Inter-municipal cooperation based on Institutional Collective Action: the effects of public health consortia in Brazil

Cooperación intermunicipal basada en Institutional Collective Action: los efectos de los consorcios de salud pública en Brasil

Abstract

This article adopts institutional collective action (ICA) to verify the difference in collective effects when observing inter-municipal cooperation arrangements to provide public health in Brazil (public health consortia). The study compares municipalities that joined consortia in 2009/2010 and municipalities that did not join until 2015. The analysis estimated collective effects of public health consortia and how they relate to contextual variables of policies in this area in the country. The methodology is longitudinal-retrospective deductive research, using the difference-in-differences statistical technique. The results show that municipalities engaged in local inter-municipal cooperation to provide public health in Brazil improved the services in terms of outpatient appointments and the number of primary health care (PHC) consultations, as well as reducing infant deaths.

Keywords:
inter-municipal cooperation; institutional collective action; public consortium; health

Resumen

El objetivo del artículo es verificar la diferencia en los efectos colectivos entre los municipios que decidieron adherirse a un consorcio de salud pública en 2009/2010 y los municipios que no se adhirieron a los consorcios públicos hasta 2015. Se utilizó la Institutional Collective Action (ICA) para estimar los efectos colectivos y verificar su relación entre variables contextuales de la política de salud en Brasil, a través de consorcios públicos. Se trata de una investigación deductiva longitudinal-retrospectiva, que utiliza la técnica estadística denominada “diferencias en diferencias”. Los resultados muestran que los municipios que participan en un consorcio de salud pública en Brasil mejoran la prestación de servicios en términos de número de consultas externas y número de consultas médicas, además de reducir el número de muertes infantiles.

Palabras clave:
cooperación intermunicipal; acción colectiva institucional; consorcio público; salud

Resumo

O objetivo do artigo é verificar a diferença de efeitos coletivos entre os municípios que decidiram aderir a algum consórcio público de saúde em 2009/2010 e os municípios que não aderiram a consórcios públicos até 2015. Utilizou-se o Institutional Collective Action (ICA), para estimar os efeitos coletivos e verificar a sua relação entre variáveis contextuais da política de saúde no Brasil, via consórcios públicos. Trata-se de uma pesquisa dedutiva de tipo longitudinal-retrospectiva, com o uso da técnica estatística denominada “diferenças em diferenças”. Os resultados mostram que municípios que participam de consórcio público de saúde no Brasil melhoram a oferta de serviço em número de atendimentos ambulatoriais e número de consultas médicas, além de reduzir o número de óbitos infantis.

Palavras-chave:
cooperação intermunicipal; institutional collective action; consórcio público; saúde

1. INTRODUCTION

This article verifies the difference in collective effects between Brazilian municipalities that joined inter-municipal cooperation arrangements to provide public health - public health consortia - in 2009/2010, and the municipalities that did not join until 2015, adopting the institutional collective action (ICA) framework.

Collective action theories have been used extensively to identify drivers for cooperation. Case studies based on such theories analyse the issues related to the actors’ context and region in order to understand the emergence of cooperative arrangements (Matos & Dias, 2012; Meza, Grin, Fernandes & Abrucio, 2018; Oliveira & Ganzeli, 2013; Wolfart, Silva & Schmidt, 2013). The ICA framework (Feiock, 2004, 2007, 2013) assumes that in regions of fragmented governments - multiple governments interacting with each other to provide common public services - local authorities can cooperate, express interests, share resources, and commit to collective action rules in various policy areas.

Studies have examined the effects of inter-municipal cooperation (Bel & Warner, 2015; Dollery, Grant & Kortt, 2012; Henderson, 2015; Lago-Penas & Martinez-Vasquez, 2013; Tomkinson, 2007), particularly in Europe (Henderson, 2015; Hulst & Monstfort, 2007), North America (Holzer & Fry, 2011), and Australia (Dollery et al., 2012). However, it is possible to observe numerous studies in other parts of the globe, such as in South Korea (Kim, Andrew & Jung, 2017), and China (Yi & Cui, 2018).

