National Policy for Hospital Care: con(di)vergences among the Federal Executive's rules, Conferences and strategies

Santos, Thadeu Borges Souza; Pinto, Isabela Cardoso de Matos

doi:10.1590/0103-11042017S308

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ORIGINAL ARTICLE • Saúde debate 41 (spe 3) • Sept 2017 • https://doi.org/10.1590/0103-11042017S308 copy

National Policy for Hospital Care: con(di)vergences among the Federal Executive's rules, Conferences and strategies

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

This paper is aimed at analyzing the National Policy for Hospital Care and its convergences and divergences regarding National Health Conferences and National Health Plans in the 1988 Brazilian Federal Constitution. Documents were collected from January to June 2016, then processed and analyzed until December 2016. Results on policy making were subdivided into pre-decision and decision periods. In the first one, the normative character pointing to the formalization of contracts and the decentralization of hospital management at the state level can be highlighted. During the decision period, the indirect management model was strengthened, thus enhancing tensions involving decisions made in Conferences.

KEYWORDS
Public health policy; Policy making; Public hospitals

Periods	First normative period of formulation					Second normative period of formulation
Governs	Sarney	Collor	Itamar	FHC 1	FHC 2	Lula 1	Lula 2	Dilma 1
Dimensions	1985-89	1990-92	1992-94	1995-2002		2003-10		2011-14
Political- administrative	Along the democratization process, this period became the legitimating perspective as CFB and LOS were sanctioned. In this period, SUS was created as a social welfare element, with directives that involved decentralization, integrality and social control. SUS was launched along with NOB and Noas, Five different federal governments were elected over this period, characterized as: development-driven, with neoliberal agenda, inflationary control, specific tributes destined to the health area, normative procedures aimed at purchases and contracts, and contracts by the public power and administrative modernization. New managerial procedures were implemented as neo-developmental practices took place with privatization plans, reduction of public civil service, selectivity of social policies and social welfare reform.					Started during the fifth post-Constituent government elected, it was characterized by continuity known as neo-developmental, socio-liberal character. Consequently, the agenda was built on inclusion, social policies and incentives for income re-distribution.Concerning administrative procedures, transparency and State control were improved and public management strategies aimed at partnerships and concessions were widened. Remarkable normative remodeling of health care procedures, specifically as to hospital care, stressing inter-sector procedures and relation between the different care levels.
	Administrative landmarks:					Administrative landmarks:
	- CFB/1988: exposing the principles of the public administration (legality, impersonality, morality and publicity) and its configuration as either direct or indirect character (by means of autarchies and foundations); - Law #8666/1993: established norms for bids and contracts by the public administration; - EC #01/1994: created the Social Emergency Fund (FSE); - Mare/1995: a ministry was created to be responsible for the Directive Plan for Reforming the State Operational Structure (PDRAE) ;- EC #19/1998: includes the principle of efficiency in public administration; - Law #9637/1998: created OS along with the National Publicizing Program; - Law #9790/1999: created the Civil Society Organizations of Public Interest (Oscip) and the Partnership Agreement; - Law #101/2000: established public norms for fiscal management responsibility; - EC #27/2000: renaming the Emergency Social Fund (FSE) to Disentailing of the Union's resources (DRU).					- Law #1.1079/2004: established general norms for PPP biddings and contracts in the public administration sphere; - Administrative Act #161/2010: established cooperation among public entities; - Administrative Act #1.034/2010: rules for complementary participation of either private or non-profit institutions:- Complementary Act #141/2012: rules for minimum values to be paid for health services in the government spheres; - Law #12.550/2011: creates the EBSERH; - Law #13.019/2014: creates the Organization of Civil Society (OSC);- EC #42/2003, EC #56/2007, EC #68/2011: DRU renewals.
Legal normative landmarks of the Health Policy	1986: VIII CNS; 1988: Created the new CFB, where health is considered a social right and a State duty, services are linked to SUS and may be either public or private, rendered as straightly public, complementary and supplementary; 1990: LOS #8080 and #8142; 1991: NOB 91; 1993: NOB 93; 1996: NOB 96; 2000: EC #29, altering articles and assuring, under the Constitution, minimum resources for financing public health actions and services; 2001: Noas 01; 2002: Noas 02;					2003: PNAU; 2004: RAHB, PNH, PN-HPP; 2006: Health Pact; PPI-Assistance; 2008: PN-Regulation; 2009: Beneficent Entities Regulation;2010: RAS/SUS; Cooperation Agreement between Public Entities; Complementary Participation of either private or non-profit institutions; 2011: RAU/SUS; Ruling LOS; Conitec; Stork Network; Psycho-social; RDC Best Functioning Practices; Readequa PNAU, RAU, PNAB and Certification of Beneficent Entities; 2012: Attention Network for Disabled Persons; National List of Health Actions and Services; 2013: Redefine Home Care; Care Network for Chronic Diseases; Creates the PNHOSP, procedures for celebrating contracts with hospitals/SUS.
Strategic Convergencess and/or Divergencesas	Deliberations made between VIII CNS and XI CNS displayed important (dis)alignments regarding the PNHOSP formulation. Among alignments, stand out: organic participation of the society in SUS, decentralization from the municipalization perspective. As dis-alignments: health priority in the context of political and economic crises, changes in the hegemonic care and tripartite financing, complementarity of services characterized as public right or covenant, improvement in quality and assistance coverage, opposition to multiple forms of privatization and alternative management models, greater autonomy, inadequate follow-up tools, evaluation and regulation.					National Health Conferences (CNS) from XII to XIV were realized. There was alignment with Brazilian Sanitary Movement, de-bureaucratization, decentralization towards regionalization, reinforcement of social welfare, pacts and tripartite financing flows, improved RHS management, wider coverage and strengthening of HPP. (Dis)alignments: tributary reform and adjustment of social responsibility, private initiative concerning financing and regulation, health as a marketable item, regulatory function and no more privatization, no more DRU and managerial procedures.

