Interdependence between government levels in Brazilian health policy: the implementation of Emergency Care Units in the State of Rio de Janeiro, Brazil

Lima, Luciana Dias de; Machado, Cristiani Veira; O'Dwyer, Gisele; Baptista, Tatiana Wargas de Faria; Andrade, Carla Lourenço Tavares de; Konder, Mariana Teixeira

doi:10.1590/1413-81232015202.02512014

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FREE THEMES • Ciênc. saúde coletiva 20 (2) • Feb 2015 • https://doi.org/10.1590/1413-81232015202.02512014 copy

Interdependence between government levels in Brazilian health policy: the implementation of Emergency Care Units in the State of Rio de Janeiro, Brazil

Authorship SCIMAGO INSTITUTIONS RANKINGS

This article addresses policymaking related to Emergency Care Units (ECU) in the State of Rio de Janeiro between 2007 and 2013, duly identifying the relationships between the various levels of government in this process. It prioritized the context of policy formulation, the factors that motivated the inclusion and maintenance of ECUs on the state agenda and the process of how the policy was implemented in the state. The study was based on the literature that defines the agenda and implementation of public policies and on contributions from historic institutionalism. The research involved analysis of documents, secondary data, and 51 interviews with people in positions of authority in state and municipal governments. The priority given to ECUs in the government agenda was the result of a confluence of historical, structural, political and institutional factors, as well as the current context. The results of this study indicate the existence of interdependence between levels of government, however federal coordination problems have prejudiced the integration of the various components of emergency health care in the state.

Federalism; Health policy; State government; Emergency medical services; Unified Health System

	2007-2008	2009-2010	2011-2012	2013^* * Situation in January 2013.
Aspect	Introduction, and expansion in metropolitan area	Expansion in the interior, transfer to municipalities, regionalization initiatives	Support from federal government; initiatives to constitute the Emergency Care Network (RAU)	Transition, with stabilization and reorientation of the management model
Political coalition	PT and PMDB Parties, at federal and state level. Federal: Presidency / Health Ministry (Lula / Administration José Temporão);	PT and PMDB Parties: federal, state and municipal levels. Federal: Presidency / Health Ministry (Lula / Administration José Temporão);	PT and PMDB Parties: federal, state and municipal levels. Federal: Presidency / Health Ministry (Dilma / Administration Padilha);	PT and PMDB Parties: federal/state/municipal. Presidency / Health Ministry (Dilma / Administration Padilha);
	State: Rio state government, and state Health Dept. (Sergio Cabral / Administration Sérgio Côrtes).	State: Rio state government, and state Health Dept. (Sergio Cabral / Administration Sérgio Côrtes);	Rio state government, and state Health Dept. (Sergio Cabral / Administration Sérgio Côrtes);	Rio state government, and state Health Dept. (Sergio Cabral / Administration Sérgio Côrtes);
		City: prefecture of Rio / Municipal Health Service (Eduardo Paes / Hans Domann).	City: prefecture of Rio / Municipal Health Service (Eduardo Paes / Hans Domann).	City: prefecture of Rio / Municipal Health Service (Eduardo Paes / Hans Domann).
Dynamics of inter-governmental relations	Political conflicts between state government and city of Rio (Administration: Cesar Maia).	Relations of cooperation between federal, state and city governments. Cooperation and conflicts between state and municipal governments (in metropolitan region and in regions of the interior).	Relations of cooperation between federal, state and city governments. Cooperation and conflicts between state and municipal governments (in metropolitan region and in regions of the interior).	Relations of cooperation between federal, state and city governments. Important politicalparty changes in some prefectures of the Baixada Fluminense region (result of 2012 elections).
Directionality	Predominance of the state executive in conduct of the policy in the state. Policy basically directed to the city of Rio and the Baixada Fluminense, aiming to make good areas with ‘absence of care’, and reduce demand on emergency services, with the state taking over management of the UPAs.	Greater balance between the federal and state executives in conduct of the policy in the state. State/city partnership in the conduct of policy in the municipality of Rio. Expansion of implantation of UPAs in the regions of the interior of the state, with municipalization and efforts for regionalization. Implementation of UPAs under the initiative of the municipality in the city of Rio.	Greater balance between the federal and state executives in conduct of the policy in the state. State/city partnership with stronger activity of the Municipal Health Service in conduct of the policy in the municipality of Rio. Strengthening of implementation in the metropolitan region and support for the constitution of the RAUs in the health regions	Greater balance between the federal, state and municipal executives in conduct of the policy in the state. State-city partnership, with: predominance of the Municipal Health Service in the conduct of the policy in the municipality of Rio de Janeiro; influence of municipal policy over the state policy; and stagnation of the process of implementation of the UPAs.
Institutionality	Creation of SESDEC (2007). Rules and incentives predominantly coming from the state.	Rules and incentives coming from state and federal government. Transfer to municipalities, and strategies to articulate the process of regionalization (start of implementation of the Regional Management Committees – CGRs – in 2009). Creation of the Municipal Health and Civil Defense Department in the city of Rio. Adoption of the Social Organizations (SO) model in the UPAs, under management of municipality in Rio de Janeiro city.	Rules and incentives coming from state and federal government (Emergency Care Network – RAU). Separation of SESDEC (2011) and creation of the RAU Coordination Unit (2012). Fiotec removed from the process of hiring of staff (2012). Adoption of the SO model in the UPAs under management of the municipality in Rio de Janeiro city. Creation of Regional Emergency Centers in the municipality of Rio.	Rules and incentives coming from state and federal government (RAU). Start of implementation of the SO model in the UPAs under management of the state.
Number of UPAs created in the period, by location	City of Rio: 15	City of Rio: 9	City of Rio: 7	^* * Situation in January 2013. City of Riol: 0
	Metropolitan region: 4	Metropolitan region: 6	Metropolitan region: 4	Metropolitan region: 0
	Regions of the interior: 1	Regions of the interior: 12	Regions of the interior: 3	Regions of the interior: 0
	Total: 20	Total: 27	Total: 14	Total: 0

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E-mail: cienciasaudecoletiva@fiocruz.br

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[1] Collaborations LD Lima and CV Machado were responsible for the conception, collection and analysis of the information and for writing the article. GO'Dwyer, TWF Baptista, CLT Andrade and MT Konder participated in the collection and analysis of the information, preparation of the tables and diagrams, and writing and final revision of the article.