In Brazil, inter-municipal cooperation is a strategy used more often in the areas of solid waste and health care. Our choice here to focus on Brazilian health policies consider three characteristics. The first is the design of the country’s national health system (SUS), which has allowed, since its very first legislation, the establishment of interlocal cooperation to provide services (Lei nº 8.080, de 19 de setembro de 1990). The second characteristic is the fact that the system’s organisational principles lead to creating mechanisms to decentralise and regionalise service provision (Aguiar, 2015; Dourado & Elias, 2011). And finally, the Law on Public Consortia (Lei nº 11.107, de 06 de abril de 2005) which establishes that “Public consortia, in the health area, shall comply with the principles, guidelines and norms that regulate the Unified Health System - SUS.

The dissemination of inter-municipal cooperation arrangements in the country is attributed to the Law on Public Consortia, enacted in 2005 (Abrucio & Sano, 2013). However, it was in 2009 and 2010, according to the National Confederation of Municipalities (Confederação Nacional dos Municípios [CNM], 2018), that the highest number of municipalities joined these initiatives to provide services in health. Finally, observing the end of 2015 shows the differences between the two groups with enough time for the treatment group to be exposed to the experience of public health consortia.

2. INSTITUTIONAL COLLECTIVE ACTION

The environment for cooperation is largely based on the perception of collective gain associated with the interest of public agents. For certain public policies (and collective goods), public agents may seek local partnerships and cooperative agreements inspired by other governments’ collective actions that proved to be successful (Kim et al., 2017). Therefore, it is crucial to understand the collective and individual interests involved in cooperation among municipalities to create coordination mechanisms that extend collective actions and measure their effects. The literature indicates that the provision of public services gains effectiveness with knowledge sharing and economies of scale (Bel, Fageda & Mur, 2014; Bel & Warner, 2015; Hulst & Montfort, 2007; Silvestre et al., 2019; Voorn, Genugten & Thiel, 2019). Research analysing European countries corroborate this finding, demonstrating that inter-municipal cooperation reduces costs based on the economy of scale (Niaounakis & Blank, 2017).

Several theories address collective action and its dilemmas: overfishing problem (Gordon, 1991); the tragedy of the commons (Hardin, 1968); logic of collective action (Olson, 1971); common-pool resource theory (Ostrom, 1990, 2005, 2011); and institutional collective action (Feiock, 2004, 2007, 2013).

This study focuses on the institutional collective action (ICA) framework (Feiock, 2004, 2007, 2013; Tavares & Feiock, 2018). This approach assumes that individuals act collectively based on their interests, aiming to obtain benefits at a lower cost than if pursuing the same benefits individually; or to promote political, economic, and social goals and preferences, influenced by contextual and regional aspects.

The intergovernmental approach may be understood as the combination of structural and contextual aspects that drive the operation of government institutions and how government actors relate. Feiock (2004, 2007) highlights the importance of interactivity between the actors but adds contextual institutional elements of the region where the collective action takes place. The ICA is comprised of four dimensions: (1) characteristics of communities; (2) structure of policy networks; (3) political institutions; (4) transaction characteristics of goods.

First, the characteristics of communities forge the actors’ preferences regarding the collective goods and contribute to identifying the potential gains involved. These characteristics of the context also affect the delivery of public services. They can be demographic and economic (Aly, Reis, Carneiro, & Moraes, 2017; Bastos, Santos, Costa & Capilheira, 2011; Oliveira, Freitas, Silva & Carvalho, 2011; Viacava, Oliveira, Carvalho, Laguardia & Bellido, 2018), social (Politi, 2014; Thum, Baldisserotto & Celeste, 2019), and fiscal characteristics (Bel et al., 2014; Hefetz & Warner, 2011; Lima & Silveira, 2017; Rossi, Chaves, Almeida, Santos & Santana, 2018).

The second element is “the structure of policy networks”. The assumption is that, when local authorities engage in several dyadic relations with each other, they constitute, at the macro level, a regional government in the form of a “policy network”. Therefore, over time, this regional policy network builds a trustworthy reputation among partners with potential for cooperation (Carr, Hawkins & Westberg, 2017; Feiock, 2007). The social capital necessary to foster cooperation is created from the strengthening of the bonds among actors, as identified by Percoco (2014). The author studied the case in Italy, showing that a large social capital and a history of collaboration increased the likelihood of a strategic plan for collaboration in Italian municipalities.

