Federal dimension
|
1
|
Viana et al. (2010) |
Theoretical analysis. Construction of typologies of the health regions |
2010 |
Original paper |
Theoretical essay. Analysis of secondary data by the factorial and grouping analysis methods |
2
|
Lima et al. (2012) |
Process of regionalization in the Brazilian states |
2007 to 2010 |
Original paper |
Case study with qualitative approach. Sources: interviews linked to management (91), field visits, analysis of documents |
3
|
Albuquerque (2014)* |
Process of regionalization in the Brazilian states |
2001 to 2011 |
Doctoral thesis |
Theoretical analysis. Case study with qualitative approach. Sources: interviews linked to management (91), field visits, analysis of documents |
4
|
Duarte et al. (2015) |
Proposal of typology of health regions based on human development |
2013 to 2015 |
Original paper |
Secondary data |
State-level
|
5
|
Souto Júnior (2010) |
Role of the CIBv in regionalization of the SUS of Minas Gerais |
2004 to 2007 |
Original paper |
Case study with qualitative approach. Sources: minutes of meetings of the CIB/MG |
6
|
Brandão et al. (2012) |
Health regionalization network of PB (State of Paraíba) |
2008 |
Original paper |
Analysis of documents |
N
|
Principal empirical findings
|
Federal dimension
|
1
|
● Regional typology: “two Brazils” – North/South 1. Less-developed socio-economic situation and less complex health system: high PSF (Programa Saúde da Família = Family Health Program) coverage; low doctors/population ratio; higher percentage SUS beds 2. More developed socio-economic situation and more complex health system: more than 30% private health plans and insurance, higher number of doctors and medical faculties. ● Service: public-private mix disseminated and without defined pattern (predominance of public provision in the North, followed by the South: “aligned with the extremes”) ● Regional question more accentuated from the economic and social point of view than in relation to health policy ● Perception of a vector reducing the distances between the “two Brazils” |
2
|
● Three stages of institution nullity in the process of regionalization in the states: incipient, partial, advanced ● Institutional impacts of the process: radical, incremental, embryonic or absent ● Governance: polarization: between two standards – coordinated/cooperative vs. conflicted/undefined ● No state of the political context is unfavorable to the process of regionalization of health ● Broadly speaking: N and NE have contexts unfavorable to the process ● Regional process oriented by equity – access and financing (19 states); focus also on expansion of installed capacity (17); integration with other economic and social policies (5) ● Almost all the states: organization of networks and flows induced by the federal rules ● Importance of federal inducement and activity of the Health Ministry, especially in North and Northeast ● Inducement strategies: CGR (Colegiado de Gestão Regional = Regional Management Committee) and regional/SES (Secretaria Estadual de Saúde = State Health Department); planning; regulation; installed capacity and technical qualification ● Actors: predominance of SMS (Secretaria Municipal da Saúde = Municipal Health Department) and SES; private (11 states), universities (3), consortia (3) and legislative (2) ● Regulation of care fragile: general characteristic ● Conditioning factors: historic and structural nature (socio-economic dynamics, characteristics of the systems, inequalities); political-institutional (accumulated experience, culture of negotiation, legitimacy, political power and technical qualification); context (profile of the actors, political dynamics and priority on the agenda) |
3
|
● The process of regionalization tends to be more advanced and have more cooperative and coordinated governance in the States with a greater tradition of regional planning, more favorable contexts, and where priority is given in the state and municipal agendas, as well as strong activity of the SESs in planning ● Also in the more populated, densely urbanized and modernized areas, with concentrations of technologies, professionals, material and immaterial flows, equipment and public and private health resources ● Amazon region – Less favorable contexts, incipient and intermediary institutionality of regionalization ● Northeast – more or less favorable contexts, institutionality of regionalization incipient and advanced ● More favorable contexts, institution of regionalization intermediate and advanced ● Concentrated region - more favorable contexts, institution of regionalization intermediate and advanced |
4
|
● “The typology proposed approximates to the theoretical assumptions related to the social determinants of the health-illness process adopted in the PROADESS. ● It is compatible, also, with categories of analysis proposed by the theoretical-methodological current of the social determinants of health such as population characteristics, social inequities, living conditions, needs and contexts of health problems” |
State-level
|
5
|
● CIB (Comissão Intergestores Bipartite = Bipartite Inter-managers Committee)-MG (State of Minas Gerais): Participation of state and municipal managers and technical staff, also representatives of inter-municipal health consortia ● Regionalization: strong presence on agendas ● Predominance of interests of regions with greater economic and political power in the sharing of resources, maintenance of the status quo of the system, and care-centered healthcare model |