Period	CNS	Deliberations
First normative period of the formulation	VIII CNS	Occurred during the Constituent Assembly, this conference is a decisive landmark concerning the formulation and inclusion of SUS into the 1988 CFB. It established directives, systematization of ascendant management levels, complexity of health problems, stimulus to the public state character and need for hospitals to be unified under SUS.
	IX CNS	This was the first one to take place in the context of SUS implantation, of the implementation of the Health Organic Law and first NOB. It opened the chance for intense debates aimed at prioritizing health, against the dramatic scenery of recession and unemployment at the time. Resistance was manifested to the multiple forms of privatization (recommending the character of public right or covenant in contracts involving services complementarity. The need for changes as to the hegemonic model in place was pointed out, as well as the dependence on the private sector and the limited assistance coverage.
	X CNS	Opposition to NOB was manifested, attributions for managers were defined and concern was made clear as to the direction RAE was taking, characterized by the wider relationship between public and private sectors. Therefore, this Convention defended the character strictly complementary, refusing management contracts, outsourcing and privatization of public services.
	XI CNS	Discussions on fiscal adjustments impelled by the State reform, the scenery of ever growing plans and private security, disarticulation of care levels, precarious access and insufficient control by the government. The Conference recommended strengthening regulation, improvement of the public services, inclusion of a culture of evaluation/auditing/control, new mechanisms for social control and refusal to the LRF.
Second normative period of the formulation	XII CNS	Concerning the tax reform, the cause of democracy is supported, besides effective integrality and social welfare, reiterating the importance of assuring social control, regionalization, decentralization and less bureaucratic services management and social welfare funds The Conference opposed to private initiative in mediation in financing and regulation activities of medical-hospital assistance. As to health management, SUS consolidation by means of decentralization was defended, with mechanisms that may hinder client-like and merchant attitudes in health assistance, with pacts flow regulations. Redefinition of the relationship of university hospitals and integration of the Sara System (Rede Sara) to SUS. Assuring resources for investments and for costs of urgency and emergency services, home care and widening reference public hospitals with less than 50 beds, financial incentive to those that reach the goals established in the National Program for Evaluation of Hospital Services (Programa Nacional de Avaliação dos Serviços Hospitalares - PNASH) and equitable dealing when transferring resources to both public education and philanthropic hospitals.
	XIII CNS	It was stressed that SUS is a State policy and, particularly concerning hospital management and assistance, the Conference points out to the need of assistance networks, humanization, integration of University Hospital to SUS, existence of a managing council and rendering of accounts in services financed by SUS, state and municipal support to HPP, establishment of protocols for assistance and referral procedures, as well as beds and coverage.
	XIV CNS	Considered SUS as a public policy and patrimony of Brazilian people. Refused management alternatives involving Social Organizations, Civil Society Organizations of Public Interest, State Foundations of Private Law and the creation of Brazilian Company of Hospital Services. The Conference manifested concern about DRU, the regulation of EC #29, how to guarantee financing for health care in the Tax Reform, specific resources for maintaining the Regulatory Complex and exclusion of expenses with health personnel under the Fiscal Responsibility Law. The creation of Organizing Contracts of the Public Action was recommended (pursuant Resolution #7508/2011) and the Health Pact agenda. The suggestion to create the Sanitary Responsibility Law was maintained, as well as implementing a National System for SUS Regulation, besides structuring the National Audit System (enlarging control, evaluation, and auditing procedures on contracts and expenses). As to the health care and hospital network, recommended university hospitals to become 100% SUS; implementation of the Home Care Program (Programa de Internação Domiciliar - PID) and the Out-of-Domicile Assistance (Tratamento Fora do Domicílio - TFD); optimization of flows and creation of central offices for regional regulation. The Conference manifested concern about qualification of the urgency and emergency hospital network and widening the number of beds available (Intensive Therapy Units, trauma-orthopedics, perinatal, children, obstetrics, oncology and rehabilitation, and high complexity procedures and exams. It pointed out to the need to widen resources for acquisition of equipment and permanent materials, of debates on integrating emergency assistance units (Unidades de Pronto Atendimento - UPA) to the basic care network, and of yearly updating procedures costs under SUS, according to inflation rates.