The federal and state legislation shape the “characteristics of political institutions”, which guide elected officials. These institutions are connected to interlocal cooperation based on their ability to influence decision-making processes. However, actors play a role in creating cooperative alliances with other local governments, differing in their institutional capacity and ability to negotiate (Feiock, Krause & Hawkins, 2017)

The “transaction characteristics of goods” refers to the characteristics of the services provided through the cooperation arrangement, i.e., the collective goods the individuals pursue. According to Feiock (2007), the particularities of the collective problems influence the way in which actors seek solutions. Thus, public problems with collective solutions and low transaction costs are more likely to be the object of collective agreements. This correlation between transaction costs and the likelihood of collective agreement is inversely corroborated in the study by Johansson, Niklasson and Persson (2015) in Sweden. The authors observed that collective action is rare in an environment of high transaction costs, even though the collective initiative is designed through a bottom-up strategy, i.e., contemplating the interests of all participants and under their leadership.

Among the theories addressing collective action mentioned before, Feiock’s (2007) ICA showed to have the key elements to help to explain interlocal cooperation, since the theoretical framework integrates currents of thought from economic sciences, public administration, political science, and social sciences. In addition, the many studies using ICA in Europe (Tavares & Feiock, 2018; Voorn et al., 2019), China (Yi and Cui 2018), and North America (Feiock et al., 2017), have formed a research agenda based on this framework (Scholz, Feiock & Ahn, 2006). Finally, studies adopting ICA are still scarce in Brazil, where the work by Fernandes, Pinheiro, Nascimento and Grin (2020) analysing how contextual variables influence local governments’ decision to engage in inter-municipal consortia designed to provide waste services in metropolitan regions, stands out.

3. INTER-MUNICIPAL COOPERATION ARRANGEMENTS - PUBLIC CONSORTIA

The interdependence among administrative units is one of the main attributes of a federation (Anderson, 2009). The political life in a federation is characterised by the interest of all public agents to influence the outcomes observed in other jurisdictions, which is an element that gains complexity since federated units have administrative autonomy.

Cruz, Araújo and Batista (2012) argue that the cooperation among local, state, and national governments in a given territory is built based on the intergovernmental relations already in place and may contribute to minimising the problems within such relations. This type of cooperation entails strengthening ties among the public agents; knowledge about the common problem, the territory, and the regional characteristics; clear notion of the interests involved, and especially, knowledge of the resources available to implement the collective action.

According to Teles (2016 “as cited in Teles & Swianiewicz, 2018, p. 2), inter-municipal cooperation is amid a critical “paradigm change or […] territorial instability. It is not just a makeover: it is a profound, yet new, reshaping of structures, institutions, roles, competencies, borders and scale”.

In this article, inter-municipal cooperation is understood as a pact among municipalities, made in order to provide public services (Bel & Warner, 2015; Citroni, Lippi & Profeti, 2013). Inter-municipal cooperation may vary according to the number of local governments and the type of public service (Blåka, 2017; Citroni et al., 2013). Therefore, regional contextual characteristics may influence the various formats of inter-municipal cooperation.

Intergovernmental cooperation (or public consortia) is a strategy that has gained strength in the face of the “municipal dilemma” when Brazilian federalism grants autonomy to local governments. Municipalities assumed responsibilities regarding the provision of services to meet constitutional obligations, but the design of Brazilian federalism has left local governments with a very low fiscal capacity (Abrucio, Filippim & Dieguez, 2013; Abrucio, Sano & Sydow, 2010; Nascimento & Fernandes, 2015). Brazilian municipalities have low capacity to fund obligations even when considering their entire revenues, formed of locally collected taxes, the distribution of taxes collected at the federal and state levels, and the federal and state transfers received to fund locally implemented social policies as provided in the constitution.

The heterogeneity among municipalities in a vast country such as Brazil results in some local governments facing more financial difficulties than others, revealing different economic, political, and administrative capacities. Studies have demonstrated that municipalities with higher GDP tend to offer better public services (Aly et al., 2017; Bastos et al., 2011; Oliveira et al., 2011; Viacava et al., 2018), and municipalities with high poverty rates face greater difficulties to serve the population. Social problems are different across the country, requiring solutions that vary according to each region and municipality. One of the solutions that has been adopted nationwide is the establishment of inter-municipal cooperation arrangements or public consortia.

A public consortium is an organisational arrangement provided in Brazilian law, by which local, state of federal governments decide to act collectively to solve problems of common interest and in specific territories. These arrangements address problems that would need more resources or could not be solved if a government had to address them alone.

Research by Abrucio and Sano (2013) highlights ten factors that explain the emergence of public consortia in Brazil: active political leadership; fear of the tragedy of the commons; policy design; induction of state and federal governments; initiative from local membership organisations; territorial awareness of the collective action (social capital); previous legacies of cooperation; regional political pacts; activities of civil society organisations; and laws favouring membership organisations and the territory.