6
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● Points to deficiencies in the process of the decision on the regional design |
N
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Author
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Objective / Dimension
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Period
|
Type of publication
|
Methodology
|
State-level
|
7
|
Vargas et al. (2014) |
Factors of influence in the political implementation of Integrated Health Networks - PE (State of Pernambuco) |
2010 to 2012 |
Original paper |
Case study with qualitative approach. Sources: interviews linked to management (17), focus group, observation, analysis of documents |
8
|
Bretas Jr, Shimizu (2015) |
Macro regional planning developed by COSEMS of Minas Gerais |
2007-2012 |
Original paper |
Case study with qualitative approach. Analysis of documents Sources: reports (26) and minutes (125) of COSEMS |
9
|
Guerra (2015) |
Regional decentralization in São Paulo, based on the percentage of municipal management and index of outpatient and hospital dependency of the health regions |
2013 |
Doctoral thesis |
Review of bibliography and documents. Analysis of secondary data |
Macro-regional (intra-/inter-state)
|
10
|
Stephan-Souza et al (2010) |
Regulation of access in Juiz de Fora; focus on UFJF)(Universidade Federal de Juiz de Fora = Federal University of Juiz de Fora) and its Hospital. Southeast MG macro-region (94 munic./pop 1.6 mn) |
2007 |
Original paper |
Case study with qualitative approach. Sources: interviews linked to management (10) |
N
|
Principal empirical findings
|
State-level
|
7
|
● Financing of the CIR (Comissão Intergestores Regional = Regional Inter-managers Committee) and functioning structure undefined ● Criteria for construction and coordination of the networks imprecise ● Initiatives isolated by area or process, lacking a systemic outlook ● Limited technical capacity in the municipalities ● State activity in leading and coordinating the process fragile ● Fragmentation of the Health Ministry harms coordination of the policy ● Disincentives: municipal autonomy, low interest in regionalization, competitiveness for funds, party politics ● Underfinancing ● Turnover of managers ● Difficulties in the process more related to municipal isolation than to the policy of networks in particular ● More obstacles that facilitators – in four groups 1. Implementation based on negotiation instead of planning 2. Great responsibility of the municipalities with low technical capacity 3. Failings in planning and coordination of the competencies involved 4. Lack of clarity on the political rules of implementation |
8
|
● COSEMS(Conselho Nacional de Secretarias Municipais de Saúde = National Council of Municipal Health Departments)/MG: – Important support role (SDS (Sistema do Departamento de Saúde = Health Department System): 22 support units directed to technical support of COSEMS) – Involvement of all the managers – Effective mechanism of communication ● Agreement of the CIRs and CIRAs (Comissão Intergestores Regional Ampliada = Expanded Regional Inter-managers Committee): predominance of fragmented discussions; handling is bureaucratic and authoritarian ● Agendas give priority to the formal procedures of the CIT (Comissão Intergestores Tripartite = Tripartite Regional Inter-managers Committee)-CIBs to the detriment of the local problems ● Difficulty in making the technical committees operational ● Fragility in the System for Requests and Accountability |
9
|
● 52% of hospital procedures and 72% of outpatient procedures were carried out under municipal management ● Highest indices of dependency on hospital care in relation to outpatient care ● The regions of the Metropolitan Region of Greater São Paulo showed greater dependence in relation to the Interior ● The municipal management has influence over the index of dependence, but is subject to conditions of the demographic context (scale of population) and the socio-economic context (IPRS (Índice Paulista de Responsabilidade Social = São Paulo State Social Responsibility Index)) ● Importance of institutionalized agreement mechanisms and regulations between the regions in the guarantee of equity ● In spite of the larger role of the municipalities, average hospital complexity is still shared with the SESs, with management predominantly private (majority non-profit and OS (Organização Social = Social Organization)) ● High complexity, predominantly state-related, also with a high percentage of private-sector establishments ● Difficulty in planning and execution of care in the health regions ● The SES: execution of care, but with low coordination of the process of regionalization |
Macro-regional (intra-/inter-state)
|
10
|
● University hospitals (HUs (Hospital Universitário = University Hospital))/UFJF: informal intra- and inter-state flow ● Intra-state PDR: Does not regulate flow from Rio de Janeiro to the MAC (Assistência Ambulatorial de Médio e Alto Custo = Medium and High Cost Outpatient Care) of the municipality ● Working agreement/contracting of HUs: difficulty of integration and compliance with the management commitments ● HU/UFJF: Internal resistances to the proposal for regionalization of the SUS; mismatch between thinking of the manager, and management of the HU; priority for teaching on extension and research ● Underfinancing ● Managers’ low knowledge of management instruments |
