that were implemented at the time there in 2011 were closing” (Municipal Health Secretary V).

Evidence	Excerpts
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).
Asymmetrical capacity for regional management among the	“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).

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[1] Collaborations

ÍRS Aleluia collaborated in the design of the project, analysis and interpretation of data; in the writing of the article and its critical review of the intellectual content; in the review and final approval of the version to be published and in the guarantee of its integrity and accuracy. MG Medina collaborated in the design of the project, analysis and interpretation of data; in the writing of the article and its critical review of the intellectual content; in the review and final approval of the version to be published and in the guarantee of its integrity and accuracy. ALQ Vilasbôas collaborated in the analysis and interpretation of data; in the writing of the article and its critical review of the intellectual content; in the review and final approval of the version to be published and in the guarantee of its integrity and accuracy. ALD Viana collaborated in the writing of the article and its critical review of the intellectual content; in the review and final approval of the version to be published and in the guarantee of its integrity and accuracy.