Period	PNS	Strategies
Second noramative period of the formulation	PNS 2004-2007	The Multi-annual Plan and the XII CNS are the basis the proposal is grounded on. The document mentions the need to consolidate the Brazilian Sanitary Reform and presents the following strategic actions: adjustment of resources allocation, EC 29 regulation and reform of the assistance model. For those purposes, some aspects must be prioritized: management improvement, financing and social control and reorganization of hospital care, with wider coverage and alignment of ambulatory, urgency and emergency care, as well as high complexity procedures.
	PNS 2008-2011	One purpose was to strengthen SUS management in all three government levels, acknowledging the challenges posed to hospital assistance, the need to improve resolution capabilities, wider access, re-structuration of contracting procedures and qualification of the regulatory function. Aspects supporting the 4th. Directive include embracing services organization in attention networks that involve pre-hospital care, both mobile and fixed; hospital care; re-habilitation care and organs raising and transportation; increased number of beds for intensive care. A remarkable suggestion is fostering contract procedures as a management model to lead public hospitals to provide services that lead to solutions.
	PNS 2012-2015	The relevance of hospital units for structuring RAS was considered, and is more deeply linked to urgency and emergency assistance. Thus, some aspects are prioritized: widening the regulatory function, remodeling the network so as to improve its quality, solving capacity, distribution over the territory, and increased number of high complexity beds. Concerning management, the Pact for Health is stressed, with the prerogative of the commitment agreement for management, adoption of contracting procedures tools and the constitution of councils for regional management, backed by the National Audit System, and qualification of tools for immediate accomplishment. All these proposals are intended to improve hospital care by means of productivity and efficiency gains. Thus, the following planned interventions are highlighted: (1) follow-up, evaluation and internal control over SUS management, focused on results, connected with organizational contract for public action and access warranted; (2) implementation of management based on competences and administrative modernization; and (3) qualification and rationalization of expenses and wider resources provision.

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[1] Conflict of interests: non-existent