N
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Author
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Objective / Dimension
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Period
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Type of publication
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Methodology
|
Regional
|
11
|
Pereira (2009) |
Role of the SES in the regionalization of the SUS of Minas Gerais |
2003 to 2007 |
Masters’ degree dissertation |
Case study with qualitative approach. Sources: interviews linked to management (18), analysis of documents |
12
|
Assis et al.(2009) |
Constitution of the West VII Regional Committee – SP |
2007 |
Original paper |
Report of experience; signed by 11 Municipal Secretaries of the Metropolitan Region of Campinas, São Paulo state |
13
|
Coelho (2011)* |
Public-private relationships in the regionalization of two regions in Espírito Santo State: Cachoeira de Itapemirim and Vitória |
2007 to 2011 |
Masters’ degree dissertation |
Case study with quanti-quali approach. Sources: Field visit, interviews with managers and providers (17), secondary data, and analysis of documents |
14
|
Mesquita (2011) |
Consensuses of the CIR of Caucaia, Ceará State |
2009 to 2010 |
Masters’ degree dissertation |
Case study with qualitative approach. Source: minutes and decisions of the CIR |
15
|
Venancio et al. (2011) |
Referral practices in five regions/some parlous state; difficulties in reaching agreements |
2003 to 2005 |
Original paper |
Case study with quanti-quali approach. Sources: interviews linked to management (75), secondary data. |
16
|
Silva, Gomes (2013) |
Process of regionalization. Greater ABC region – São Paulo State |
2005 to 2006 (fieldwork in 2010) |
Original paper |
Case study with qualitative approach. Sources: interviews linked to management (16), analysis of documents |
N
|
Principal empirical findings
|
Regional
|
11
|
● Regionalization long-standing, but, historically, uncoordinated and fragmented ● Failings in the state’s role of controlling the process ● SES: Source of stimulus and technical support for micro-regional management and care networks; indirect administration via Hospital Foundation of Minas Gerais State (FHEMIG) ● CIB and micro and macro-regional CIB: Importance spaces for negotiation, in particular of the PPI (Programação Pactuada e Integrada da Assistência à Saúde = Integrated Agreed Healthcare Program). Low consensus on capacity for planning and regional regulation ● Low technical capacity of the municipalities ● Local point of view, to detriment of regional ● Discontinuity of management |
12
|
● Participative process: important for integration and overcoming resistances ● COSEMS: important role ● SES: Active participation as an essential requirement ● SES: Notable structural and technical fragility for assuming new regulator role ● Health Plan: importance of structuring it under a regional viewpoint ● Absence of legal instrument that can guarantee agreements are kept |
13
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● Two predominant patterns of public-private relationships: interdependent cooperative; and multiple proposed solutions, with conflicts ● Mutual dependency between SUS and private. Private interest in incorporation of high cost technology ● Centralizing role of SESA (Secretaria da Saúde = Health Department). Conflict of roles between Regional Health Centers and SES ● Low capacity for planning and regulation of contracted private-sector agents: absence of effective tools for coordination, regulation and control ● Regionalization strongly influenced by private sector in formal and informal relationships. – either due to supply, or political negotiation, or professionals’ multiple links ● Reduction in political guidance by the State ● Inter-sector integration is only latent |
14
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● CIR: Cases of consensus on legalist, government-ist and techno-bureaucratized bases ● Agendas: Consensuses without argument, automatically approved. ● Ad hoc decisions with low intentionality in political and planning terms. |
15
|
● Facilitators of regional integrality: – Installed capacity; stability of management; strengthening of basic healthcare/Family Health Program; strengthening of negotiation spaces; technical structures of support to the managers through regular functioning; well-delineated microregions; permanent regional regulation facility; conversion of HUs to contract status; municipal Assessment and Control Units; agreements negotiated in the DRSs (Departamentos Regionais de Saúde = Regional Health Departments); contracting for fixed resources; zero vacancy mechanism. ● Obstacles to regional integrality: – Limited technical capacity of the SMSs; management suspicion on transparency of the process (supply concealment); formal and informal agreement mechanisms coexisting; technical rationality of the PPI; underfinancing; interference of municipal hospitals in regional regulation; lack of regional and municipal governability to discuss financial competencies; metropolitan regions; invasion from external locations; insufficient formal mechanisms of coordination of healthcare; lack of submission protocols; focus on MAC; medical housing model; reduction of supply in academic services; distance and transport; payment by production. |
