Abstract
The study analyzes regional Brazilian Unified National Health System (SUS, in Portuguese) governance arrangements according to providers' legal sphere and the spacial provision of middle and high-complexity services. These arrangements express the way in which State and health system reforms promoted the redistribution of functions between governmental and private entities in the territory. We carried out an exploratory study based on national-scope secondary data from 2015-2016. Using cluster analysis based on the composition of the provision percentages of the main providers, we classified 438 health regions. In middle-complexity health care, municipal public providers (outpatient) and private philanthropic providers (hospital) predominate. In high complexity provision, philanthropic and for-profit providers (outpatient and hospital) predominate. Middle-complexity provision was recorded in all health regions. However, in 12 states, more than half of the provision is concentrated in only one health region. High-complexity provision is concentrated in state capital regions. Governance arrangements may be more or less diverse and unequal, if different segments and regional concentration levels of middle and high-complexity provision are considered. The study suggests that the convergence between decentralization and mercantilization favored re-scaling of service provision, with increase in the scale of participation of private providers and strengthening of reference municipalities. Governance arrangement characteristics challenge SUS regionalization guided by the collective needs of the population.
Highlights
In the international public policy literature, governance has been a frequent object of investigation, with different meanings, purposes and approaches [1,2,3].Especially in Latin America, Marques 4 identifies an association between the concept and two distinct forms of government organization
We did not include the medication group in this study for a few reasons: (a) medication dispensation is not comparable to the other procedures; (b) in 15 states, this procedure only takes place in the capital; (c) it falls under state responsibility in almost all municipalities and health regions; (d) since this group represents 95% of all procedures, its inclusion would make it impossible for us to apprehend the diversity of actors who participate in the provision of the others
The degrees of regional concentration of production are related to SUS governance arrangements
Summary
In the international public policy literature, governance has been a frequent object of investigation, with different meanings, purposes and approaches [1,2,3].Especially in Latin America, Marques 4 identifies an association between the concept and two distinct forms of government organization. In the international public policy literature, governance has been a frequent object of investigation, with different meanings, purposes and approaches [1,2,3]. Though they point to different perspectives, in both meanings, the “State is viewed with suspicion”. These interpretations favor the dissemination of prescriptive views on governance, as synonymous with “good government”, one that is efficient, horizontalized and democratic. They contributed to disseminating “fictions regarding public policies and the politics that surround them” 4 They contributed to disseminating “fictions regarding public policies and the politics that surround them” 4 (p. 15), such as using governance as an alternative arrangement to traditional government institutions and the necessarily positive meaning attributed to governance
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