In the health area, the institutional design of the SUS induces cooperation through public consortia through inter-federative coordination, potentially contributing to the distribution of collective benefits in a decentralized manner and without compromising the autonomy of entities (Arretche, 2012; Holzinger, 2003).

The study by Grin and Abrucio (2017) identified that issues such as social inequality and funding significantly influenced the local governments’ likelihood to join public health consortia in Brazil in 2011. The authors revealed that the local governments joined such arrangements to reduce costs and gain economies of scale. These results encourage more profound study on the influence of managerial mechanisms in the decision to engage in public health consortia, considering the previous literature and the fact that the design of the Brazilian national health system (SUS) privileges regionalisation of health policies to increase effectiveness.

Grin and Abrucio (2017) synthesise the literature on intermunicipal cooperation/public consortia into four main approaches: 1) Formal (legal, organisational, and managerial); 2) Economic (scale, efficiency, and rationality); 3) Political (intergovernmental coordination and cooperation, responsiveness, and accountability); and 4) Managerial (expansion of management capacity and regional planning).

The study by Grin and Abrucio (2017) identified that issues such as social inequality and funding significantly influenced the local governments’ likelihood to join public health consortia in Brazil in 2011. The authors revealed that the local governments joined such arrangements to reduce costs and gain economies of scale. These results encourage more profound study on the influence of managerial mechanisms in the decision to engage in public health consortia, considering the previous literature and the fact that the design of the Brazilian national health system (SUS) privileges regionalisation of health policies to increase effectiveness, efficiency and rationality.

Second Nicoletto, Cordoni and Costa (2004), public consortia have the potential to optimize health services. However, the effects on public health have other intercurrent issues, called Social Determinants of Health - DSS (Organização Mundial de Saúde [OMS], 2008), which are all those social, economic, cultural, ethnic/racial, psychological, and historical conditions that directly or indirectly influence the occurrence of health problems.

For Zioni and Westphal (2007), the level of health results from social stratification, which determines the territorial context, as well as the distribution of essential elements for health: material, biological, psychosocial and behavioral. In other words, socioeconomic inequalities classify the position that the individual occupies in social stratification and determines the access to factors of good or bad health, leading to an increase in health inequities.

In this sense, the model by Dahlgren and Whitehead (2007) was proposed to estimate the DSS from the most individual to the most comprehensive scope, called macrodeterminants. And the latter are used in this research, especially regarding the dimensions: demographic, economic and social.

4. METHODOLOGY

The study adopts a deductive-inductive, observational, and longitudinal-retrospective approach, analysing treatment and control groups (Dahlgren & Whitehead, 2007), to compare municipalities that joined public health consortia (treatment group) and municipalities that did not join these arrangements (control group).

The difference-in-differences (DID) technique was used for statistical estimation, comparing the effects in both groups. According to Peixoto, Foguel, Pinto, Lima and Barros (2016), DID is a quasi-experimental technique. The researchers’ activity is limited to collecting the data affected by exogenous forces (economic, political, social, or natural), i.e., the researchers do not interfere in the treatment of individuals.

DID consists of a double subtraction, as shown in Box 1:

BOX 1
DIFFERENCES IN DIFFERENCES - MATHEMATICAL REPRESENTATION

The reason for selecting municipalities that joined public health consortia in 2009 and 2010 is because most local governments that engaged in intermunicipal cooperation after the enactment of the Public Consortia Law (Lei nº 11.107, de 06 de abril de 2005) did so in this period (433 municipalities joined at least one public health consortium). Therefore, the period of analysis starts in 2005 (when none of the municipalities of the sample were involved in health policy consortia) and ends in 2015 (when some of the municipalities of the sample, at the treatment moment, had joined public health consortia) (Figure 1).

FIGURE 1
DIFFERENCE-IN-DIFFERENCES

The universe of the research comprises all municipalities that joined at least one public health consortium in 2009/2010 (n = 433 municipalities) added to all municipalities that had not joined any public health consortium until 2015 (n = 2,271 municipalities), totalling 2,704 municipalities. To obtain homogeneity of the analysed data, we excluded the municipalities a) with missing information in the CNM database; b) that appeared engaged in public health consortia but, according to a survey of the CNM (2018), the consortia were not active; and c) municipalities that declared to be in a consortium, but in an administrative type consortium. After this exclusion and using the propensity match score technique, the sample resulted in 1138 municipalities, 276 in the treatment group and 862 in the control group.