16
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● Invasion of the services of the SUS by neighboring municipalities ● Negotiating disputes with disadvantage for small municipalities ● Importance of participation of by the SES ● Clarity on the role of regulation lacking |
N
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Author
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Objective / Dimension
|
Period
|
Type of publication
|
Methodology
|
Regional
|
17
|
Silva MJ (2014) |
Analysis of the west CGR Region – Mato Grosso state (MT) (12 municipalities) |
2010 to 2012 |
Masters’ degree dissertation |
Case study with qualitative approach. Sources: interviews linked to management (11), observation, analysis of documents |
18
|
Santos, Giovanella (2014) |
Regional governance in the CIR of Vitória da Conquista, Bahia State (19 municipalities) |
2011 and 2012 |
Original paper |
Case study with qualitative approach. Sources: interviews linked to management (17) analysis of documents, focus groups, observation |
19
|
Silva, Gomes (2014) |
Application of the PDR, PPI, and PDI in the Greater ABC Region of São Paulo |
2010-2011 |
Original paper |
Case study with qualitative approach. Sources: interviews linked to management (10), analysis of documents |
20
|
Martinelli (2014)* |
Process of regionalization and public-private mix in region of Tangará da Serra (Center-North of MT(State of Mato Grosso), 10 Municipalities) |
2006 - 2011 |
Doctoral thesis |
Estudo de caso de abordagem quanti-quali . Fontes: questionários auto-aplicados com gestão pública e privada, análise documental e de dados secundários |
21
|
Mendes (2015) |
Implementation of the COAP++ in five regions of São Paulo Proposal for analysis of regional health profiles |
2011 |
Original paper |
Case study with quanti-quali approach. Sources: interviews linked to management (8), analysis of monitoring and assessment indicators |
N
|
Principal empirical findings
|
Regional
|
17
|
● Discontinuity of the regionalization policy strengthened between 1995 and 2002. ● CGRs weakened by ‘re-centralization’ of the SES of MT ● Institutionalization of the intermediary CGR: instituted and organized; structure insufficient for appropriate functioning ● Actors value the space, but its legitimacy is arguable ● Technical fragility of the municipal managers ● Party political and clientelist interferences ● Municipal interests to the detriment of regional interests. State interests dominate ● Highlight role of the Intermunicipal Health Consortium in the integration of municipalities ● Important technical support from COSEMS |
18
|
● CIR: Principal strategy of regional governance – conflicted, and with institutionalization of intermediaries ● CIR: Important space for debate and communication, but eminently bureaucratic ● Low degree of autonomy of managers in relation to the municipal executive power ● Priority for municipal interests, clientelist tradition and influence of party politics ● Turnover of health secretaries ● Low technical qualification. Low capacity for regional planning ● Insufficient financial resources make compliance with PPI difficult ● Low degree of regulation of the contracted private sector. Buying of services in the private sector market for prices higher than the SUS Table (direct payment to doctors of other municipalities for procedures already costed by the SUS) |
19
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● PDR: need for updating to balance supply/demand ● PPI: arena of competition, rather than a space for coordination, negotiation and agreement ● PDI: low significance, due to underfinancing ● Difficulty of changing the focus from supply to demand ● CGR: innovation and point for regional mobilization and coordination ● Technical fragility of the municipalities ● Need for state-level leadership ● Small municipalities: low standing for agreements/perception of low influence |
20
|
● Political and administrative discontinuity in changes of management ● CGR: An important space, but with partial governability: “sum of the parts” ● Fragmented healthcare network, installed capacity insufficient ● Absence of construction of regionalized units. ● Private sector: expansion and strengthening in the healthcare network ● MAC: Guaranteed by system of contracting with the private sector (mutual dependency) ● Low qualification of municipal managers. Low degree of culture of planning ● Party political interference ● Need for leadership of the SES |
21
