Abstract
OBJECTIVE To analyze the dynamics of operation of the Bipartite Committees in health care in the Brazilian states.METHODS The research included visits to 24 states, direct observation, document analysis, and performance of semi-structured interviews with state and local leaders. The characterization of each committee was performed between 2007 and 2010, and four dimensions were considered: (i) level of institutionality, classified as advanced, intermediate, or incipient; (ii) agenda of intergovernmental negotiations, classified as diversified/restricted, adapted/not adapted to the reality of each state, and shared/unshared between the state and municipalities; (iii) political processes, considering the character and scope of intergovernmental relations; and (iv) capacity of operation, assessed as high, moderate, or low.RESULTS Ten committees had advanced level of institutionality. The agenda of the negotiations was diversified in all states, and most of them were adapted to the state reality. However, one-third of the committees showed power inequalities between the government levels. Cooperative and interactive intergovernmental relations predominated in 54.0% of the states. The level of institutionality, scope of negotiations, and political processes influenced Bipartite Committees’ ability to formulate policies and coordinate health care at the federal level. Bipartite Committees with a high capacity of operation predominated in the South and Southeast regions, while those with a low capacity of operations predominated in the North and Northeast.CONCLUSIONS The regional differences in operation among Bipartite Interagency Committees suggest the influence of historical-structural variables (socioeconomic development, geographic barriers, characteristics of the health care system) in their capacity of intergovernmental health care management. However, structural problems can be overcome in some states through institutional and political changes. The creation of federal investments, varied by regions and states, is critical in overcoming the structural inequalities that affect political institutions. The operation of Bipartite Committees is a step forward; however, strengthening their ability to coordinate health care is crucial in the regional organization of the health care system in the Brazilian states.
Highlights
Federations represent systems of the political and territorial organization that require the combination of “self-rule and shared-rule”.4 Federal countries can be identified on the basis of institutional characteristics, including: legal arrangements, which define the government responsibilities; rules and decision-making mechanisms that incorporate territorial variables and interests; fiscal arrangements; intergovernmental transfers; formal and informal arrangements between vertical and horizontal governments.[10,11,18]The federal institutions influence and are influenced by social policies through relations that vary according to regional and temporal contexts.[10]
The federation legal framework has been historically relevant for health care, it assumed greater importance after the promulgation of the 1988 Constitution, which established a public and universal Unified Health System (SUS), guided by the establishment of administrative and political decentralization, with a single health authority at each government level
Dynamism in intergovernmental relations was achieved by government adherence to the Health Care Pact and the emphasis on regionalization
Summary
Federations represent systems of the political and territorial organization that require the combination of “self-rule and shared-rule”.4 Federal countries can be identified on the basis of institutional characteristics, including: legal arrangements, which define the government responsibilities; rules and decision-making mechanisms that incorporate territorial variables and interests; fiscal arrangements; intergovernmental transfers; formal and informal arrangements between vertical and horizontal governments.[10,11,18]The federal institutions influence and are influenced by social policies through relations that vary according to regional and temporal contexts.[10]. Federations represent systems of the political and territorial organization that require the combination of “self-rule and shared-rule”.4. Federal countries can be identified on the basis of institutional characteristics, including: legal arrangements, which define the government responsibilities; rules and decision-making mechanisms that incorporate territorial variables and interests; fiscal arrangements; intergovernmental transfers; formal and informal arrangements between vertical and horizontal governments.[10,11,18]. The federal institutions influence and are influenced by social policies through relations that vary according to regional and temporal contexts.[10] This influence is expressed through the emergence of new elements and definition of strategies and shared political processes.[12]. The formulation and implementation of social policies in federations require federal coordination strategies, for example, intergovernmental negotiation committees.[1,2]. The federation legal framework has been historically relevant for health care, it assumed greater importance after the promulgation of the 1988 Constitution, which established a public and universal Unified Health System (SUS), guided by the establishment of administrative and political decentralization, with a single health authority at each government level
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