With the software Stata/MP® version 14. 0 we tested the assumptions of multiple regression, which were: normality (Shapiro-Wilk test, the null hypothesis is the normal distribution, p-value<0.10); homoscedasticity (Breusch-Pagan test, the null hypothesis is the presence of heteroscedasticity, p-value<0.10); no perfect collinearity (VIF test, tolerance below 10.0); and independence of error term (Durbin-Watson test, the null hypothesis is the presence of autocorrelation of the error term, p-value<0.05, the result should be approximately equal to 2) (Fávero, 2015; Hair, Black, Babin, Anderson & Tatham, 2009; Wooldridge, 2012).

The data were organised in a short-balanced panel of two periods (2005 and 2015). With these data, clustering of regressions for each dependent variable was generated, each with three models, explained below. We used the regression for panel data with random effects, which is recommended when the variation in time between individuals is considered random, therefore, preserving the differences between them (Fávero, 2015).

The regression with random effects showed heteroscedasticity, i.e., not constant variation in terms of errors, so we used the method of generalised least squares (GLS). Thus, maintaining the variances of the effects between municipalities, the mathematical expression for this modelling is:

$Y_{it}={\mathrm{}\mathrm{\beta }}_1{\mathrm{X}}_{1it}+{\mathrm{\beta }}_2{\mathrm{X}}_{2it}+{\mathrm{\beta }}_{\alpha }{\mathrm{D}}_{it-1}\cdots {\mathrm{\beta }}_k{\mathrm{X}}_{kit}+({\mathrm{\alpha }}_i+{\mathrm{\epsilon }}_{it})$ (1)

Where:

Y = dependent variable (answer)

β = parameter of coefficient

X = independent variable (explanatory)

D = dummy DID (pre-treatment - post-treatment)

k = index of variables

α = behaviour of individual effects

ε = (Robust) error term

i = index of municipalities

t = period of data collection

After performing the regressions, the interpretations followed the ‘t’ statistic tests, indicated by Fávero (2015), Hair et. al. (2009), and Wooldridge (2012), which checks the significance of each parameter of the regression model. The t-test hypotheses for the intercept (β0) are (H0: β0 = 0; H1: β0 ≠ 0); and for the parameters (βk) (H0: βk = 0; H1: βk ≠ 0). These are significant when the P-value < 0.05.

The study used the following databases: Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatísticas, 2019a, 2019b); National Treasury Secretariat (Secretaria do Tesouro Nacional, 2019); National Confederation of Municipalities (Confederação Nacional dos Municípios, 2018); Department of Informatics of the Single Health System DataSUS (Departamento de Informática do Sistema Único de Saúde Data SUS, 2019); and the Superior Electoral Court (Tribunal Superior Eleitoral, 2019). Box 2 below presents the description of the variables:

BOX 2
DESCRIPTION OF VARIABLES

BOX 2
continuation

For 2005 all municipalities were codified with DID=0, since none of them participated in a public health consortium. For 2015 the treatment group municipalities were codified with DID=1, since they joined at least one public health consortium in 2009/2010.

The general hypothesis is: contextual characteristics of municipalities contribute to explain the collective effects of health policy. These characteristics influence differently the indicators of health service provision and infant death in municipalities that join public health consortia in comparison to municipalities that do not (Feiock, 2004, 2007, 2013).

We prepared a regression table for each dependent variable, and three models were tested in each table: (1) In the first model all independent variables were included; (2) the second maintained demographic, economic, and social variables; (3) and the third maintained demographic, economic, fiscal, political, and institutional variables, allowing to test the results of fiscal stress variables and other ICA groups (‘structure of policy network’ and ‘political institutions’).