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● Vale do Ribeira. Low regional disposition to take protagonist roles. Dependency relationship with DRS. Support of the consortium of the region. Weakness in technical ability, administrative and political matters and installed capacity; and party interests ● Bauru: Municipality taking protagonist role, political, technical-operational, financial and installed-structure strength ● ABC region of São Paulo: greater protagonist role, dynamics more shared and horizontalized. Relationship with metropolitan consortium. ● Santos region: Dismantling of prior process. Turnover of managers ● Extreme political-administrative fragility, in general, of municipal managers ● COSEMS: important role ● DRS: holder of power, but weak in taking protagonist political positions ● State government: distant, authoritarian, bureaucratic – when not actually creating obstacles. Strong provider with low productive relationship with the municipalities ● Quality of the technical team (e.g. the Technical Chamber) is a conditioning factor for agreements and leadership of the municipality in the regional committee ● CIR: difficult to avoid the agenda of healthcare, municipal interests, vulnerable to private interests ● COAP not widely referred to – more when raising funds than in making regional agreements |
N
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Author
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Objective / Dimension
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Period
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Type of publication
|
Methodology
|
Regional
|
22
|
Kehrig et al. (2015) |
Regionalization of health from the point of view of institutionality and governance Region of Mato Grosso do Sul (MT) |
1995-2009 |
Original paper |
Case study with qualitative approach. Analysis of documents Sources: minutes of CIB-CGR (also management regulations and instruments). |
23
|
Medeiros, Gerhardt (2015) |
Analysis of the RAS (Rede de Assistênica a Saúde = Healthcare network) - cardiovascular - in two small municipalities. 16th health region – state of Rio Grande do Sul |
2012 |
Original paper |
Case study with qualitative approach. Sources: interviews linked to management (3); focus group (2). |
Frontier region
|
24
|
Preuss, Nogueira (2012) |
Regionalization on the frontier between Brazil (Rio Grande do Sul), Argentina and Uruguay |
? |
Original paper |
Case study with qualitative approach. Sources: interviews linked to management (n=?) |
Metropolitan
|
25
|
Spedo et al. (2010) |
Metropolitan regionalization of the municipality of São Paulo (focus on Technical Supervision) |
2005 to 2008 |
Original paper |
Case study with qualitative approach. Sources: interviews linked to management (5), analysis of documents |
26
|
Ianni et al. (2012) |
Regionalization and factors conditioning access to basic healthcare in the Santos region – São Paulo state |
2007 to 2010 |
Original paper |
Case study with qualitative approach. Main sources: interviews connected with management (n=?); analysis of the minutes of the CIR and CONDESB |
N
|
Principal empirical findings
|
Regional
|
22
|
● Strong inducement by SES, especially in the first eight years of the Regional CIB’s existence (1995–2002) Organization of intermunicipal consortia, created by the Regional CIBs, AIH clearing chambers; audit chambers and control and assessment system Regionalization permeated by the public-private mix Distancing of the SES in the regional process after 2002 Important role of COSEMS Absence of any regional planning Obstacle factors: – non-definition of responsibilities between the spheres of government and the regional instances – turnover of managers – predominance of party political aspects |
23
|
Healthcare model fragmented and focused on procedures Network organized principally based on supply Sufficiency of services, but low integrality and coordination (low role for basic healthcare) CIR: Important forum for negotiation and agreements, but with limited participation of managers Low social participation Low technical capacity of the SMSs, low planning capacity Absence of monitoring and assessment SES: Centralizing, but absent on issues of regulation and limited technical support for the municipalities |
Frontier region
|
24
|
Municipal Health Council: the main actor in the process of agreement Isolated integration actions, distance from the centers of decision Bureaucratic, centralizing and rule-making management Managers: superficial understanding of the Pact for Health |
Metropolitan
|
25
|
Failure of the intra-municipal regional reform SMS: Centralizing nature; political-administrative separation between basic healthcare, hospital care and U/E (Urgência e Emergência = Urgency & Emergency). Did not in fact take over responsibility for management of state outpatient and hospital facilities Institutional power, and hospitals’ resistance to integrating into the health system Turnover of Secretaries and coordination management jobs Lack of prior negotiation with institutional actors. Low inclusion of the various representations (e.g. users) Role of the state not clearly defined |
26
|
“Double identity”, city and region: probable regionalization vs. probable implementation of the metropolitan region “For the local and regional manager, the subject of the Metropolis is invisible. Invasion of the services of the SUS by neighboring municipalities, including MAC and basic healthcare Inefficiency of the instances, instruments and infrastructure of regional management. Underfinancing DRS: Centralizing culture, and technical and political weaknesses CIR: Important space for debate. Technical-political weakness maintains its status as a space merely for confirmation Low regulation capacity: informal and interpersonal mechanisms associated Intermunicipal competitiveness for funds from the state Municipal interests above regional |