5. RESULTS AND DISCUSSION

In the first dependent variable (outpatient) the results were significant only in model 03, which excluded the social variables from the model. The demographic and economic characteristics corroborate the positions of ICA by highlighting the importance of contextual characteristics in the decision to cooperate. Fiscal and structural characteristics were also included in this model, contributing to explain the influence of the health consortium in the number of outpatient services (Table 1):

TABLE 1
REGRESSION - NUMBER OF OUTPATIENT APPOINTMENTS - 2005/2015

Group	VAR	(1) outpatient	(2) outpatient	(3) outpatient
Differences in Differences	DID	79892,386	68455,274	134813,965**
		(57401,891)	(56643,504)	(64040,772)
Demographic characteristics	pop	3,492**	3,604***	3,484**
		(1,422)	(1,327)	(1,367)
	PD/km²	975,674*	1098,273**	973,762*
		(536,160)	(522,613)	(533,634)
Economic characteristics	cap_GDP	-15659,366**	-14186,728*	-10856,764*
		(7848,367)	(8109,996)	(6550,369)
	GDP	0,406***	0,408***	0,402***
		(0,020)	(0,019)	(0,019)
Social characteristics	%poverty	-6733,788***	-9927,631***
		(2418,627)	(2805,055)
	unemployed	1686,876	2897,844
		(2044,886)	(2219,640)
	sanitation	-1,732	0,957
		(7,292)	(6,110)
Fiscal characteristics	fin_depend_	-782851,911		-100062,333
		(601707,771)		(647359,490)
	$cap_health	0,003		0,003
		(0,006)		(0,005)
	tax	1124318,137		1626147,344
		(1079771,981)		(1078661,764)
	pub_debt	-260745,702		-438736,677**
		(179936,126)		(200745,688)
Structure of political networks	other_consor	-83903,099		-77012,371
		(82540,917)		(82545,612)
Political institutions	civil servants	-1,331		4,910
		(101,833)		(101,717)
	re-election	-8520,258		-10003,042
		(26335,524)		(26779,556)
	Constant	1471713,652*	723589,389***	1401301,836*
		(775155,250)	(243065,339)	(732011,248)
	Obs	1138	1138	1138
	R²	0,966	0,965	0,966
	Wald chi²	5838,91***	5953,05***	3323,12***

• Note: Robust standard errors in brackets [*** p<0.01, ** p<0.05, * p<0.10] Source: Research data collected in 2019.

These results show that factors foreseen in the ICA influence the effects of collective benefit and support the argument that contextual aspects of fragmented governments influence the number of outpatient appointments. Above all, the results validate the hypothesis that public health consortia increase outpatient service in comparison to municipalities that did not join one.

This finding corroborates the study by Kim et al. (2017), who analysed the supply of health services through collaboration among governments in South Korea. The authors suggested that strengthening communication among governments that cooperate in providing public health policy results in better services.

Ceteris paribus, an increase in population and Gross Domestic Product (GDP) have a positive influence on the number of outpatient appointments, which was also observed in previous literature (Aly et al., 2017; Bastos et al., 2011; Oliveira et al., 2011; Viacava et al., 2018). On the other hand, the variable GDP per capita behaves oppositely to the number of outpatient appointments, leading to the conclusion that smaller municipalities with high GDP are more likely to fail in providing outpatient services.

As for social characteristics, only the variable ‘%poverty’ reduces the number of outpatient appointments, and this corroborates the theoretical propositions of Politi (2014) when the author argues that regions with higher rates of poverty are also those with greater difficulties of access to health services and other essential public services.

Among the fiscal characteristics, the variable ‘pub_debt’ indicated that indebted municipalities present a lower number of outpatient appointments, i.e., the increase in new services may be negatively affected by the indebtedness of local governments (Lima & Silveira, 2017; Rossi et al., 2018).

In Hefetz and Warner’s (2011) research, corroborated by Bel et al. (2014), fiscal stress is a community characteristic that hinders collective gains in cooperation. This condition challenges the municipalities ability to obtain new resources and establish partnerships, forcing managers to set fiscal priorities that may compromise essential areas such as health. Moreover, when considering the responsibilities of municipalities participating in arrangements as provided in Brazilian law on public consortia, those with debt problems may have difficulties to honour their financial obligations. Therefore, the negative significance corroborates the literature.

In the regression with the number of PHC consultations (consult), the difference-in-differences was significant in all models. Therefore, municipalities that joined public health consortia increased the number of PHC consultations (Table 2).

TABLE 2
REGRESSION - NUMBER OF PRIMARY HEALTH CARE CONSULTATIONS - 2005 AND 2015

Group	VAR	(1) consultation	(2) consultation	(3) consultation
Differences in Differences	DID	8470,550**	6429,556*	8364,630**
		(3535,982)	(3363,054)	(4120,295)
Demographic characteristics	pop	0,061*	0,038*	0,062
		(0,032)	(0,023)	(0,038)
	PD/km²	26,056***	27,740***	27,499***
		(9,636)	(9,640)	(10,520)
Economic characteristics	cap_GDP	-48,679	-70,759	-171,632
		(108,341)	(127,731)	(153,448)
	GDP	0,003***	0,003**	0,005***
		(0,001)	(0,001)	(0,001)
Social characteristics	%poverty	39,298	-23,024
		(103,548)	(117,727)
	unemployed	366,732	500,043
		(266,532)	(269,741)
	sanitation	1,450***	1,525***
		(0,378)	(0,540)
Fiscal characteristics	fin_depend_	-39903,742		-45393,923
		(28476,820)		(30032,886)
	$cap_health	0,000		0,000
		(0,000)		(0,000)
	tax	8745,869		20796,833
		(58434,360)		(60772,911)
	pub_debt	7513,308		16773,250
		(8538,873)		(10724,460)
Structure of political networks	other_consor	-5594,044		-5620,632
		(4498,662)		(4967,641)
Political institutions	civil servants	-8,629		-8,910
		(5,711)		(6,316)
	re-election	-1601,902		-1509,637
		(2576,943)		(2794,573)
	Constant	22853,828	-9830,239	44444,626
		(41990,182)	(22198,974)	(31371,310)
	Obs	1138	1138	1138
	R²	0,832	0,827	0,823
	Wald chi²	1328,7***	1366,2***	3320,3***

• Note: Robust standard errors in brackets [*** p<0.01, ** p<0.05, * p<0.10]. Source: Research data collected in 2019.

The results infer that municipalities that joined public health consortia in 2009/2010 increased the number of PHC consultations significantly compared to municipalities that did not join one. This confirms Grin and Abrucio (2017) argument that ‘economies of scale’ is one of the factors that explain the engagement in inter-municipal cooperation arrangements. This result contributes to confirming the hypothesis, allowing to say that public health consortia tend to improve PHC and outpatient services.

These findings confirm the conclusions of Nicoletto et al. (2004), who demonstrated that inter-municipal cooperation expanded the capacity to offer specialised medical consultations in the Brazilian state of Paraná. They also corroborate the literature on collective action in regions of fragmented governments and contradicts the economic and ‘non-contextual’ arguments predicting the occurrence of selfish use of finite collective goods in cooperative environments. On the contrary, collective effects may be encouraged by increased public service provision.

As for the demographic characteristics in Table 2, this research corroborates a study by Thum et al. (2019). The authors observed the influence of these characteristics on the prevalence of medical consultations. They noted that this relationship varies according to the singularities of the country analysed. In Brazil, Boing, Matos, Arruda, Oliveira and Njaine (2010) identified inequities among the economically underprivileged population. Even with greater frequency of diseases, and therefore the need for more services, they are the stratum of the population that is least able to get medical consultations.

The variable measuring the number of households with sanitation suggests that municipalities with more homes with adequate sanitation have higher numbers of medical consultations. However, this indicator may seem paradoxical at first glance, since municipalities with better sanitation structures also have better health structures and, therefore, offer more public services, as opposed to the results of Siqueira, Rosa, Bordin and Nugem (2017).

As for infant deaths, the data show that the municipalities in a public health consortium achieved a significantly higher reduction in the number of child deaths than the municipalities in the control group, contributing to confirm the research hypothesis. The effects of joining public health consortia not only affected the delivery of services but also improved indicators used to evaluate health policy (Table 3).

TABLE 3
REGRESSION MODEL - INFANT DEATHS - 2005 AND 2015

Group	VAR	(1) infant_death	(2) infant_death	(3) infant_death
Differences in Differences	DID	-1,709**	-1,399	-2,124***
		(0,847)	(0,899)	(0,804)
Demographic characteristics	pop	21,068***	22,143***	22,456***
		(3,535)	(4,226)	(3,586)
	PD/km²	0,063**	0,071**	0,064**
		(0,026)	(0,033)	(0,028)
Economic characteristics	cap_GDP	-0,290	-0,279	-0,271
		(0,212)	(0,183)	(0,189)
	GDP	-2,397*	-2,574**	-3,301***
		(1,456)	(1,223)	(1,062)
Social characteristics	%poverty	0,088	0,068
		(0,056)	(0,056)
	unemployed	0,071	0,053
		(0,048)	(0,046)
	sanitation	-0,000	-0,000
		(0,000)	(0,000)
Fiscal characteristics	fin_depend_	4,827		7,034
		(16,179)		(16,362)
	$cap_health	-0,000		-0,000
		(0,000)		(0,000)
	tax	10,580		10,352
		(29,259)		(31,156)
	pub_debt	11,840**		10,576***
		(5,285)		(4,079)
Structure of political networks	other_consor	1,508		1,265
		(2,184)		(2,096)
Political institutions	civil servants	0,015		0,014
		(0,009)		(0,007)
	re-election	-0,993		-0,908
		(0,859)		(0,781)
	Constant	-196,360***	-186,386***	-189,957***
		(38,949)	(35,864)	(40,843)
	Obs	1.138	1.138	1.138
	R²	0,575	0,404	0,567
	Wald chi²	291,60***	144,78***	210,21***

• Note: Robust standard errors in brackets [*** p<0.01, ** p<0.05, * p<0.10]. Source: Research data collected in 2019.

A practical implication aligned with the results of this research can be observed in the studies by Niaounakis and Blank (2017). They affirm that supplying services in larger scale through cooperation results in cost reduction depending on factors such as the total cost to offer the service, the intensity of work, degree of the service complexity, and the level of standardisation required.

The reduction in infant deaths in the municipalities of the treatment group demonstrates that the expansion in health service provision is related to improving the population’s health quality.

The population (pop) variable denotes that municipalities with larger population tend to have a higher number of infant deaths. This number, however, may be explained by ‘reverse causality’ (Fávero, 2015; Hair et al., 2009) since the number of infant deaths is naturally greater in municipalities with larger populations. This rationale may apply to the variable of demographic density.

The results indicate that the increase in GDP reduces the number of infant deaths, corroborating the research by Lourenço et al. (2014), which identified a negative relationship between socioeconomic and demographic variables and infant mortality rates in the state of São Paulo.

The indebtedness rate presented positive significance in two models (1 and 3). That is, among the observed municipalities, the analysis of 2005 and 2015 indicated that the higher the indebtedness rate, the higher the infant death rates. Although we cannot attribute a causal relationship, it is possible to infer that there are ‘behaviours’ of positive trends between these two variables. That is, municipalities that have tax debt have higher infant death rate. This situation confirms the relationship between fiscal stress and worse public service delivery (Bel et al., 2014; Hefetz & Warner, 2011).

6. FINAL CONSIDERATIONS

Inter-municipal cooperation in a federation is a complex issue due to the multiplicity of interests among the government instances. Estimating the effects of a policy implemented in these contexts is challenging and at the same time urgent in the face of the recent practices of intergovernmental partnerships in contexts presenting increasingly common problems.

Demographic, economic, and fiscal characteristics have influenced the results of outpatient service provision, suggesting that these contextual factors of the ICA are also important to observe the effects of health policy. Therefore, municipalities that joined public health consortia in 2009/2010 increased the supply of public health services when observing the years 2005 to 2015.

Therefore, the factors in the ICA framework - characteristics of communities, the structure of policy networks, political institutions, and transaction characteristics of goods - are relevant to observe the collective effects of governments in fragmented environments, as well as to explain the effects of the policy in the municipality, as demonstrated in this research.

This study shows that the collective gains of inter-municipal cooperation in Brazil validate the assumptions of the literature on collective action. Therefore, the results are sufficient to encourage the formulation of public policies to promote inter-municipal cooperation.

Finally, future research could perform cluster efficiency tests in specific consortia, assessing more accurately the effects of health policies in the regions served by these arrangements and their contextual characteristics. Limitations of this research include the absence of annual municipal data that would allow regressions with long panel data or a difference-in-differences with multiple periods. In addition, other epidemiological variables that characterize the profile of municipal public health, not included because it is not the focus of the ICA model, can influence the model’s results.

ACKNOWLEDGMENTS

The authors thanks to CNPq financing, process 42771 2018 4; FUNCAP, process BP4-0172-00029.01.00/20.

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• Zioni, F., & Westphal, M. F. (2007). O enfoque dos determinantes sociais de saúde sob o ponto de vista da teoria social. Saúde e Sociedade, 16(3), 26-34. Retrieved from https://doi.org/10.1590/S0104-12902007000300004
  » https://doi.org/10.1590/S0104-12902007000300004

• 7
  [Original version]

Publication Dates

• Publication in this collection
  17 Jan 2022
• Date of issue
  Nov-Dec 2021

History

• Received
  17 Feb 2021
• Accepted
  04 Oct 2021